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High Possibility STEM
Classrooms

This book offers a new, research-based approach to STEM education

in early, elementary, and middle years of schooling, concentrating on
building teacher agency and integrated approaches to teaching and
learning in High Possibility STEM Classrooms.
Author Jane Hunter presents a globally oriented, contemporary
framework for powerful Integrated STEM, based on mixed-methods
research data from three studies conducted in 14 schools in language-
diverse, disadvantaged, and urbanized communities in Australia.
Theory, creativity, life preparation, public learning, and contextual
accommodations are all utilized to help educators create hands-on,
inquiry-led, and project-based approaches to STEM education in the
classroom. A set of highly accessible case studies is offered that places
pedagogy at the center of practice – an approach valuable to researchers,
school leaders, and teachers alike.
Ultimately, this text responds to the call for examples of what successful
Integrated STEM teaching and learning looks like in schools. The book
concludes with an evidence-based blueprint for preparing for less siloed
and more transdisciplinary approaches to education in schools. Hunter
argues not only for High Possibility STEM Classrooms but for High
Possibility STEM Schools, enriching the dialogue around the future
directions of STEM, STEAM, middle leadership, technological literacies,
and assessment within contemporary classrooms.

Jane Hunter is a researcher and teacher in K–12 education, Faculty of

Arts & Social Sciences, University of Technology Sydney, Australia.
High Possibility STEM
Classrooms
Integrated STEM Learning
in Research and Practice

Jane Hunter
First published 2021
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Taylor & Francis
The right of Jane Hunter to be identified as author of this work
has been asserted by her in accordance with sections 77 and 78 of
the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted
or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from
the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested
ISBN: 978-0-367-89784-0 (hbk)
ISBN: 978-0-367-89786-4 (pbk)
ISBN: 978-1-003-02112-4 (ebk)
Typeset in Baskerville
by Apex CoVantage, LLC
For my loving parents, Patrice and Noel, and my
remarkable young people, Claire and Will.
Contents

About the Authorviii

List of Figuresix
List of Tablesx
Forewordxi
Acknowledgmentsxiv

Introduction: Why Integrated STEM? 1

1 Models and Approaches to STEM Education

in Schools 20

2 High Possibility STEM Classrooms 47

3 Teaching Integrated STEM to Students From Language

Backgrounds Other Than English 76

4 Disadvantage Is No Barrier to Integrated STEM 103

5 Urban Classrooms Leading From the Middle for

Integrated STEM 131

6 Turning High Possibility STEM Classrooms Into

High Possibility STEM Schools 164

7 What’s Next for Integrated STEM: A Blueprint

and Beyond 195

Index219
About the Author

Jane Hunter is a researcher in teacher education at the University of

Technology Sydney (UTS), Australia. She is based in the Faculty of
Arts & Social Sciences, where she teaches postgraduate students who are
in the final stages of preparation for classrooms in schools. Prior to her
position at UTS, she taught in teacher education at Western Sydney Uni-
versity and Sydney University. In between these appointments, she had a
7-year stint as a senior policy officer in the NSW Department of Educa-
tion. Her theory-practice background and passionate advocacy for great
teaching and learning in classrooms stems from more than 10 years as
a head teacher and teacher in K–12 schools. Hunter is an international
and national award-winning teacher and a popular keynote speaker, and
in 2019, her research in Australian schools was awarded “high impact”
by the prestigious national body for research the Australian Research
Council. She tweets @janehunter01.
Figures

2.1 The High Possibility Classrooms framework, featuring

the five conceptions 53
2.2 The IO Professional Learning Model 61
2.3 Graphic of the Concerns-Based Adoption Model (CBAM) 65
3.1 Word cloud of teachers’ responses to questions of
capability in the final High Possibility Classrooms workshop 76
3.2 Combined results for Stages of Concern 93
4.1 Creative memo from an 11-year-old student in a special
needs support unit 103
4.2 Combined results for Stages of Concern 125
5.1 Sample of themes and titles of Integrated STEM
programs, challenges, and units of work in early,
elementary, and middle years classrooms in highly
urban contexts 131
5.2 Sharing Day 2 Agenda 151
5.3 Combined results for Stages of Concern 153
7.1 Blueprint for High Possibility STEM Schools 198
Tables

2.1 The five conceptions and 22 underpinning themes

of the HPC framework 54
3.1 Teachers’ experience and numbers of students 80
3.2 HPC conceptions and focus of the Integrated STEM
programs, units of work, and projects 81
3.3 Results of the changes reported in percentage terms 93
4.1 Teachers’ experience and numbers of students 106
4.2 HPC conceptions and focus of the Integrated STEM
unit/project/challenges108
4.3 Results of the changes reported in percentage terms 126
5.1 Middle leaders’ experience and numbers of students 136
5.2 Development of confidence, personal capacity, and
understanding139
5.3 Middle leaders’ responses to perceptions of Great
Teacher Leaders 142
5.4 Sharing Day 1 responses from participants 150
5.5 Sharing Day 2 responses from participants 152
5.6 Results of the changes reported in percentage terms 154
Foreword

I have an insatiable curiosity. That’s why I am a scientist – I love learn-

ing. It leads me to discover things that previously no one in the world
knew and then question the why, what, how, and “what if” of that new
thing. We address these questions every day as human beings – to sur-
vive. However, as Albert Einstein alluded and in my words, we cannot
solve problems with the same thinking we used when we created them;
so true of our lives right now with a viral pandemic and climate change
at a crisis point. It is the LEARNING TO LEARN that is critical to our
lives, the difference between surviving and thriving. This is why we need
to do education differently – learning in a new way – for the sake of our
future and for the planet.
In this book, Jane Hunter explores learning STEM disciplines in a new
way with emphasis on elementary schools. She presents evidenced-based
arguments for STEM education using an “integrated” approach, mean-
ing that it crosses discipline boundaries, with less emphasis on siloed
content and more on students learning to learn through pedagogy and
practice in education. Integrated STEM learning allows students to be
less restrictive in their thinking, in their ways of working, and in their
ways of being – and to be in the best position to solve real-world problems.
The scene is set in the first chapter, with a review of the current global
efforts by governments and industries to support increased STEM knowl-
edge and expertise in society. Dr. Hunter identifies that a gap in all these
efforts is in traversing the STEM disciplines in student learning. The
author uses her previously developed High Possibility Classrooms frame-
work as a pedagogical approach to support Integrated STEM education
in the second chapter. Details of the research questions, the research
design, and her analysis are underpinned by rich, capability building
teacher professional learning opportunities that take the reader into this
fascinating world of action research in schools.
She presents three excellent case studies in Australian elementary
schools in Chapters 3, 4, and 5. The first case study includes five schools
with predominantly non-English speaking background students; the sec-
ond comprises a trio of disadvantaged schools; and the third uses teams
xii Foreword
of middle leaders in six highly urbanized schools. As an education aca-
demic, Dr. Hunter “partners” with teachers in providing professional
learning and practical support in this pedagogical research – it is an
authentic two-way learning experience. Her approach to the case studies
is rigorous, humble, and admirably reflective, and these studies make a
convincing case for Integrated STEM learning as a critical element in
learning and life in the 21st century.
Following the case studies is a chapter that argues for extending High
Possibility STEM Classrooms to High Possibility STEM Schools. Here,
Dr. Hunter draws on examples from several schools, classrooms, and
educators who are steeped in the practices, structures, and programs
the evidence-based case studies support. Clearly, and not surprisingly,
there is no quick fix in creating these kinds of schools without address-
ing significant challenges, including changes to curriculum, structural
re-organization, and physical modifications to school buildings, and,
above all, rapid adoption of new reporting and assessment methods.
It was courageous of all these schools, their principals, middle leaders,
and teachers to embark on this journey – one that produced worthwhile
learning outcomes for younger children to address and solve important
practical contests.
The final chapter presents 10 directions in what Dr. Hunter calls a
blueprint for Integrated STEM. The blueprint features inquiry-based ped-
agogy with a much-needed framework, such as her High Possibility Class-
rooms, to enable Integrated STEM. It is, as the author so aptly refers to
it, an “education shake up” and supports the opportune gear change
to High Possibility STEM Schools. It includes middle leaders in a new
systems strategy for Engineering to effect Integrated STEM in schools,
academic partnerships to provide a two-way learning platform, and, of
course, urgently needed serious funding from the government for pro-
fessional learning and STEM resources.
In reading this book, I experienced many thrilling moments, particu-
larly from the positive comments by both teachers and students experi-
menting with Integrated STEM through the High Possibility Classrooms
framework. These comments speak volumes for this model of learning
and demonstrate that the teachers were engaged, and their students
were creative, socially connected, communicative, and benefitting from
working in teams. Through Integrated STEM learning, students were
developing a problem-solving mindset, and the hands-on style of learn-
ing was hugely popular. A common comment from students was that
learning in these classrooms is exciting; they did not want to leave these
classes, and they asked why other classes at school do not work like this.
Teacher comments included “aha” moments, such as the realization of
“Why haven’t I been teaching like this all along?” Typically, the teach-
ers and middle leaders had fun too and, seeing the results of learning
outcomes, were “willing to do whatever it takes” to learn STEM concepts
 Foreword xiii
and other content they were unfamiliar with – a challenge facing many
teachers. One content area is Engineering – teachers generally being
less familiar with the concepts of this discipline. Not surprisingly, then,
the High Possibility Classrooms–directed pedagogy for Integrated STEM
resulted in effective student learning, as judged by both teachers and
students.
Importantly, Integrated STEM practiced in High Possibility Classrooms
was of equal benefit to students and teachers in low-equity settings, includ-
ing non-English speaking, disadvantaged, and gender contexts. In particu-
lar, this hands-on learning approach was seen to gain girls’ confidence; in
finding their own way to explore their curiosity, they remained engaged,
attracted to the content, and able to see themselves in it because they were
“doing”.
As an academic for nearly 30 years, I understand and support the need
for deep knowledge in a particular discipline. And this learning should
not be stopped. However, if we continue to think and work in silos, as we
have done in schools and universities for years, we will not be capable of
solving real-world problems for the benefit of all. COVID-19 is a case in
point: How could we possibly get by on just Mathematics, or just Engi-
neering, or by applying the same solution to all countries with their con-
trasting resources and cultures? As Dr. Hunter argues very effectively, we
need all disciplines to make a real and positive impact in the world, hence
the need for STEM to include Arts, as in STEAM. And integrated learn-
ing does not mean the dumbing down of the curriculum; Dr. Hunter’s
book is testament to that. There is a clear need for learning content to
be less siloed and to include skills that cut across the disciplines, as the
current global pandemic and its fallout demonstrate.
The book is beautifully written, the content thoroughly researched;
it is rigorous, contemporary, and, as with all great pieces of research
writing, thought-provoking. As Dr. Hunter suggests, Integrated STEM
learning is timely, and we have no time to waste. The world needs this
now. I look forward to seeing step-changes at all levels of education, and
I put my hand up to support and contribute where I can, as a scientist, a
critical thinker, and a lover of learning. Dr. Hunter has risen to the chal-
lenge of progressing the High Possibility Classrooms framework through
to Integrated STEM learning for High Possibility Schools, and, in this
book, she provides insights critical for changing the direction of elemen-
tary school education towards a better future for all.
– Professor Liz Harry,
University of Technology Sydney, Australia
Acknowledgments

