The Treatment and Cure of A Case of Mental and Moral Deficiency
The Psychological Clinic Vol. II. No. 6. November 15, 1908 :Author: Lightner Witmer, Ph.D. University of Pennsylvania.
Some children stand at a point where the path of individual development forks. One road leads on through a life of imbecility or markedly subnormal efficiency. The- other road will bring the child at maturity to a life of normal activity. That such widely divergent possibilities are open to one and the same child, will appear incredible to those who have not had the opportunity to watch the course of development of these children.
What is feeblemindedness ? Is it a mental condition, or is it an incurable brain defect ? The brain itself cannot be directly examined, and its condition determined. In severe cases of idiocy the existence of a serious and incurable defect of the brain is readily enough inferred from the mental condition of the child and from associated physical signs or stigmata, such as a malformation of the skull, peculiarities of the physiognomy, the condition of the bony structure, skin, and blood vessels, and from other somatic and physiological abnormalities. In many cases the diagnosis of a brain defect has been substantiated by post-mortem examination, but in those other cases, which stand on the borderland between feeblemindedness and normality, post-mortem examination has often failed to reveal any apparent defect of the brain. If such defect exists, it must reside in the minute structure of the brain cells,?a defect, the nature of which, for the present, science is unable to ascertain. In these cases, therefore, which are the very ones that have the greatest interest for the psychologist, the existence of the brain defect is merely an inference from the mental condition and the associated stigmata of degeneration. If we make the inference that this brain defect is incurable, we have done more than diagnose or posit the existence of feeblemindedness. We have in addition expressed a prognosis or prophecy of the ultimate outcome of the development process. Is every brain defect necessarily incurable ? This is not the case with defects of other organs. Certainly deficiencies of eyesight may be cured or at least ameliorated. Even if a defect persists, its consequences may be overcome by the application of proper remedies. Thus the wearing of glasses is a simple device for avoiding the consequences of an optical defect, which may in itself be incurable. But in some cases, if taken in time, the wearing of glasses will actually assist in the removal of a defect. Why may not brain defects be ameliorated and cured to the same extent ?
If at the outset we define feeblemindedness as an incurable brain defect, then naturally we are compelled to say that if those cases are cured in which feeblemindedness has been diagnosed as existing, a mistaken diagnosis has been made. It is my contention that feeblemindedness is a term that should be restricted solely and simply to the mental condition. If the mental status presens of a child is one of imbecility, the child is at that moment to all intents and purposes an imbecile. If appropriate treatment can restore him to normal condition, he ceases ipso facto to be an imbecile, thus proving that the imbecility did not rest upon an incurable brain defect. If asylum training is competent to develop a low grade imbecile into a middle grade imbecile, why may not the appropriate training be found to elevate a feebleminded child, say an imbecile of high grade, into a child of normal intelligence % If the application of every method known to modern psychology fails to elevate a feebleminded child above the grade of the imbecile, then and only then are we justified in diagnosing the existence of an incurable brain defect.* From Seguin’s time, feeblemindedness has been viewed as a retardation or arrest of mental and physical development. If the feeblemindedness is a form of retardation, the question naturally arises in our mind, as it did in that of Seguin, whether the arrested processes cannot be stimulated into activity and the retardation be overcome, or in other words whether feeblemindedness may not be cured. Seguin himself distinguished between idiotism as the mental condition, and idiocy as the brain defect upon which the *For the purposes of this discussion, children are distinguished as either normal or feebleminded. The feebleminded are either (1) imbeciles or (2) idiots. Imbeciles are of three grades:?high, middle and low. The high grade imbecile therefore represents the class of feebleminded children which stands next below the normal child in intelligence.