I am fortunate to work in a field that holds personal curiosity and chal-

lenge every day. I am a teacher and researcher who likes to lead and
provoke pedagogical transformations in education in schools and in
my work in teacher education in universities. This book presents the
findings of 4 years of research in 14 Australian schools with 59 teachers
whose principals invited me in to see what their schools do and to sup-
port groups of teaching staff to conceive the curriculum of STEM in new
ways. I thank them for their trust and belief in what I do as a teacher,
as a researcher, and as a co-collaborator who seeks to continually better
understand what builds capacity in professional learning and what hap-
pens in classrooms when curriculum is conceived in different ways.
The case studies in the book are school stories. I take responsibility for
their contents and any flaws. In a world of numbers, statistics, and big
data, we still need engaging case studies of great practice in education –
not all research is without its challenges, especially when there is the
pressure and support of a research study wrapped around leadership
expectations. There were few, if any, odd moments. It is an honor and a
privilege to champion the extraordinary daily work of principals, middle
leaders, and teachers in schools.
Without the support of the Faculty of Arts & Social Sciences at the Uni-
versity of Technology Sydney (UTS) and my sabbatical leave – as it turns
out, during the COVID-19 pandemic – the research conducted in these
schools may have remained as stored data in secure files. I would espe-
cially like to thank the clever, kind, and generous Professor Liz Harry
from the ithree institute in the Faculty of Science at UTS who wrote the
foreword to this book. Liz was serendipitously introduced to me by the
inspirational UTS Deputy Vice-Chancellor Teaching and Learning Pro-
fessor Shirley Alexander. I am lucky to be supported by these wonderful
female role models – both powerhouses in STEM education and more.
In particular, I would like to also thank my research assistant Dr. Lynne
Swarts for her transcription of data and support to the smooth running
of the HPC workshops. Amazing. I would also like to thank Mel Silk for
her involvement in the workshops through her STEAMpop work and
 Acknowledgments xv
Dr. Darrall Thompson for introducing me to REVIEW and for his read-
ing of some of the draft chapters. Dr. Aedeen Cremin from Yass – near
where I used to live in country NSW – provided thoughtful suggestions
to chapter structures in the early stages. Thank you. As this manuscript
was prepared during the COVID-19 pandemic, my wonderful colleague
Dr. Louise Zarmati from the University of Tasmania offered to read draft
chapters and provided excellent, timely, and detailed feedback and
generous academic scholarship. It was wonderful to see her excitement
about my work – almost like it was her book.
Heartiest appreciation must go to Dr. Terry Fitzgerald from UTS who
assisted me in editing this book. Without his steady and thoughtful atten-
tion to every aspect, I would not have been able to complete the task in
such a short time. For an engineer who writes well, he certainly proves
why the Arts are essential to communicating STEAM and Integrated
STEM.
I was meant to travel to the United States as part of my sabbatical leave,
but I couldn’t. Instead, I interviewed Anita Yu in New York via Zoom.
Her delightful children, Tate and Anna Davidson, were part of that fun.
I learned so much about a truly innovative math teacher who believes
STEAM education is the priority for education in the middle years. Back
in NSW and a shout out of appreciation to Department of Education
people: to Kirsten Beck for conferring with me about her report that
I quote from in this book, to John Goh for just being . . . John . . . and
pushing education in new directions, to Stephanie McConnell for her
remarkable work at Lindfield Learning Village, and to Aimee Philips for
her perceptive comments about “the new normal” in schools.
I thank my family and wonderful friends – you know who you are.
I acknowledge my wonderful parents – with me in spirit. What a pity I
cannot see the expression on my dad’s face – he was a civil engineer – as
I advocate for engineering to be taught from the early years in schools.
And finally, to Simon Jacobs and his excellent editorial team at Rout-
ledge for their invitation to write another book and for their support
with this one – thank you.
Introduction
Why Integrated STEM?

STEM is an acronym that has been almost completely absorbed into eve-
ryday parlance. STEM stands for science, technology, engineering, and
mathematics. The origins of the term are diverse and so too are the per-
mutations of the four disciplines with which it is associated. For exam-
ple, eSTEM, STEMM, and STEAM – the “e” for electronics, the extra M
for medicine, and the A for the arts. According to Bybee (2013), STEM
was initially METS, but that’s a baseball team, and even SMET, which was
thought to sound doubtful. Sometime in the 1990s, the letter order was
changed, and the current STEM became widely recognized in the popu-
lar vernacular (Moore, Johnson, Peters-Burton, & Guzey, 2016). Increas-
ingly, a case for the critical role of the arts and the humanities is made
in the education literature (Colucci-Gray, Burnard, Gray, & Cooke,
2019), sometimes referred to as HASS – STEM, that is, humanities, arts,
social sciences – STEM. Yet another contraction, but perhaps a simple
reminder that, in many respects, we need to look beyond acronyms.
The focus of this book is Integrated STEM in school education from
the early years through to the elementary and middle years.1 The find-
ings of three Australian studies underpin this examination. Moreover,
it presents evidence-based illustrations of the importance of build-
ing teacher capacity and confidence through professional learning in
Integrated STEM and removing the discipline “silos”, whether they be
mathematics, technology, engineering or science.2 My premise is that,
globally, we require STEM- or STEAM-literate societies if the world’s
problems are going to be overcome or at least diminished. This goal
is achievable when we integrate learning and assessment in these areas
through multi-, inter-, and transdisciplinary knowledges and processes
(Epstein, 2019; Nadelson & Seifert, 2017; Reid, 2019).
The ongoing professional development of classroom teachers is cen-
tral to achieving the ambition of Integrated STEM and the challenges
and opportunities of an interdisciplinary agenda (Tytler, Williams,
Hobbs, & Anderson, 2019). Integrated STEM in teaching and learn-
ing requires the best education for young people, regardless of their
stage of schooling. This goal needs ongoing support from education
2 Introduction
systems, school leaders, and the teaching profession more broadly. Too
often subject-matter specialists in these disciplines adopt a myopic view
of what is important; they do not look around to see or embrace what
their colleagues in other disciplines are doing. Subject matter could be
made more relevant by, for example, harnessing core concepts, using
real-world applications, and genuine integration through problem solv-
ing, creativity, and critical thinking (Honey, Pearson, & Schweingruber,
2014; Kurup, Li, Powell, & Brown, 2019; Tregloan & Wise, 2018).

The Research
Research examining Integrated STEM through the perceptions of teach-
ers in schools informs the effective practices detailed in this book. I con-
ducted three studies in 14 Australian public schools.3 This research took
place over a 4-year period and involved 59 teachers who volunteered to
participate in professional learning and a program of professional devel-
opment in a series of action research projects with an academic part-
ner (myself). The first two studies were conducted over one school term
(approximately 10 weeks), and the third study, longitudinal in nature,
was for six terms (approximately 60 weeks over 15 months). All studies
were approved by the University of Technology Sydney (UTS) Human
Research Ethics Committee (HREC) and the state education regulator.4
More than 1,500 students from the early years (ages 4–5) through to
elementary and the middle years (ages 6–13) were involved.5
Designs for each study were consistent. All used mixed methods
involving common data-collection elements, such as online pre- and
post-intervention surveys, and whole days of professional development
that prioritized Integrated STEM education and familiarity with the
High Possibility Classrooms framework (Hunter, 2015a).6 In the third
study, coaching and mentoring were additional features targeting the
upskilling of middle leaders who worked with more junior colleagues
(coachees) in each school. Rich qualitative data were gained from semi-
structured interviews with teachers, middle leaders, and principals; focus
groups with students; classroom observations; notes from coaching meet-
ings; analyses of school policies; and an online network that connected
all participants over the research period and was vital for resource and
program sharing. The Stages of Concern survey, one of the CBAM ques-
tionnaire tools, was used in each study to inform the findings, NVivo 11
software was used for analysis of the qualitative data, and online forms
were used for evaluations of the professional development workshops.

The Purpose of STEM Education in Schools

Academic and systemic disputes in jurisdictions about what constitutes
STEM education are common (Beane, 1997; Bybee, 2018; MacDonald,
 Introduction 3
Danaia, & Murphy, 2020; Shernoff, Sinha, Bressler, & Ginsburg, 2017;
Zollman, 2012). So, before examining the global picture of STEM edu-
cation, it is necessary to define its purpose. Bybee (2013) argues that
“you must give students experiences in which they apply knowledge and
skills if you want them to learn how to apply knowledge and skills” (p. 5).
In Australia, the National STEM School Education Strategy (Education
Council, 2015) defines STEM education as

a term used to refer collectively to the teaching of the disciplines

within its umbrella – Science, Technology, Engineering and Math-
ematics – and also to a cross-disciplinary approach to teaching that
increases student interest in STEM-related fields and improves stu-
dents’ problem solving and critical analysis skills.
(p. 5)

Terms used concomitantly with STEM are “integrated curriculum” and

“integrated STEM”, both of which also stimulate debate (Williams, 2011,
p. 28). For example, in recent reflections on the Australian Curriculum,
Mockler (2018) suggests that curriculum integration is not a new idea,
and a renewed focus on STEM might be just the innovation needed for
furthering it and developing students’ capacity and knowledge across
disciplinary boundaries. A key aim of this book is to expand the discus-
sion and offer Integrated STEM learning as the main lever to take this
important dialogue forward.
Integrated STEM learning may be cross- or multidisciplinary (content
from disciplines linked to a chosen theme), interdisciplinary (differ-
ent disciplines focused on skills), or transdisciplinary (using big ideas
to drive natural connections between the disciplines). These learning
approaches offer effective support to students in ways that may lead to
increasing the numbers graduating from STEM courses in post-school
education (Beane, 1997; Honey et al., 2014; National Academy of Engi-
neering and National Research Council, 2014). As well, in a promising
advance in education in high schools, Thibaut et al. (2018) cite inte-
grated curriculum as demonstrating improvement in students’ interest
in STEM and a subsequent motivation to extend this interest beyond
isolated study in the four or five disciplines. This position is supported
by the research findings I present in this book.
Although based on research in pre–high school classrooms, each of
the studies presented here sought to foster initial engagement and moti-
vation for an integrated approach to STEM that would give early years,
elementary, and middle years students positive STEM experiences and
increase their enthusiasm for considering these disciplines in their sen-
ior years of schooling. While the findings are favorable, ongoing follow
up and further research are needed to determine just how successful
such interventions might be over the long term.
4 Introduction
A Pedagogical Solution for Integrated STEM
Integrated STEM in this book refers to a pedagogical approach whereby
a teacher or team of teachers adopts a pedagogy for STEM teaching
and learning that blends multi-, inter-, and transdisciplinary approaches
involving knowledge and skills applied to big questions, significant prob-
lems, and complex ideas to structure a total learning experience. The
teachers participating in the research studies drew on the High Possi-
bility Classrooms framework (Hunter, 2015a) and inquiry-based learn-
ing approaches (Murdoch, 2015) to develop programs, units of work, or
projects including design challenges for teaching and learning that gave
equal attention to at least the four STEM disciplines.
The rationale for a pedagogical approach to Integrated STEM in these
classrooms arose out of a call to action by Tytler, Osborne, Williams,
Tytler, and Cripps Clark (2008) in their influential literature review:

Pedagogy . . . will strengthen the intellectual rigor of STEM learning

and interest students in STEM content from kindergarten until the
end of secondary [high] schooling. . . . [It] is the critical element in
enlisting student engagement with STEM subjects.
(pp. vii–ix)

Their proposition informs the core argument in this book for a peda-
gogical solution to Integrated STEM. It also supports the notion that
teachers use the term STEM only when it relates to genuinely integrated
approaches (English, 2017; Rosicka, 2016). STEM is not integrated when
science or mathematics education is the sole focus. The educational
answers to an integrated approach to STEM revealed by the participat-
ing teachers’ use of the High Possibility Classrooms framework offers a
contemporary vision of what is feasible when the disciplines are brought
together around sets of questions, big ideas, or complex problems. The
framework was initially developed out of exemplary teachers’ knowledge
of technology integration (Hunter, 2013) and was further validated over
2 years by research conducted in the curriculum areas of science, math-
ematics, humanities, English, and health & physical education (Hunter,
2015a, 2015b, 2017a, 2017b).7
There is more to Integrated STEM than teaching two, three, or
four disciplines together or using one discipline as a tool for teaching
another (STEM Task Force Report, 2014). While a discipline may have
a learning goal, the pedagogical conceptions and themes in the High
Possibility Classrooms framework support subject integration through
meaningful practitioner inquiry in two, three, or more content areas
(Hunter, 2015a, 2019). The examples in this book illustrate how mastery
of various technology tools to enhance learning content can also serve
understanding the objectives in, for example, computer programming
 Introduction 5
and computational thinking in a design and technologies curriculum
(ACARA, 2015; Honey et al., 2014). Teachers’ concerns about the
integration of content with technology has intensified in recent years
(Urban & Falvo, 2016; Tytler et al., 2019). Taking the Australian Curricu-
lum as an example, Blackley and Howell (2015) report: “There has been
no attempt to either replace or offer as an alternative, an integrated
STEM curriculum to support teachers” (p. 106). This book addresses
that gap by drawing on deep understandings of how teachers approach
the integration of STEM in elementary schools and how such examples
might progress Integrated STEM teaching and learning in the latter
years.

The Place of Professional Learning in Building

Teacher Capacity and Confidence
The term “professional learning” used throughout this book refers to
the processes and experiences teachers engage with in order to develop
their practice, while “professional development” describes structured
learning activities for teachers, sometimes one-off but preferably ongo-
ing and well resourced. The teachers participating in this book’s research
engaged in both professional learning and professional development.
Building teacher capacity and confidence in STEM education, even
without the crucial notion of integration, is recognized as a core chal-
lenge in many countries.8 In Australia, for example, it is often couched
in such terms as supporting students’ ability, engagement, and aspiration
for STEM subjects; the teaching quality of STEM in classrooms; more
STEM education opportunities within school systems; effective partner-
ships with tertiary education providers, businesses, and industries; and
the building of a strong evidence base (Department of Education and
Training, 2018). Fulfilling such goals, however, requires not only curricu-
lum change but also the delivery of both funding and time for teachers’
professional development (Ringland & Fuda, 2018). Keen to make its
STEM priorities known, in 2015, the Australian government announced
its National and Innovation Science Agenda (NISA, 2015) and commit-
ted funding of more than AUD 1.1 billion (USD 738 million) to it.
A recent study of 119 Australian teachers (Kurup et al., 2019) found
that even at the pre-service level, they did not have strong understandings
of STEM. However, they did have robust beliefs and intended to teach
STEM in their future careers. The capacity they built provided them with
explicit views on how to teach STEM in primary schools and informed
them of what they need for the future teaching of it. The authors suggest
it is essential to “formulate a course work and professional development
in STEM capable of integrating disciplines, providing an understanding
of pedagogical approaches, and connecting to real-life relevance with
the twenty-first century competencies” (p. 7).
6 Introduction
In the United States (US), the findings of a randomized control trial
(RCT) undertaken by Cotabish, Dailey, Robinson, and Hughes (2013)
on the impact of professional development and inquiry-based science
instruction on student outcomes in science skills and knowledge con-
cluded that the professional development “had a statistically significant
impact on student skills and knowledge” (p. 219). Moreover, ongoing
support was effective in allowing teachers to reflect on their teach-
ing practice. A “knowledge synthesis” conducted 2 years prior by the
National Commission on Teaching and America’s Future and WestEd
(Fulton & Britton, 2011), based on an analysis of nearly 200 STEM edu-
cation research articles and reports, revealed that in order to meet the
needs of today’s learners, and for teacher capacity and confidence build-
ing to be a priority,

[the] tradition of artisan teaching in solo-practice classrooms will

have to give way to a school culture in which teachers continuously
develop their content knowledge and pedagogical skills through col-
laborative practice that is embedded in the daily fabric of their work.
(p. 22)

In a project that began in the US in 2010 and involved 30 schools,

750 hours of observations, and more than 300 interviews, Mehta and
Fine (2019) found that making a move to “deeper learning in class-
rooms”, which in many respects is exactly what is required in Inte-
grated STEM,

is dependent or whether or not we can summon the courage and

the will to make the shift [and] if we cannot shift from a world where
learning deeply is the exception rather than the rule, more is in
jeopardy than our schools. Nothing less than society is at stake.
(p. 400)

Here, policy is central to addressing the need for Integrated STEM

learning – it matters – but principals, middle leaders, and teachers also
know that the actual translation of education policy into practice var-
ies. Context matters, too, and within-school differences (from classroom
to classroom and from teacher to teacher) are more crucial than any
school mantra or bureaucratic directive.

Where Are Education Policy and Practice

in the Conversation?
Apprehensions surrounding STEM education policy and practice
populate discussions of school education in the mainstream media in
Australia, the US, and parts of Asia and Europe (Honey et al., 2014;
 Introduction 7
Kelley & Knowles, 2016; Smith, 2018). Using measures such as GDP
(gross domestic product), education jurisdictions are charged with raising
national productivity because of a perceived “STEM drain” and the declin-
ing students’ standardized test scores in international tests, notably the
cycles of PISA (Program for International Student Assessment) and TIMSS
(Trends in International Mathematics and Science Study). These testing
systems are the subject of considerable political controversy and debate
(Koziol, 2018; Lin, Lin, Potvin, & Tsai, 2018), and it often seems that many
business leaders, political elites, and social media commentators have an
opinion about STEM education without checking what already exists in
various education programs and resources (Berry, 2018; Light, 2018).
Both the National Research Council (2012) in the US and the Organi-
zation for Economic Co-operation and Development (2012) suggest that
reform initiatives focusing on STEM will require substantial changes in
how the four disciplines are taught. They also recognize that the arts
and humanities have a central space in the schema, not only in schools
but also in university preservice teacher education courses and in
professional learning opportunities for in-service teachers (Chapman &
Vivian, 2017; Timms, Moyle, Weldon, & Mitchell, 2018). Global compari-
sons of education policy and practice provide insight into the priorities
of STEM education. Such comparisons with Australia were addressed by
Marginson, Tytler, Freeman, and Roberts (2013) in a project commis-
sioned to identify useful lessons and ideas. These were nation specific
and fell into five main groups: 1) English-speaking countries, including
the UK, the US, Canada, and New Zealand; 2) Europe, including Western
Europe, drawing in France, Portugal, Finland, and Russia; 3) emerging
STEM-focused education systems, such as those in China, South Korea,
Japan, Taiwan, and Singapore; 4) emerging economies in places such as
South Africa, Brazil, and Argentina; and 5) countries where there is a
focus on Indigenous policy issues in STEM education, such as Canada,
the US, Aotearoa New Zealand, Brazil, and South Africa.
Across each report in this global project, there is a pronounced pre-
occupation with “STEM in the senior years of secondary school and
while there is active policy discussion the focus is on building high-end
STEM skills, linked to research and development, and industry innova-
tion” (p. 53). While attention is also drawn to labor market and industry
settings, which remain somewhat of a dark domain or black box every-
where, emphasis on schooling dominates because

schooling is subject to direct government regulation and responsibil-

ities, whereas universities are more autonomous, technical institutes
in most systems lack adequate status and the economic utilisation of
STEM, on which the rationale for STEM policy (ostensibly) pivots,
are largely beyond governmental reach and public scrutiny.
(p. 54)
8 Introduction
This focus on schooling, and on STEM more broadly, cannot happen
in a vacuum or in education alone and is further supported in more
recent work in which these scholars urge STEM learning to become
a whole of society project (Freeman, Marginson, & Tytler, 2015). The
issue is coupled with STEM teacher shortages – it is a global concern
that has not been addressed. And the problem is confirmed once
again in research with high school teachers being assigned to teach
STEM out of field (i.e., out of their specialization) (Shah, Richard-
son, & Watt, 2020).
In addition to those already mentioned, international organizations
that pay significant attention to global STEM education issues include
the World Bank; United Nations Education, Science and Cultural
Organization (UNESCO); the European Union (EU); and the Interna-
tional Association of the Evaluation of Educational Achievement (IEA).
The European Commission, as the guardian of EU treaties, has focused
on STEM policy since the 1990s. France and Germany have emphasized
STEM as part of their framing of national policy on education and indus-
try; they see an apparent STEM shortage rather than a crisis. Blackley
and Howell (2015) suggest that many challenges need to be overcome
for Integrated STEM education to flourish:

When teachers and students are positioned in a regime of standard-

ised testing (e.g. in the US, UK, and Australia), and the results of the
tests impact upon school funding, school image, and teacher per-
formance pay, priority will understandably be given to the subject
areas that are being tested: mainly mathematics and literacy. The
challenge is to reassure teachers that embracing integrated STEM
education and preparation for standardised tests are not mutually
exclusive.
(p. 110)

Are we at an impasse or at a fork in the road, as suggested by Blackley and

Howell (2015)? “Either the education community holds the pedagogical
high-ground resulting in integrated STEM education (integration) OR
the education community supports the original political agenda by shor-
ing up the discrete discipline areas (concentration)” (p. 111, emphasis
in original). The research findings reported in this book support this call
for keeping to the high ground.
In Australia, it is now required that elementary teachers have a learn-
ing area specialization.9 In a recent systematic literature review, Mills,
Bourke, and Siostrom (2020) focused on what could be learned about
such “disciplinary expert teachers” of elementary science and mathe-
matics. They reviewed 589 potentially relevant articles and, after a final
 Introduction 9
analysis of 37 that scrutinized issues such as teacher preparation, coach-
ing, and impacts on teaching and learning, they concluded

there is insufficient evidence to suggest that specialist teachers or

teachers with a specialization have a positive impact on student
learning . . . [and] little support for this reform in Science and Math-
ematics education research in schools to date.
(p. 10)

Cases are also being made for policy and practice in STEM that involve
the arts and humanities education (for STEAM) in education reform.
In Australia, for example, MacDonald, Hunter, Wise, and Fraser (2019)
argue that between STEM and STEAM disciplinary intersections there is
“an integral space, within which risk, mess and disruption foster key 21st-
century skills in teaching and learning, industry and life” (p. 86). How-
ever, they recognize that several significant challenges exist for teachers
seeking to enact the pedagogical transformations required to achieve
meaningful and authentic interdisciplinary STEM and STEAM educa-
tion outcomes:

How to assess students in these spaces is largely absent within all of

the agendas. This key observation emerges as a major inhibitor; an
‘elephant in the classroom’, in terms of impacting the lived activa-
tion and mobilisation of STEM and STEAM.
(p. 87)

Agendas that ignore the “backwash effect” of assessment on student

learning are perhaps missing a key element in effecting integration
(Havnes, 2004). Thompson (2009) argues assessment criteria that make
explicit the capabilities being developed across subject and project bound-
aries are an important “fulcrum of engagement between teachers and
students” (p. 403).
Such observations would also hold for the research findings in the
three studies presented in this book; in each case, there were no spaces
or places to adequately report student work in STEM and/or STEAM to
parents in half-yearly and annual reports. While it seems important for
schools’ and school systems’ assessment policies to offer STEM educa-
tion, there is still enactment hesitation unless it falls under project- or
inquiry-based learning. Parents and the public are often invited to view
the fruits of a whole term of STEM and STEAM activity in the form of
a showcase or annual fair. I have been to many such events, and they
are high stakes, excellent, and without exception hugely popular with
students, teachers, principals, system leaders, and school communities.
However, the assessment and reporting of STEM teaching and learning
10 Introduction
now warrant enhanced value and status (Association for Science Educa-
tion, 2019; National Science Teachers Association [NSTA], 2017, 2018;
Teacher Education Ministerial Advisory Group [TEMAG], 2014).

To Whom Will This Book Appeal?

I envisage that readers of this book will be from across the educational
spectrum. It will appeal to in-service teachers of all levels of experience in
public and private schools who are seeking ways to foster student interest
in STEM and STEAM – where integration is the focus and the approach
revolves around big questions, real-world ideas, and complex problems.
Principals, too, an audience that I have always sought to engage with in
my education work in schools, will find the case study examples highly
relevant to their leadership roles. Teacher educators, research schol-
ars of STEM, and preservice teachers in education courses – in fact,
all who desire genuine opportunities to engage in more contemporary
approaches to teaching and learning in schools – should also find this
book useful. And, of course, system leaders will collectively find the book
of interest as a road map for considering the ways Integrated STEM can
progress the needs of their education jurisdictions.
Schools where material resources are scarce should find the approaches
of the case study schools helpful as the principals in these places prior-
itized available funds for STEM professional learning and for the forma-
tion of sustained and robust school–university partnerships that drew on
both quantitative and qualitative evidenced-based research collected at
the school site. This approach speaks to education colleagues who sup-
port Integrated STEM professional learning that involves professional
development opportunities that include authentic partnerships with
experts from the STEM and STEAM fields beyond the school gate, while
honoring the profound expertise of practicing teachers who know how
their students learn and see themselves as lifetime learners and owners
of their own work.
This book is part of a timely conversation for all those in education
who are committed to taking teaching and learning in schools forward
and is even more pressing since the 2020 COVID-19 pandemic and the
online pivot that many schools worldwide enacted over a short period
of time (Ferdig, Baumgartner, Hartshorne, Kaplan-Rakowski, & Mouza,
2020). It highlights research conducted in HPC and Integrated STEM
since publication of my earlier book Technology Integration and High Pos-
sibility Classrooms: Building from TPACK (Hunter, 2015a). Teachers may
choose to read this new book from cover to cover or to strategically focus
on particular case studies as evidence-based examples suitable for pro-
fessional practice or for leading Integrated STEM professional devel-
opment in their school or district. For others, in particular education
 Introduction 11
scholars, the focus on pedagogy, professional learning, and curriculum
may be more appealing.
Each of the case study chapters aims to give clear examples of what Inte-
grated STEM looks like in practice. Teachers believed they became more
effective in teaching through the action-learning processes learned and
implemented during an academic partnership. Included are specifics of
the professional development workshops and the common structure of
the more than 85 units of work, challenges, programs, and projects cre-
ated. While there is insufficient space to describe each one, the case
studies can form a complete suite on their own or act as springboards to
programming and planning; they comply with sets of teaching standards
common in education jurisdictions for elementary school teachers at all
levels of accomplishment. I acknowledge the participation of those teams
of teachers in Australia who so diligently worked and reworked their con-
tent and pedagogical practices to ensure the best possible teaching and
learning experiences for all students in their diverse classroom settings.

In This Book You Will Discover . . .

This book has seven chapters. The case studies in Chapters 3, 4, and 5
begin with a creative memo from teacher and student moments in the
research. Each memo is testament to innovative, deep, and unique prac-
tices in Integrated STEM and describes an observed instant that was
quite typical of the school, a student, or a professional development
experience. At the suggestion of many readers who purchased my earlier
book, I have added at the end of each chapter a section titled Profes-
sional Conversation. This offers a series of provocations on why Integrated
STEM matters that serve as starting points for reflection and dialogue
about practice. These can be used as preparatory points for planning,
for teaching, for leading, and as sustenance for your ongoing work in
school-education settings. To that end, it will be helpful to explain what
each chapter is about.
In Chapter 1, I focus on the early, elementary, and middle years of
schooling by examining models of multi-, inter-, and transdisciplinary
approaches, and whether it is STEM or not, there are places for the arts
and humanities to make it STEAM education. This chapter situates the
three case studies in the global context of STEM education, drawing on
international scholarship and research studies in schools in 10 countries
located in non-English speaking, disadvantaged, and highly urbanized
communities.
Chapter 2 features the High Possibility Classrooms (HPC) framework
and explains its pedagogical role in the creation of transformative profes-
sional learning that impacts teaching and learning in schools and teacher
education in universities. This chapter examines the critical role of an
12 Introduction
academic partnership in tandem with structured professional learning
focused on the HPC framework. It also explains how such partnerships
foster practitioner inquiry that supports the integration of the STEM
disciplines and shifts STEM education in early, elementary, and middle
years classrooms to where it needs to be.
Chapter 3 presents the first case study. This involved five schools where
there were significant numbers of students whose language backgrounds
were not English. The chapter details findings from a 10-week study of
16 teachers in these language-diverse contexts and how the professional
learning led by an academic partner using inquiry and project-based
approaches in classrooms influenced their teaching and learning of
Integrated STEM. The perceptions of participating teachers, students,
and principals contributed to this study.
Chapter 4 offers the second case study. It begins with a narrative from
a student in a special-needs classroom; the formidable voice of this young
person is a reminder of why great teaching matters and how a pedagogy
involving rigor and structure can support Integrated STEM content in
elementary classrooms. Three low-socioeconomic schools participated
in this 10-week case study. In total, 21 teachers co-programmed, co-
taught, and collaborated using authentic equipment to unleash memo-
rable education experiences for students. This case study offers unique
insights into how parent and community involvement in Integrated
STEM was significant at these disadvantaged schools.
Chapter 5 features the third case study, which involved six highly
urban schools and 22 middle leaders in early- to middle-years classrooms
who acted as STEM coaches to build their professional capacity in Inte-
grated STEM and impact practice more widely across their own contexts.
This case study draws on longitudinal data collected over 15 months that
noted changes in student learning outcomes as a consequence of radi-
cal changes to teacher pedagogy and the kinds of assessments students
completed.
Chapter 6 argues for the creation of Integrated STEM and STEAM-
literate societies as crucial to living well in global communities and the
notion that turning High Possibility STEM Classrooms into High Possi-
bility STEM Schools will require, at the bare minimum, systemic changes
to assessment, reporting, and organizational structures. Who is taking
the lead? What curricula resources for the early, elementary, and mid-
dle years are helping to prime the conversation? Long-term partnerships
with academic colleagues in universities are fundamental to the success-
ful integration of STEM in school education at all levels. The challenge
should not be treated as a purely technical one. Where are the inspira-
tional revolutions for extending STEM to STEAM taking place? Reform-
ing teacher professional learning in Engineering within the Integrated
STEM agenda for middle leaders in elementary schools is also essential.
Noteworthy demonstrations of Integrated STEM education are provided
 Introduction 13
from principals, teachers, front-running schools, and academies in the
US and Australia.
Chapter 7, the final chapter, offers a blueprint for High Possibility
STEM Schools that is drawn from research in Australian elementary
schools, from individuals, the literature, and the exemplary contexts
mentioned in Chapter 6. It also asks and responds to five questions:

1. What are the non-negotiable principles for effective Integrated

STEM in schools? Should school education just be STEAM?
2. Is pedagogical transformation in Integrated STEM dependent on
resources?
3. How do schools working with professional associations, teacher
networks, and university academics in Engineering or Science
departments who are from outside teacher education harness their
expertise in promoting worthwhile Integrated STEM education?
4. If the associated disciplines are framed as having critical knowledge
components, then how can transdisciplinary education offer a solu-
tion to boundary crossing the S.T.E.M. silos; is it linking assessment
criteria to an agreed STEM and STEAM capability framework that
holds the key to curriculum integration?
5. And if that is a workable solution, what are the roles of universities
and vocational education providers in the space?

Together, these chapters respond to many calls in the literature (e.g.,

English, 2016, 2017; English & King, 2019; Thibaut et al., 2018; Timms
et al., 2018) for case studies of Integrated STEM from the field of school
education. One recent example of innovation in university education
is the new Faculty of Transdisciplinary Innovation at the University of
Technology Sydney, Australia. Now in its fifth year, this faculty is attract-
ing large cohorts of post-secondary school students and is set to radically
expand its offerings and student places. The future of Integrated STEM
involving multi-, inter-, and transdisciplinary knowledges and processes
are promising. Many leaders from within and outside education are step-
ping into sometimes uncomfortable and challenging roles to lead the
critical next leaps. However, we need whole communities to champion
its importance and take greater responsibility for creating informed,
humane, and thriving Integrated STEM- and STEAM-literate societies.
The next 10 years are critical.

Notes
1. The capitalization of “I” for Integrated (i.e., Integrated STEM) is for added
emphasis and is used throughout the book. The research was conducted in
Australian primary schools, where the early years are children aged 4–7, and
in upper and lower primary classrooms with children aged 8–10, then 11–12,
14 Introduction
respectively. Internationally, this approximates as the early years (4–7 y.o.),
elementary (7–10 y.o.), middle years (11–13 y.o.), and high school (14+ y.o.);
these year or stage descriptors are used throughout the book.
2. In Australia, engineering is not taught in the early, elementary, or middle
years of schooling, although it is in some countries, for example, in the US (in
the Next Generation Science Standards). In Australia, it is taught in schools as
part of a Design and Technology curriculum in high schools. It is a neglected
area (English, 2017). However, it is construed as a type of “making” and in
some schools, students are involved in Engineering Challenges, where, for
example, physics concepts of gravity and motion are taught.
3. In Australia, public schools are funded by the government; private, non-
government, or independent schools encompass faith-based and charter
schools that receive government funding together with fees paid by parents.
4. The High Possibility Classrooms research was awarded “high impact” by
the Australian Research Council (ARC) in March 2019. As Australia’s lead-
ing publicly funded research and development authority, university-based
researchers count on the ARC’s investment and support.
5. School leaders or principals of the 14 schools funded the involvement of their
staff in the research, and an academic partner (the author) was invited to
conduct each of the studies. It was an honor and a privilege to work with these
schools and their communities.
6. Throughout the book, the five conceptions of theory, creativity, public learn-
ing, life preparation, and contextual accommodations are denoted with italics for
emphasis.
7. The terms “content”, “subject-matter knowledge”, “discipline”, and “key
learning area” are used interchangeably to denote subject content students
learn at school. The term “syllabus” refers to the subjects in a course of teach-
ing – sometimes called the “curriculum”; in the US, “the common core” spec-
ifies what students should know at each grade or year level, and in Australia
that is known as the Australian Curriculum (AC).
8. The notion of “building teacher capacity and confidence” aligns with per-
sonal capacity (skills and knowledge), beliefs (professional and personal),
and values. It acknowledges that teachers may come to a situation equipped
with substantial capacity (e.g., skills and knowledge), but an innovation may
prove too risky to enact. Sometimes recounted as teacher agency, it is charac-
terized as an emergent phenomenon in education and the work of teachers.
Here, research findings in the three case studies in the book reflect what
Priestley, Biesta, and Robinson (2015) determine as an “ecological approach
to teacher agency” in that it offers potential for “teachers to become more
reflexive about their professional working practices, as they take on responsi-
bility for the long term development [in this case enabling Integrated STEM]
of the students they work with” (p. 9).
9. The move to specializations for primary mathematics and science teaching
in Australian preservice teacher education in universities became a phenom-
enon in 2019.

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 Introduction 17
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education from 2013 to 2017: A systematic content analysis of publications in
selected journals. International Journal of Science Education. doi:10.1080/09500
693.2018.1550274
MacDonald, A., Danaia, L., & Murphy, S. (Eds.). (2020). STEM education across the
learning continuum. Singapore: Springer.
MacDonald, A., Hunter, J., Wise, K., & Fraser, S. (2019). STEM and STEAM and the
spaces between: An overview of education agendas pertaining to ‘disciplinarity’
across three Australian states. International Journal of STEM Education, 5(1), 75–92.
Marginson, S., Tytler, R., Freeman, B., & Roberts, K. (2013). STEM: Country com-
parisons. Report for the Australian Council of Learned Academies. Retrieved
from www.acola.org.au.
Mehta, J., & Fine, S. (2019). In search of deeper learning: The quest to remake the
American high school. Cambridge, MA: Harvard University Press.
Mills, R., Bourke, T., & Siostrom, E. (2020). Complexity and contradiction: Disci-
plinary expert teachers in primary science and maths education. Teaching and
Teacher Education, 89. doi:10.1016/j.tate.2019.103010
Mockler, N. (2018). Curriculum integration in the twenty-first century: Some
reflections in light of the Australian Curriculum. Curriculum Perspectives, 38(2),
129–136. doi:10.1007/s41297-018-0047-9
Moore, T. J., Johnson, C., Peters-Burton, E. E., & Guzey, S. S. (2016). The need
for a STEM road map. In T. J. Moore, C. C. Johnson, E. E. Peters-Burton, &
S. S. Guzey (Eds.), STEM road map: A framework for integrated STEM education.
London: Routledge.
Murdoch, K. (2015). The power of inquiry. Northcote: Seastar Education.
Nadelson, L. S., & Seifert, A. L. (2017). Integrated STEM defined: Contexts,
challenges and the future. International Journal of STEM Education, 11(3),
221–223. doi:10.1080/00220671.2017.1289775
National Academy of Engineering and National Research Council. (2014).
STEM integration in K-12 education: Status, prospects, and an agenda for research.
Washington, DC: The National Academies Press. doi:10.17226/18612
National Innovation and Science Agenda (NISA). (2015). Welcome to the ideas
boom. Retrieved from www.industry.gov.au/sites/default/files/July%202018/
document/pdf/national-innovation-and-science-agenda-report.pdf
National Research Council (NRC). (2012). Education for life and work: Devel-
oping transferable knowledge and skills in the 21st century. Washington, DC:
National Academies Press. Retrieved from www.nap.edu/resource/13398/
dbasse_070895.pdf
National Science Teaching Association (NSTA). (2017). NSTA position statement:
Science teacher preparation. Retrieved from www.nsta.org/about/positions/
preparation.aspx
National Science Teaching Association (NSTA). (2018). NSTA position statement:
Elementary science education. Retrieved from www.nsta.org/about/positions/
elementary.aspx.
Organization for Economic Co-operation and Development (OECD). (2012).
Preparing teachers and developing school leaders for the 21st century: Lessons from the
around the world. Paris: OECD Publishing. Retrieved from www.oecd.org/site/
eduistp2012/49850576.pdf
18 Introduction
Priestley, M., Biesta, G. J. J., & Robinson, S. (2015). Teacher agency: What is it
and why does it matter? In R. Kneyber & J. Evers (Eds.), Flip the system: Chang-
ing education from the bottom up. London: Routledge.
Reid, A. (2019). Changing Australian education: How policy is taking us backward and
what can be done about it. Crows Nest, NSW: Allen & Unwin.
Ringland, N., & Fuda, B. (2018, February 2). We have a national STEM strat-
egy, but what we need is a successful one. The Conversation. Retrieved from
https://theconversation.com/we-have-a-national-stem-strategy-but-what-
we-need-is-a-successful-one-87088
Rosicka, C. (2016). From concept to classroom: Translating STEM education research
into practice. Camberwell, VIC: Australian Council for Educational Research
(ACER).
Shah, C., Richardson, P., & Watt, H. (2020). Teaching ‘out of field’ in STEM sub-
jects in Australia: Evidence from PISA 2015. GLO Discussion Paper Series 511. St.
Louis: Global Labor Organization.
Shernoff, D. J., Sinha, S., Bressler, D. M., & Ginsburg, L. (2017). Assessing
teacher education and professional development needs for the implemen-
tation of integrated approaches to STEM education. International Journal of
STEM Education, 4(13). doi:10.1186/s40594-017-0068-1
Smith, A. (2018, March 21). STEM has become a buzzword and a fad: NSW edu-
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20180321-p4z5iw.html
STEM Task Force Report. (2014). Innovate: A blueprint for science, technology, engi-
neering and mathematics in Californian public education. Dublin, Ireland: Califor-
nians Dedicated to Education Foundation.
Teacher Education Ministerial Advisory Group (TEMAG). (2014). Action now:
Classroom ready teachers. Retrieved from https://docs.education.gov.au/node/
36783
Thibaut, L., Ceuppens, S., De Loof, H., De Meester, J., Goovaerts, L., Struyf,
A., & Depaepe, F. (2018). Integrated STEM education: A systematic review of
instructional practices in secondary education. European Journal of STEM Edu-
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Thompson, D. G. (2009). Successful engagement in graduate attribute assess-
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Timms, M., Moyle, K., Weldon, P., & Mitchell, P. (2018). Challenges in STEM learn-
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 Introduction 19
Tytler, R., Williams, G., Hobbs, L., & Anderson, J. (2019). Challenges and
opportunities for a STEM interdisciplinary agenda. In B. Doig, J. Williams, D.
Swanson, R. Borromeo Ferri, & P. Drake (Eds.), Interdisciplinary mathematics
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1 Models and Approaches to
STEM Education in Schools

If STEM is to be truly implemented, curriculum designers will have to

address how to ensure all parts of this challenge are addressed and cope
with defining the knowledge and skills necessary for each discipline in
a durable way that is able to accommodate future changes in discipli-
nary knowledge and scope. The design will have to account for the lim-
ited space in the overall curriculum and assessment systems will have to
reflect the breadth of STEM.
(Timms, Moyle, Weldon, & Mitchell, 2018, p. 12)

Schools around the world are racing to include STEM education in

daily, weekly, or sessional classes. Beyond the logistical challenges of
scheduling, as Timms et al. (2018) suggest, there are greater hurdles
for teachers, namely, defining the important knowledges in contempo-
rary learning in schools and determining where assessment fits within
regimes of curriculum integration. Such moves apply not just in high
school environments but also, importantly, in the early, elementary, and
middle years of schooling (Baker, 2020). The classrooms featured in
this book’s case studies have adopted various approaches to Integrated
STEM that include the arts and humanities, extending STEM to STEAM.
These align with the remit of the participatory action research methods
of each study to build teacher capacity in the STEM disciplines through
professional learning in a sustained academic partnership that focused
on pedagogy, knowledge and skill building, co-teaching, reflection, and
coaching. As research studies in Integrated STEM are a knowledge gap
yet to be filled by education jurisdictions around the world (English,
2016, 2017; Honey, Pearson, & Schweingruber, 2014; STEM Task Force
Report, 2014; Tytler, Williams, Hobbs, & Anderson, 2019), the focus
here is on STEM education in schools more broadly.
In this chapter, I examine selected examples of advances in STEM
education from around the world. The emphasis is on STEM as core con-
tent, although recent research conducted in K–12 schools in countries
 Models and Approaches 21
like Singapore, Australia, and Korea hold substantiated examples and
offer inspirational alternatives (English & King, 2019; Jho, Hong, &
Song, 2016; Tan, Teo, Choy, & Ong, 2019). Many of these evidence-based
illustrations are congruent with findings in the Australian case studies
presented in Chapters 3 and 4, which feature teachers and principals in
schools with large cohorts of non-English speaking and disadvantaged
students, and in Chapter 5, the case study examines middle leaders who
teach in highly urban contexts (OECD, 2017). According to Thibaut
et al. (2018), the most promising approach to STEM education revolves
around an integrated curriculum that provides significant and motivat-
ing experiences for learners. They suggest high schools might need to
become more like elementary schools with a generalist approach to
teaching and learning: “Real-world problems are not fragmented in iso-
lated disciplines as they are taught in schools and to solve these problems
people need skills that cut across the disciplines” (p. 20). In his best-
selling book, Range, journalist David Epstein (2019) gives examples of
how generalists will triumph in the increasingly more specialized world
of the 21st century. Since the 1990s, research in a broad range of disci-
plines has shown that students involved in integrated curricula perform
as well or even better than their peers in traditional instruction with sep-
arate disciplines (Beane, 1995; Czerniak, Weber, Sandmann, & Ahern,
1999; Hinde, 2005). However, research on student learning outcomes in
Integrated STEM contexts remains limited and inconclusive, especially
from a long-term perspective (How to STEM, 2018; Tytler et al., 2019).
According to Thibaut et al.’s (2018) systematic review of the litera-
ture, a theoretical framework has emerged that features the following
five principles related to instructional practices in Integrated STEM in
secondary education: “integration of STEM content, problem-centered
learning, inquiry-based learning, design-based learning and cooperative
learning” (p. 4). The authors acknowledge that empirical research is
needed to confirm the validity of the framework. Even so, it is one of the
most important theoretical developments toward introducing Integrated
STEM into secondary education “to improve implementation of inte-
grated STEM education, ultimately contributing to students’ increased
motivation for STEM” (p. 9). A notable finding is that many of the com-
mon instructional practices in this emergent framework for Integrated
STEM are already familiar pedagogies in early years, elementary, and
middle years classrooms throughout the world. Hence, a call to action
from some in education circles that high schools need to become more
like elementary schools (McGrath & Fischetti, 2019). Research featured
in the case studies in this book provides empirical data that, to date, is
absent from other studies. Here, I begin the conversation with models
and approaches to STEM education from around the world that focus
on pre–high school contexts.
22 Models and Approaches
Selected Examples of Advances in STEM Education
For this analysis, I draw on two main sources; the first is the comprehen-
sive report edited by Marginson, Tytler, Freeman, and Roberts (2013),
STEM: Country Comparisons, written for the Australian Council of Learned
Academies (ACOLA), and the second source is their more recent com-
parisons in the book The Age of STEM (Freeman, Marginson, & Tytler,
2015). Both texts contain chapters on STEM education in more than
26 countries. My intention here is to build on this work by illustrating
how 10 countries have extended their applications of STEM in pre–high
school environments since STEM: Country Comparisons was published.
I begin with Australia, in particular the state of New South Wales
(NSW), since this is the jurisdiction with which I am most familiar (see
also Murphy, MacDonald, Danaia, and Wang, 2019). I will then continue
with this international analysis of recent STEM initiatives in pre–high
school education by looking at Aotearoa New Zealand, Argentina, Brazil,
Canada, China, Singapore, Thailand, the UK, and the US.

Australia
Since 2012, the Australian Government’s Office of the Chief Scientist
has emphasized the urgency of advancing societal knowledge in STEM
(Department of Education and Training, 2018; Prinsley & Johnston,
2015). Central to such arguments are research data stating that too few
students are taking higher levels of mathematics and science in second-
ary schools (Prinsley & Johnston, 2015); too many STEM teachers are
either unqualified to teach the subjects well (Varadharajan, 2017) or are
in a cohort moving toward retirement (Audit Office of New South Wales,
2019). Moreover, students who study higher-level mathematics and sci-
ence risk achieving lower university entrance scores as these subjects are
treated differently in exit examinations, and studying them may come
at the expense of not scoring well enough to gain university entrance
(Palmer, 2020; STEM Partnerships Forum, 2018).
Prinsley and Johnston (2015) outline steps “to make great teaching of
Science, Technology and Mathematics the norm in Australian schools,
and teaching a profession of choice” (p. 1) by attracting high achievers
in STEM to the teaching profession, boosting the rigor of preservice
teacher education programs in universities, and ensuring that STEM
education is supported by specialist teachers, professional development,
and the education of principals to be leaders in STEM. Fulfilling such
goals, however, requires not only curriculum change but also the deliv-
ery of both funding and time for teachers’ professional development
(Ringland & Fuda, 2018).
While the STEM conversation has mostly revolved around high school
education in Australia, there has been increasing recognition that
 Models and Approaches 23
interest in the STEM disciplines needs to start from the early years of
schooling. An example is Little Scientists (n.d.), a program of inquiry-
based learning experiences that targets children from 3 to 6 years of
age and is funded by the Australian Government. But opportunities to
participate in STEM should not only depend on pre-school and early
childhood learning experiences; there are a multitude of out-of-hours
enrichment activities, for example, local coding clubs, Citizen Science
activities at the Australian Museum, and the highly successful Common-
wealth Scientific and Industrial Research Organisation (CSIRO) STEM
in Schools programs (Moomaw & Davis, 2010).1
In 2015, the Australian Government widely publicized its STEM prior-
ity in the National and Innovation Science Agenda (NISA, 2015) and
committed funding of more than AUD 1.1 billion to it. As part of this,
the Australian Government’s (2020) Support for STEM program allo-
cated AUD 64 million to the following early learning and school STEM
initiatives:

1. School STEM
2. Supporting Artificial Intelligence in Schools
3. STEM Professionals in Schools (including Principals as STEM
Leaders)
4. Early Learning STEM for children aged 3 to 5 years (including Little
Scientists)
5. the National STEM School Education Strategy 2016–2026 (includ-
ing a Resources Toolkit)
6. Coding Across the Curriculum.

A concern for STEM educators in Australia is the under-representation

of girls in STEM, not only in the latter years of schooling, where the
trend continues at the tertiary education level. Hobbs et al. (2017)
found that participation rates of girls in STEM in schools, particularly
in physics and advanced mathematics, have remained unchanged or
declined since the mid-1990s. Factors like providing quality career
advice, changing teaching and learning environments, working with
teachers on their pedagogy, creating partnerships with industries and
local communities, and funding through state and federal jurisdictions
are critical for supporting girls. Particular stakeholder areas play key
roles in girls choosing and staying with STEM, some examples being
girls-only opportunities, family involvement, authentic connections,
and practical STEM programs that target girls with effective and inclu-
sive messaging (Chapman & Vivian, 2017). Further measures like the
Girls in STEM Toolkit (GiST) launched in 2019. Funded by the Austral-
ian Government and developed by Education Services Australia (ESA,
2020), the toolkit aims to encourage girls to study and pursue careers
in science, technology, engineering, and mathematics (STEM) and
24 Models and Approaches
features information, resources, activities, and a career quiz to build
girls’ confidence in STEM. Furthermore, a new and very welcome ini-
tiative is the STEM Equity Monitor, a national data report on girls’
and women’s participation in STEM. It presents the current state of
STEM gender equity in Australia and provides a baseline for measuring
change and trends over time in key sectors and career phases of girls’
and women’s engagement with STEM.2
This consistent message for an equity-driven vision for STEM edu-
cation in Australia requires collaboration across prominent bodies;
strategies that generate a more inclusive culture of STEM; a balanced
representation of all groups (for example, schools, organizations, indus-
tries, underrepresented minorities, and universities) within the STEM
ecosystem; engagement from early childhood through to professional
leadership; curricula that empower students in learning choices, includ-
ing mentoring and capacity building through professional opportunities
(English, 2016); and activism from teacher associations, environmental
groups, unions, and industry partnerships that value and advocate for
local ideas (Hobbs et al., 2017).
In the Australian context, aspirations for STEM education are not
enacted around curriculum integration; in many instances, documenta-
tion at the grassroots level refers to STEM as “Science Teacher Educa-
tion Partnerships, or My Science, or Primary Connections, or Regional
Science Hubs – all are deemed features of successful elementary school
education programs” (Noakes, 2018, pp. 4–5). One promising example
at scale is the cross-disciplinary application of STEM content knowledge
to solve real-world problems that is articulated in the Sydney Catholic
Schools (2019) Statement on STEM, which involves six principles: “i)
an engineering design process, ii) inquiry-based learning, iii) learner
agency, iv) partnerships, v) learner capabilities, and vi) disciplinary and
cross-disciplinary learning” (p. 3). In the early stages, this state-based,
non-government, metropolitan jurisdiction has promoted authentic
inquiry through design and curriculum implementation within syllabus
and extra-curricular outcomes (MacDonald, Danaia, & Murphy, 2020;
Vasquez, 2015).
The case studies described in this book are from public schools in
the state of NSW, a geographical area the size of Germany. The NSW
Department of Education serves more than 800,000 students with 2,300
schools, ranging from inner-city environments to regional and remote
landscapes (NSW Government Centre for Education Statistics and Eval-
uation, 2019). Unlike the other Australian states, NSW does not have a
stand-alone STEM education strategy (Gotsis, 2017). However, it does
have an innovation strategy that has satisfied the National STEM School
Education Strategy 2016–2026 (Education Council, 2015). Since 2017,
efforts have revolved around the delivery of STEM education for giving
 Models and Approaches 25
consideration to learning across the curriculum, having high expecta-
tions for all students, and ensuring:

1. Students have a voice in their learning

• in their choice of project
• in their mode of communication
• in findings/solution materials
• in investigations and strategies to be undertaken;
2. The length of allocated class time sustains deep thinking, investiga-
tion, and an integrated approach;
3. The co-creation of learning experiences and assessment tasks
includes all stakeholders;
4. Students experience a variety of strategies involving the manipula-
tion of a variety of materials and the development of skills in the use
of a variety of tools and equipment;
5. STEM education is a way of thinking and doing that involves peda-
gogy, spaces, and internal and external agencies; and
6. Sharing results and/or products of project-based learning experi-
ences with authentic audiences (New South Wales Government,
2020).

Another undertaking shaping what is deemed Integrated STEM in NSW

public schools is significant investment in the Education for a Changing
World agenda, which outlines strategic implications that advances in
technology will have for education, and its schedule seeks to prepare
students to thrive in a rapidly changing world by empowering schools
and communities to lead innovation (Loble, Creenaune, & Hayes, 2017;
New South Wales Government, 2019).
Provision of STEM education in the state of NSW is supported by
two dedicated STEM advisors; a team of experienced curriculum advi-
sors in science, technology, and mathematics; the program of sharing
STEM kits – these are hands-on loaned resources for schools (AUD
23 million or equivalent USD 17 million program funded by the NSW
government); mentoring programs; online project templates; teacher
surveys to understand what schools are doing in STEM; participation in
the research studies (for example, Principals as STEM Leaders); STEM
school and industry partnerships; and bespoke teacher professional-
learning resources. The NSW government education statutory author-
ity is NESA (NSW Education Standards Authority); it is responsible for
the establishment and monitoring of teaching, learning, assessment, and
school standards. It has developed a number of cross-curriculum sam-
ple units in STEM that revolve around pedagogy, inquiry, collaboration,
and design thinking (NSW Government Education Standards Authority,
26 Models and Approaches
2020). Although schools in the research in this book actively pursued a
STEM focus in programming for Integrated STEM, the arts and humani-
ties were often included to make it STEAM; as MacDonald and Wise
(2018) observe, STEAM research and curriculum development in Aus-
tralia “continues to grapple with different, disparate or conflicting inter-
pretations of how STEM education unfolds from the theory-practice
nexus, and the push for and push back against a STEAM conversation
serves to further complicate and iterate contentions” (p. 2).
Timms et al. (2018) are keen to offer solutions to the “whirlpool of
factors” contributing to the decline in student engagement and per-
formance in STEM and the chronic undersupply of qualified teachers
in the STEM disciplines. They recommend four strategies: “a re-think
of STEM curriculum, adoption of an agreed definition for STEM, a
shift towards a focus on STEM practices, and movement towards an
Integrated STEM curriculum” (p. 25). While such initiatives at the
national level have focused on the need for higher levels of STEM
literacy in secondary students and the Australian population at large,
a dominant concern is for programs that are merely a STEM veneer
and do not genuinely integrate the disciplines (Shaughnessy, 2013).
Elementary teachers are generalist teachers; they have limited science,
technology, and engineering discipline knowledge, and some also
have mathematics anxiety (Buckley, Reid, Goos, Lipp, & Thomson,
2016). This has led to a mandate in preservice teacher education in
primary education in Australian universities of specialist mathemat-
ics and science components in undergraduate programs. School sys-
tems are recruiting and placing specialist teachers into these years.
However, this may not solve the problem if it simply provides release
time for class teachers rather than encouraging them to teach science
or mathematics and may ultimately serve to de-professionalize them
as they have fewer opportunities to teach all subjects. Research for
this book supports this fear as there is insufficient evidence at present
to know whether specialist teachers or generalist teachers with a spe-
cialization positively impact instructional quality and student learning
(Mills, Bourke, & Siostrom, 2020).

Aotearoa New Zealand

In a paper titled STEM Education: Proceed With Caution, New Zealand
researcher John Williams (2011) argued the goals of “STEM literacy is
vague at best but as an education outcome they are problematic” (p. 28).
His reservations were founded on the belief that “[The] STEM move-
ment has developed from a non-educational rationale, and it is the social
and economic rationales that have initiated STEM spurred on by the
2007–2009 global financial crisis” (p. 31). He presents a case for STEM
 Models and Approaches 27
whereby developing interaction between STEM subjects and fostering
cross-curricular links retains respect for the integrity of each subject.
With respect, the case studies in Chapters 3, 4, and 5 are quite possibly
reflective of Williams’s interaction concept of Integrated STEM.
New Zealand has a devolved curriculum centered on key competen-
cies developed across all learning areas. High-level achievement aims are
defined for each learning area, and each school is responsible for defin-
ing specific learning objectives and contexts within which learning will
be set. The national strategic plan announced in 2014, A Nation of Curi-
ous Minds (New Zealand Government, 2014) has a 10-year goal to pro-
mote the importance of science and technology. It targets a participatory
science approach, emphasizing collaboration on locally important ques-
tions or problems; the enhancement of teaching and learning with an
accent on science and technology education; engaging with family and
local communities; connecting research with society through science
and technology researchers and specialists; and an Ambassador program
that provides peer support, mentorship, and a community of practice.
Since 2015, the program has funded more than 200 projects (for over
NZD 10.5 million) (Curious Minds, 2020).
More recently, the New Zealand government encouraged schools
to promote STEM education in the hope it will ease a national STEM
skills shortage (Curious Minds, 2020). It supports teacher education
programs, such as Teach First NZ (n.d.), and professional development
courses, such as the Manaiakalani Digital Fluency Intensive (2019). Posi-
tive youth engagement is certainly evident in a study on the use of a
narrative-based pedagogy as a model for STEM education – an approach
centered on the development of scientific literacy as an effective means
to promote evidence-based actions by adolescents that support long-
term health benefits (Bay, Vickers, Mora, Sloboda, & Morton, 2017).
In both Aotearoa New Zealand and Australia, it is the government
who has initiated a focus on STEM in schools; by contrast, in places like
Argentina, Brazil, and Canada, it is private corporations and industry
that have set the STEM agenda with a range of business incentives, non-
profit sponsorships, voluntary programs, and “altruistic” motivations.

Argentina
The OECD’s (2018) National Science Technology and Innovation Plan for
2016–2020 in Argentina fosters STEM education in schools by drawing
on an advisory commission of people from public and private univer-
sities, scientific and technological organizations, and the public and
private financial sectors. It specifically targets education “equality”,
“reforming the teaching profession”, and the “large performance gap
between boys and girls in STEM subjects”.3
28 Models and Approaches
Congruent with this, sustainable development foundations, such as the
Siemens Stiftung Foundation (SSF, n.d.), support the teaching of STEM
disciplines in schools. In Buenos Aires, the Pan American Development
Foundation (n.d.) is conducting the #STEMamericas initiative, in part-
nership with SSF and the car manufacturer BMW. It aims to support
school-age students’ learning of STEM content through science fairs and
after-school robotics and provides teachers with professional develop-
ment to improve their leadership and capacity to teach STEM subjects.
There is little education research on the effectiveness or otherwise of
steps into STEM education in schools in Argentina. A study supported
by funding from a tech company found that students use laptop devices
when they are available as often as a combination of textbooks, work-
books, study guides, and notebooks or copybooks (Price, 2015). I argue
there are several recurring themes here, where effective school leader-
ship and the identification of ongoing, well-supported, and carefully
evaluated professional development of teachers at all levels of technology-
enhanced learning is urgently needed (Harvey-Smith, 2020).

Brazil
In Latin America, the Educando organization delivers education and
support to principals and teachers in public schools; its vision is for
“every child in Latin America to benefit from exceptional educators who
inspire them to learn the skills necessary for dignified work and life. We
believe quality education has the power to transform lives, build vibrant
communities, and strengthen societies” (Educando, 2019). One of Edu-
cando’s many projects is STEM Brasil. Launched in 2009, this is an inten-
sive training program for public school teachers that operates in 17 of
Brazil’s 27 states. It has trained 6,200 teachers from 724 schools, impact-
ing more than 570,000 students. A similar program, STEM Mexico, was
launched in 2017; both initiatives have long-term investment in human
capital, and in evaluations to date, 88% of the Brazil schools reported
an increase in teacher motivation after the implementation of hands-on
activities (Educando, 2019).4
The Malala Fund for the education of girls also operates in Brazil. It
provided a scholarship for Lorenna, a middle school student who went
from inventing with LEGO sets to working on robotics and inspiring
other girls to do the same. Lorenna has since pursued a degree in Elec-
trical Engineering (Tretler, 2017). Once again, research and ongoing
evaluation in emerging STEM education in schools is needed to track
these kinds of positive developments.

Canada
Canada has sought to generate more interest in STEM education because
of its perceived weak business innovation performance and lack of global
Another random document with
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of lesion causing this symptom, some of which have been
reproduced in our table. We will not go into any details as to the
character of this symptom, referring the reader to the sources
indicated. In the first case given in our table (Case 10) the
hemianopsia was produced by a tumor in front of, and impinging
upon, the optic chiasm; in the other four cases (Cases 40, 41, 42,
and 43) the tumor was situated in the occipital lobe, and was
surrounded by an area of destroyed tissue. Hemianopsia is not,
strictly speaking, a symptom of brain tumor, but is likely to be present
in cases occurring in certain regions of the brain. Starr's conclusions
with reference to lateral homonymous hemianopsia when it is not
produced by a lesion of one optic tract are that it may result from a
lesion situated either (1) in the pulvinar of one optic thalamus; (2) in
the posterior part of one interior capsule or its radiation backward
toward the occipital lobe; (3) in the medullary portion of the occipital
lobe; or (4) in the cortex of one occipital lobe. The conclusions of
Seguin are only different in so far as they more closely limit the
position of the lesion.
25 Vol. IV.

26 Pp. 84, 85 of present Volume.

27 Amer. Journ. Med. Sci., N. S., vol. lxxxvii., January, 1884, p. 65.

Phosphenes, or subjective sensations of light, occur in various forms

—simply flashes or sheets of light, scintillations, balls of fire, etc.
They are not very common as isolated phenomena, and probably
are dependent in most cases upon irritation of the nerve and retina in
some of the stages of neuro-retinitis. Even visual hallucinations are
occasionally present, as in one of Bennett's cases of tumor of the
Rolandic region.

Conjugate deviation of the eyes, with rotation of the head, a

symptom of the early stages of apoplectic attacks, is also sometimes
observed in brain tumor. The patient is found with both eyes turned
to one side and slightly upward, as if looking over one or the other
shoulder, the head and neck being usually rotated in the same
direction. Sometimes the deviation is slight, sometimes it is marked.
Frequently the muscles of the neck on one side are rigid. The eyes
are commonly motionless, but occasionally exhibit oscillations. This
sign, well known to neurologists, usually disappears in cases of
apoplexy in a few hours or days, although it occasionally persists for
a long time. It will be more fully considered under Local Diagnosis.

Diminution or loss of hearing, tinnitus, and hyperæsthesia of hearing

are all occasionally observed. The most decided disturbances of this
sense are those which are found in connection with tumors of the
base or of the cerebellum in such a position as to involve the
auditory nerve or auditory tracts. Tinnitus, acoustic hyperæsthesia,
with complete or partial deafness, accompanying facial paralysis,
with or without paresis of the limbs of the opposite side, indicate
clearly a tumor of the base so situated as to involve the superficial
origin or intracranial course of the auditory and facial nerves.

The sense of smell is affected, of course, when the olfactory bulbs

are involved in the growth, either directly or by pressure, as in certain
tumors of the antero-frontal region (Cases 4 and 8). Disturbances in
the power of consciously perceiving odors, or abnormal perceptions
of odors or hallucinations of smell, are sometimes present in cerebral
tumors involving certain convolutions. The lower postero-parietal
region or the temporo-sphenoidal region of the base would seem,
from the few reported cases, to be implicated when this sense is
centrally affected. Smell was lost or impaired in two cases of tumors
of the postero-parietal region, in one limited to the supramarginal
convolutions. In a case reported by Allan McLane Hamilton (Case
47), an induration of the lower part of the right temporo-sphenoidal
lobe involving the uncinate gyrus, the patient, preceding light
epileptic attacks, always had an olfactory aura of a peculiar
character—a disagreeable odor, sometimes of smoke and
sometimes of a fetid character. In this case the olfactory nerves were
examined and found to be healthy.

Taste may be involved in several ways. In the first place, subjective

sensations of taste, particularly the so-called metallic taste, may be
present when the growths involve the cranial nerves in such a way
as to cause irritation to be conveyed to the nucleus of the
hypoglossal. When it is remembered that a mild galvanic current
applied to the nape of the neck or face will often cause this metallic
taste, it can be seen that the irritation of a tumor situated at almost
any point of the base might lead to abnormal taste-phenomena.
Neoplasms involving the trunk of the portio dura may of course
cause diminution or loss of taste on the anterior extremity of the
tongue by the involvement of the chorda tympani nerve. In the very
few cases in which the hypoglossal trunk may be involved
disturbances of taste posteriorly may occur. In two cases (Cases 33
and 36) some possible indications as to the cortical areas of taste
are given. One was a tumor so situated as to cause pressure on the
orbital, and possibly anterior, portion of the temporo-sphenoidal lobe;
the other was a lesion closely localized to the supramarginal lobule.

Trophic disturbances of decided character are sometimes present in

cases of brain tumor. Their presence, character, and extent depend
upon the position of the tumor and the cranial nerves involved.
Trophic disorders of the eye have been noted in cases of tumor of
the antero-frontal region, and also of various positions at the base,
especially those so situated as to involve the trigeminal nerve. In a
fibroma of the superior antero-frontal region (Case 1) conjunctivitis
and corneitis of the left eye, with anæsthesia of the conjunctiva, were
present, and were very marked symptoms. This patient, who was
under the care of one of us at the Philadelphia Hospital, was
examined by O. E. Shakespeare, ophthalmologist to the hospital. At
his first examination the bulbar conjunctivæ were slightly injected
and the cornea clear. The sensibility of the cornea was possibly a
little lowered. Ten days later, at a second examination, the central
corneal epithelium of the left eye was found to be hazy and the
whole bulbar conjuntivæ much congested. “This condition soon
developed into a severe superficial corneitis, which was mainly
limited to a central area of an extent about equal to three-fourths of
the diameter of the cornea, which threatened to slough, a narrow
peripheral ring of the cornea being comparative unaffected. At the
same time the engorgement of the bulbar conjunctiva increased. The
sclera, the iris, and the deeper parts were apparently not involved in
the inflammatory process.”

Disturbances of respiration were observed in a number of cases in

various stages. Cheyne-Stokes breathing was usually a late
symptom. In a case of tubercular meningitis with a tubercular
granulation springing from the left side of the fourth ventricle (Case
82) it was present. Extraordinary slowing of respiration occurred in a
tumor of the right middle cerebellar peduncle and cerebellar
hemisphere which caused irritation and softening of the floor of the
fourth ventricle. The respirations ran as low as four and five per
minute two weeks before death.

Persistent epistaxis and a tendency to hemorrhage from the mucous

membranes were interesting vaso-motor phenomena in a case
situated in the upper left quarter of the pons (Case 84). Profuse
perspiration, more marked on one side, was observed in a case of
tumor in front of the optic chiasm. Polyphagia was observed in two
cases, one a growth of the cerebellum and the other on the floor of
the skull. Polyuria was a very marked symptom in Case 95, a tumor
at the base of the brain at a spot corresponding to the sella turcica,
and diabetes was present in a case of frontal tumor. Albuminuria was
recorded twice—once in the same case in which diabetes was
present, and again in a case of multiple tumor of the supramarginal
convolution of one side and the angular gyrus of the other.
Somnolence was occasionally observed.

Constipation or torpor of the bowels occurs somewhat frequently in

the early stages of the brain tumor, giving place in the terminal
periods to involuntary evacuations. The conditions of the bladder are
practically the same. It is either not involved or suffers from torpor or
paresis of the muscular walls early in the disorder, and later, and
especially very late, incontinence from paralysis of the sphincter
results.

DURATION, COURSE, AND TERMINATION.—The duration of cases of

intracranial tumor is very uncertain. In many of the reported cases no
definite information is given as to the exact length of time from the
initial symptoms until the fatal termination. The few cases in which
the time was recorded showed a duration of from three months to as
many years.

In a few cases, even in some which are not syphilitic in character, a

remission of all the symptoms and what appears to be an
approximate cure sometimes take place, the general symptoms,
such as headache, vertigo, vomiting, spasms, etc., disappearing for
a time. Even the condition of the eyes and the paralysis in rare
instances make marked improvement. In these cases, in all
probability, the progress of the growth of the tumor is arrested either
by the remedies employed or spontaneously, and the acute or
subacute phenomena of congestion, œdema, etc. around the tumor
subside. These patients may remain for a long period or until cut off
by some other disease without any change for the worse; but the
sword constantly hangs above their heads, and any excitement,
traumatism, the abuse of alcohol or other narcotics, an attack of
fever, or some other special exciting cause, may again light up the
intracranial disorder, to then progress more or less rapidly to a fatal
termination.

This fatal termination may occur in various ways. Sometimes a

sudden apoplectic attack occurs. This may be an intercurrent
hemorrhagic apoplexy, although our personal experience would not
lead us to believe this mode of termination is common. In a few
cases the enormous irritation of the cerebral growth suddenly or
gradually inhibits the heart's action through the impression made on
the pneumogastric. Apoplectic attacks which may or may not
terminate fatally sometimes are the result of a sudden giving way of
necrosed brain-tissue, the necrosis having resulted from the
obliteration of numerous blood-vessels by the advancing growth.
Blood-poisoning occasionally takes place from abscesses in
proximity to the tumor. In some cases the patients slowly but surely
emaciate, or are exhausted and worn out by the agonizing pain and
incessant vomiting which they are called upon to endure.
Occasionally a more or less diffused and violent meningitis hastens
the fatal issue.
COMPLICATIONS AND SEQUELÆ.—Tumors of the brain may be
complicated with other affections due to the same cause. Thus, for
example, in a case of gumma other evidences of syphilis may be
present in the form of nodes, eruptions, etc. A sarcoma or carcinoma
of the brain may be associated with similar disease in other organs.
Such affections as cystitis, pyelitis, keratitis, etc., which have been
discussed under Symptomatology, are secondary complications of
cases of tumor. As intracranial tumors almost invariably terminate
fatally, strictly speaking we have no sequelæ.

PATHOLOGY.—We present in tabular form the various classes of

tumors found in the one hundred cases of brain tumor in the table
appended to this article:

Carcinoma 7 Glio-sarcoma 1
Cholesteotoma 1 Gumma 13
Cyst 2 Lipoma 1
Echinococcus 2 Myxo-sarcoma 1
Enchondroma 1 Myxo-glioma 2
Endothelioma 1 Osteoma 2
Fibro-glioma 2 Sarcoma 15
Fibroma 4 Tubercle 13
Glioma 16 Unclassified 16

The histology of tumors of the brain does not in the main differ from
that of the same growths as found in other parts of the body, so that
a detailed description of their structures, even though founded upon
original research, could not offer many novel facts in a field which
has been so thoroughly cultivated. Such a description would
probably repeat facts which have already been presented in other
parts of this work, and which are better and more appropriately put
forth in special treatises devoted to the science of pathology. It is
proper, however, for the sake of convenience and thoroughness, to
make brief mention of the structure of brain tumors, and especially to
dwell upon certain features of these morbid growths which may be
considered characteristic of their encephalic location, and hence
have not only pathological but also clinical interest. It is hardly worth
while to refer to speculations which aim to elucidate the very
foundations of the science, except that in a few of these theories we
gain an additional insight into both the structure and conduct of some
very characteristic brain tumors.

Cohnheim's theory was that tumors are formed from foci of

embryonal tissue which had been non-utilized or left over in the intra-
uterine development of the body. Many have not accepted this idea,
but have rather considered that in tumors we witness a reversion of
tissue to lower or embryonic types.28 Whether we accept either or
neither of these propositions, the idea sought to be conveyed is that
in all these morbid structures we have a tissue of low or degraded
character, springing in most instances from a connective or non-
differentiated tissue. This fact is brought out very clearly in many of
these intracranial growths. Virchow29 has said that tumors originate
in the cells of the connective tissue, although his law has been
condemned as not of sufficient breadth, since it seems to ignore the
epithelial and myomatous tumors. Dermoid cysts, of which an
example is given in the table of spinal tumors,30 are said to illustrate
the embryonic function revived—i.e. the tendency of lower tissues to
spontaneously differentiate into higher and more complex ones.
28 Article “Pathology” in Brit. Encyc., by C. Creighton.

29 Quoted by Cornil and Ranvier.

30 Page 1107.

The gliomata are among the most common and characteristic tumors
of the cerebro-spinal axis, to which system and its prolongation into
the retina they are confined. They invariably spring from the
neuroglia or connective tissue of the nerve-centres, and reproduce
this tissue in an embryonal state. They greatly resemble the brain-
substance to naked-eye inspection, but have, histologically, several
varieties of structure. These variations depend upon the relations of
the cell-elements to the fibres or felted matrix of the neoplasm. In the
hard variety the well-packed fibrous tissue preponderates over the
cell-elements, and we have a tumor resembling not a little the
fibromata (Obernier). The second variety, or soft gliomata, show a
marked increase of cells of varied shapes and sizes, with a rich
vascular supply which allies these growths to the sarcomata. The
elements of gliomata sometimes assume a mucoid character, which
allies them, again, to the myxomata.
 FIG. 43.

Flat Glioma-cell with its Fibrillar Connections (Osler).

FIG. 44.
 (1) Homogeneous translucent fibre-cell; (2) cells like unipolar ganglion-
cells; (3) giant cell (Osler).

W. Osler has recently described31 to the Philadelphia Neurological

Society the structure of certain of these tumors, from which we
abstract the following facts: One point referred to is that gliomata
sometimes contain larger cells and coarser fibres than are usually
shown. The structures are (1) The “spinnen” or spider-cells
(characteristic of glioma), which present variations in size; (2) large
spindle-shaped cells with single large nuclei (some of the largest
cells met with in tumors); (3) cells like the ganglion-cells of nerve-
centres, with large nuclei and one or more processes: some are
balloon-shaped with single processes; they are larger than the
spider-cells; (4) translucent band-like fibres, tapering at each end,
without nucleus or granular protoplasm, regarded as a vitreous or
hyaline transformation of the large spindle-cells. Klebs (quoted by
Osler) holds that the ganglion-like cells are derived from the nerve-
cells of the gray matter, “and that in the development of this variety
all elements of the nerve-tissue participate.” Osler examined the
advancing region of the tumor, and was not able to satisfy himself
that the nerve-cells were in process of proliferation. He thinks they
are connective-tissue elements. He has seen but two out of five
cerebral gliomata which were of small-celled type.
31 “Structure of Certain Gliomas,” Philada. Med. News, Feb. 20, 1886.

The gliomata are subject to fatty degeneration, which usually occurs

in the central (older) portions of the mass. The more vascular forms
are also peculiarly liable to hemorrhage, which is probably caused in
some instances by this process of retrograde metamorphosis. These
hemorrhages resemble apoplexies, not only in their clinical features,
but also on gross examination. Great care is therefore often
necessary at the autopsy to distinguish such a hemorrhage,
occurring as it does in a brain-like neoplasm, from one caused by the
rupture of a diseased artery. The hypertrophy of the pineal gland,
sometimes noted, is caused by the formation of gliomatous tissue.
Under the microscope it is necessary carefully to distinguish some
forms of inflammatory new formations from the gliomata. We have
recently seen, by the courtesy of E. N. Brush of the Pennsylvania
Hospital for the Insane, photographs of microscopic sections from
the ependyma of the lateral ventricles in a case of general paresis,
which showed the structure of this degenerated tissue to be a
compound of fibres and cells of marked resemblance to gliomatous
tissue.32
32 These micro-photographs were prepared in the laboratory of the State Lunatic
Asylum, Utica, New York, by Theodore Deecke.
Sarcomata of the brain are common, as our table shows. In them the
cell-elements predominate, both in the large- and small-celled
variety. They are malignant and grow rapidly. The form known as
alveolar sarcoma, which has a distinct stroma, is to be distinguished
from the cancers; which has probably not always been done.

Tubercle, according to Ross, is the most common of all forms of

brain tumor. Our table shows 13 cases out of 100, the gliomata and
sarcomata being in larger number. Its favorite seat is in the cortex of
both the cerebrum and cerebellum: some observations appear to
show that it is more common in the cerebellum and mid-brain region
than in the fore-brain, and in children than in adults; some of which
points distinguish it from the gummata, which are more common in
adults and occur anywhere. Tubercle is another form of development
from the connective tissues, usually dependent upon a constitutional
taint or predisposition: in it the cell-elements have generally
undergone a degeneration into an amorphous cheesy mass. It is apt
to be multiple and accompanied by a similar deposit in other organs
of the body.

True neuromata are probably very rare growths, and it is likely that
some tumors which have been described as such are really
connective-tissue tumors of a gliomatous nature, in which some of
the cell-elements have been mistaken for the ganglion-cells.
Obernier33 says that these tumors are small and grow from the gray
matter on the surface, also on the ventricular surfaces. They are also
found in the white matter. He says they are only found in persons
having some congenital or acquired aberration; by which is probably
meant some other well-marked neurosis or psychosis. The one
hundred tabulated cases afforded no examples of neuromata.
33 Op. cit.

Myxomata are not, histologically, to be distinguished from the

gliomatous tissues by anything but the peculiar mucoid changes
which their structures have undergone. They are more rare in the
brain, as our tables show, than in the spinal cord.
Lipomata are very rare in the brain, according to most observers.
The table shows but one example. These tumors, as their name
signifies, are made of fat-bearing tissues—another of the connective-
tissue class.

The angiomata, somewhat rarely found within the skull, are noted for
their abnormal development of the vascular tissues: they are
composed mainly of blood-vessels and the connective tissue, which
supports them in closely-packed masses. They also present
cavernous enlargements. They are of especial interest in cerebral
pathology, because the lesion known as pachymeningitis
hæmorrhagica, often found in dementia paralytica, is considered by
some to be angiomatous; although by far the most generally
accepted view of this latter condition is that it is due to arterial
degeneration, and in part is an inflammatory exudate.

Syphilitic tumors, or gummata, are, like tubercle, a special

development with degeneration from the connective tissue, due to a
constitutional taint. This new growth is sometimes single, sometimes
multiple. The corpuscles of the neuroglia are the apparent points of
origin of the tumor, the substance of which is the firm, peculiarly
gummy, and non-juicy material from which the name is derived. It
would be impossible in our allowed space to trace this neoplasm
through the successive stages of its development. It has especial
clinical interest, inasmuch as it and its damage are probably
amenable to specific treatment when it has not progressed to too
great a destruction of brain-tissue.

The true cancers, or epithelial neoplasms, are not a common form of

tumor of either the brain or spinal cord. They present, as in other
parts of the body, a stroma forming alveolar spaces in which are
contained the nests of epithelial cells. These tumors thus present
characteristic differences in their histology from the connective-tissue
or mesoblastic groups, but clinically no very special interest attaches
to them. Their location, the rapidity of their growth, and their fatal
import are points which they share with most other new growths of
the cranial cavity.
The cholesteotomata, or pearl cancers, consist of hardened
epithelial cells which have undergone a sort of fatty degeneration.

The psammomata are loosely described as tumors containing sand-

like bodies, which bodies are normal about the pineal gland. These
sand-like bodies are found in tumors of some histological diversity,
and do not appear to have much identity of their own. They occur in
sarcomata and carcinomata, and are probably not to be
distinguished from mere calcareous infiltration and degeneration.
They are most common in sarcomata, as this is one of the most
common of cerebral tumors.

True osteomata—i.e. tumors with the structure of true bone—are

probably rare in the brain, although more common on the inner table
of the cranium; but the deposition of calcareous salts has been
recorded in a variety of conditions. F. X. Dercum, in a recent paper
read before the Philadelphia Pathological Society,34 has recorded the
autopsy of a paretic dement in which case calcareous deposits were
scattered throughout both hemispheres and the cerebellum. He
believes that “the areas in which the concretions were found were
probably foci of encephalitis of greater intensity than elsewhere. In
these foci inflammatory changes in the walls of the vessels became
pronounced; besides which the vessels increased enormously in
size and number; so marked is this increase that these foci could,
with perfect propriety, be called angiomata.” This is followed by
proliferation of the neuroglia, compression and destruction of nerve-
tissue, and deposit of the calcareous salts especially about and upon
the coats of the vessels. This case illustrates in the simplest manner
the formation of both vascular and sand tumors.
34 The Medical News, April 24, 1886, p. 460.

Pacchionian bodies are very common in the brain, and are really
small fibromata. They may form true tumors (Cornil and Ranvier)
capable of wearing away the bones of the cranium. In fact, even
when small they may have corresponding indentations in the skull.
They are not to be mistaken for tubercle. Clouston35 has described
excrescences from the white matter of the brain, growing through the
convolutions, projecting through the dura mater, and indenting the
inner table of the skull; which new growths he calls hernia of the
brain through the dura. We have not seen such a condition
described elsewhere, and think that we have here probably
Pacchionian bodies growing from the pia mater. They were found in
a case of tumor of the cerebellum.
35 Journ. Ment. Sci., xviii. p. 153.

A cystic formation, constituting a veritable tumor, not unfrequently

occurs in the pituitary body and mounts into the third and lateral
ventricles. Echinococci and hydatids also occur, and have the same
natural history as these parasitic offspring have when found in other
parts of the human body.

Obernier refers to an enchondrosis of the basilar process. Our table

presents one case of enchondroma.

Some of the gross appearances found on autopsies of tumors of the

brain are worthy of note. Often an area of congestion or
inflammation, especially of the membranes, is seen about the new
growth, and the brain-substance in its immediate vicinity is much
more frequently softened. The cerebro-spinal fluid is increased, and,
especially when direct pressure has been exerted upon the veins of
Galen, are found distended lateral ventricles. When a tumor does not
approach the surface, but has attained some size, the hemisphere in
which it is located often has a bulging appearance, crowding over
upon its neighbor, and the convolutions are flattened by the
pressure. The cranial nerve-trunks are occasionally involved in or
stretched by the tumor, and also occasionally the bones of the vault
or base of the cranium are extensively eroded. This happens
especially in cancer and osteo-sarcoma.

A few remarks should be made about the methods of making post-

mortem examinations and the gross appearances and conditions
likely to be found in brain-tumor cases. As not a few intracranial
tumors are connected with the bone or with the dura mater, the latter
being adherent to the skull-cap in some positions because of
inflammation arising from the seat of the growth, especial care
should be taken in removing the calvarium. Examination of the
external surface of the dura mater will sometimes reveal the
presence of a growth beneath or incorporated with this membrane.
The dura mater should not be roughly dragged from the surface of
the brain, but should be carefully removed by a process of partial
dissection. During this process a meningeal growth will sometimes
be found growing apparently from the fused membrane. In such
cases it is usually better to so proceed as not to entirely separate the
outer membrane from the growth. Indeed, this cannot be done
sometimes without injury directly to the specimen, and especially to
its cerebral surroundings. The dura mater having been removed, a
marked opacity, sometimes a dirty-brown hue shading off into a
lighter color, will indicate to the eye the probable presence of a tumor
beneath and growing from the pia mater of the cortex. In such a
case, and even when no such appearance is present, but a tumor is
suspected, the fingers passed carefully over the cerebral surface will
feel a hard, and it may be nodulated, mass at some position. A
growth, having been located in this way, should not be roughly
handled or at once examined by section. An effort should be made to
accurately localize it, not only with reference to lobes, but also with
reference to convolutions and fissures, and even special portions of
these. This is best done, after a thorough examination has been
made of the pia mater, by carefully stripping the pia mater from the
brain, beginning at points some distance from the growth and
gradually approaching it, and leaving the pia mater for a short
distance around the growth connected with it. The location having
been fixed and other portions of the brain having been examined, if it
is not possible or desirable to retain the entire brain as a specimen, a
block should be removed embracing a considerable portion of
healthy brain-tissue on all sides of the tumor. In order to study the
gross internal appearance of the tumor, it is a good plan to make a
clean section through the middle of the tumor. From each side of this
cut fragments can be taken for microscopical examination without
deranging appreciably the size and appearance of the tumor.
When the tumor is not meningeal or cortical, or not situated at the
base or floor of the skull, its presence may be revealed, when it is in
centrum ovale and of considerable size, by either hardness or
fluctuation of the hemisphere in which it is located, this fluctuation
not being due to the tumor itself so much as to the breakdown of
tissue around it. Large sections in known positions with reference to
convolutions and ganglia should be made when examined for tumors
deeply situated. If possible, sections close to and just before and
behind the growth should be made, so as to assist in the accurate
localization.

Small tumors are not infrequently overlooked by careless observers,

and even growths of considerable size have escaped discovery by
one examiner to be found by another. Tumors in certain special
localities, as between the temporo-occipital lobe and the superior
surface of the cerebellum in the great longitudinal fissure, or small
growths in the substance of the cerebellum or deep in the Sylvian
fissure, are more likely than others to be passed by, although this, of
course, is not likely to occur when the examination is made by a
competent or careful physician.

DIAGNOSIS.—The diagnosis of the existence of an intracranial tumor,

as a rule, is not difficult. It can be made with greater certainty than
that of almost any other serious encephalic disease.

It is sometimes important to decide as to the nature of an intracranial

neoplasm, particularly whether or not it is syphilitic. Little is to be
gained by following the plan adopted by some physicians, of treating
all cases as if they were due to syphilis, on the principle that these
are the only forms of tumor which can be reached by treatment. The
pitiable condition of such patients is sometimes thus made worse. In
every case careful and persistent efforts should be made to obtain
an authentic previous history from the patient. Whenever possible
the physician should search directly for the physical evidences of the
former existence of syphilis—for cicatrices on the genitals and
elsewhere, for nodes and depressions, for post-cervical and other
swellings, etc. A history of previous disease of the throat and of
pains in bones and nerves, of epileptiform attacks, of headache, and
eye symptoms which have disappeared under treatment, should be
sought out. It is not well to give too much credence to the stories of
patients, who are not always willing to admit their past lapses from
virtue; but, on the other hand, the plan of suspecting everybody who
presents advanced cerebral symptoms is often a grievous wrong.
Not infrequently external cranial nodes are present in cases of
intracranial syphilis.

Carcinomata and sarcomata, particularly the former, are

comparatively rapid in their progress. They sometimes involve the
bones of the skull, even to the extent of perforation.

The existence of an inherited tendency and of tuberculosis in other

organs, with the special phenomena of general tuberculosis, assists
in the diagnosis of tubercular tumors.

The frequent occurrence of gliomata in early life, and the

comparatively frequent absence of severe irritative symptoms, with
the well-preserved general nutrition of the patient, speak for these
growths.

Cerebral abscess is, on the whole, more difficult to diagnosticate

from intracranial tumor than any other affection. Abscess, however,
more frequently than tumor, can be traced directly to a traumatism. It
is often associated with disease of the internal ear. Obernier speaks
of the headache of cerebral abscess as slight, but this does not
correspond with usual experience. Headache, on the whole, may be
oftener absent or less agonizing in abscess than in tumor, but it is
frequently present, and sometimes of great severity. Its greater
mildness in a few cases is to be explained by the fact that abscess
does not produce so much pressure within the intracranial cavity,
and does not so frequently cause irritation of the branches of the
trigeminus in the dura. Undoubtedly, the symptoms of abscess often
remain for a long time comparatively latent, with then a sudden
outburst of violent symptoms. The course of brain tumor is more
uniformly and steadily progressive, and febrile phenomena, the
results of pyæmia, are of more frequent occurrence in abscess than
in tumor.

In old cases of tumor it is sometimes necessary to differentiate

between it and the results of various forms of apoplexy, such as
hemorrhage, thrombosis, and embolism. Cerebral hemorrhage,
embolism, or thrombosis leaves a condition of paralysis, sometimes
with, but usually without, accompanying spasm or convulsion, which
simulates closely the paralysis and other permanent conditions of
cases of tumor occurring in the same cerebral locality. In these
cases, in the first place, the history of the disease will throw
considerable light upon the diagnosis. In both hemorrhage and
embolism the history is usually one of a sudden attack without
special premonitory symptoms. Hemorrhage gives usually a
precedent history of diseased kidneys, hypertrophied heart, or
atheromatous blood-vessels, and occurs generally in advanced life;
embolism, a history of rheumatism and valvular disease of the heart,
occurring at any period of life, early or late. In brain tumor the
previous history is usually one of traumatism, of constitutional
infection, or of a special predisposing diathesis. Blows and falls upon
the head are common antecedents, or a history of syphilis,
tuberculosis, scrofula, or cancer is present. Tumor, like embolism
and unlike hemorrhage, may occur at any time of life. While slight or
dull headache, with more or less vertigo, may be present in cases of
hemorrhage and thrombosis, the severe and often agonizing
headache, with vomiting and serious vertiginous attacks, which
precedes the paralytic or other phenomena of tumor, is a much more
conclusive symptom in the latter cases than in the former. Choked
discs and optic neuritis are much more likely to occur in tumor than
in the other affections.

Brain tumor must sometimes be diagnosticated from the head

symptoms of some form of Bright's disease. A case not long since
presented itself to one of us with a history of having suffered at
frequent intervals for two years with headache of gradually
increasing severity. Dimness of vision and slight temporary œdema
of the feet, circumscribed and painful swellings along the lymphatics
of the thighs and legs, with some mental irritability, were other
marked symptoms. The patient had been attended by several
physicians of prominence, one of whom had diagnosticated tumor of
the brain. The violent, apparently agonizing headache, with the
diminution of vision, and the absence of marked symptoms indicating
other organic disease, made the diagnosis of a growth in some non-
excitable region of the cerebrum most probable. Examination of the
urine showed no albumen. Careful examination of the eye-ground
with the ophthalmoscope, however, revealed the appearances of
retinitis albuminurica. Under a treatment directed to the relief of
chronic nephritis the patient's headache and other symptoms
improved.

It must not be forgotten just here, however, that, on the one hand,
ophthalmoscopic appearances very similar to those of albuminuric
retinitis are sometimes present in rare cases of brain tumor, and also
in other constitutional disorders, such as leukæmia; and, on the
other hand, that, as stated by Norris,36 exceptional forms of
albuminuric retinitis have been reported where the only change seen
in the fundus oculi was pronounced choking of the disc.
36 Op. cit.

Intracranial tumors must be diagnosticated from meningitis in its

various forms. In children tubercular meningitis sometimes closely
simulates brain tumor. Tumors of the brain are comparatively rare in
children, but, as has already been shown, gliomata and other tumors
do sometimes occur in early life. The course of tubercular meningitis,
whether in children or in adults, differs from that of brain tumor. It is
more irregular in its method of advance, or if it shows the regularity
which is sometimes present, and which has led authors to subdivide
it into three more or less completely separable stages, the symptoms
of these stages do not correspond with any closeness to those of the
initial, middle, and terminal periods of brain tumor, as already given.
Headache is usually present in both affections, although the absence
of headache in some cases of gliomata in children must be here
borne in mind. When headache is present in tubercular meningitis, it