mental condition rests. May not two children present a similar picture of mental inferiority or feeblemindedness, though the feeblemindedness may in the one case rest upon an incurable brain defect, and in the other case be merely the symptom of a temporarily arrested development? If we affirm that of these two children the one is feebleminded but the other only apparently feebleminded, this may be a justifiable use of the term feebleminded. It restricts the term, as many would have it, to an incurable brain defect. But in what way are we able to determine whether an apparently feebleminded child is really feebleminded or not, or in other words whether the brain defect is incurable ? A mental and physical examination extending over an hour, or a day, or even a month, may not be sufficient to make a satisfactory diagnosis, which in its terms involves a prognosis as well. It is my belief that the distinction between real and apparent feeblemindedness, or as I prefer to put it, between a feeblemindedness which rests upon an incurable brain defect, and a feeblemindedness which is the expression of arrested cerebral development, can only be ascertained after a protracted examination, and more important still, after a persistent effort has been made to stimulate the arrested mental processes. There are children whom even the layman is able at a glance to diagnose as feebleminded, but there are other children with whom even the expert cannot distinguish between these two forms of feeblemindedness without some protracted examination and effort at education. It is my experience that careful individual training is able to restore to normality a small percentage of children who are considered feebleminded by physicians, whose diagnosis is, in my opinion, correct so long as it is understood to be merely a’statement of the status presens and not a prophecy of the future condition of the child. I do not believe that there is any reason for impugning the diagnoses which have been made in a number of cases that have come under my personal observation. It is only my desire in this and other articles to call attention to certain cases which offer a typical picture of feeblemindedness,?though of high grade, ?and which are nevertheless distinctly curable. It must be remembered that even the physical signs are not in themselves sufficient. The study of degeneration reveal^ that practically every normal person possesses one or more of these so-called degenerative stigmata. It is simply a question of the number of such stigmata which the individual can safely carry.
It is now recognized that a man may be insane in one environ156 THE PSYCHOLOGICAL CLINIC. ment, and sane in another. I believe that a child may be feebleminded in one environment, for example in his own home, and may cease to exhibit feeblemindedness when placed in a different environment. I also agree with those modern students of insanity who assert that the development of some forms of insanity may be averted by a proper course of discipline and training.* Analogously I contend that because a child of sixteen or twenty presents a hopeless case of feeblemindedness, this is no evidence that proper treatment, instituted at an earlier age, might not have determined an entirely different course of development. It is a question of persuading physicians and parents to confide these children to educational and psychological experts, and of supplying the financial means to provide for what is in the nature of the case an extremely expensive mental and physical training. The type of child whom I have under consideration ought in my opinion to be viewed as being in as critical a condition as the child who is on the verge of death from typhoid fever. In an acute disease every remedial agency will be called upon, regardless of the expenditure of money and scientific effort. The retarded child under ten years of age, from the medical standpoint, is not suffering from alarming symptoms. From the standpoint of society, the family, and from his own point of view, if he could give expression to it, his condition is more alarming than if he stood momentarily expecting a summons to another world. If I am right in the position for which I have been contending, there are children under ten years of age, who have before them a life which is little better than a living mental death, who might, if taken in time, be rescued from this condition and developed through a course of training to the normal mental stature of man. We have institutions and private schools for feebleminded children, and we have schools for normal children, we need something in the nature of a scientific home and school for those children who are suspected of feeblemindedness, but who give to the expert in this new field some promise of ultimate restoration to normal condition. The Hospital . School^ which I have established in connection with the laboratory of psychology at the University of Pennsylvania, is intended for the observation and treatment of children, for whom in my opinion there is a fighting chance of restoration to normal life, but who, if
*Meyer, Dr Adolf. What do Histories of Cases of Insanity teach us Concerning Preventive Mental Hygiene during the Years of School Life? The Psychological Clinic, Vol. II, pp. 89-101.
allowed to remain undeveloped, would inevitably be doomed to a life of imbecility and inefficiency.* The cure of a case of mental and moral deficiency is one of the first-fruits of this school. My report of this case will present a child of eleven years who had never attended a regular school, and who was unable to do even the simplest addition -or subtraction correctly. He could read, but he never read a single sentence without making several mistakes. He was subject to outbursts of uncontrollable and unreasoning anger, which caused the parents much anxiety. He did not associate with other boys in a normal fashion. His father complained that he would let other boys browbeat him, take away what belonged to him, and in other ways treat him as a distinct inferior. I was told by the father that when the boy was between four and five years of age, he had consulted several specialists in ISTew York City, none of whom gave him any hope of the child’s ultimate recovery from the condition then existing. One diagnosed the child as mentally defective, adding that there was nothing the matter with him that he could cure. Another pronounced the boy generally undeveloped, “foolish and weakminded.” Another is reported to have said, “Don’t spend any money on doctors or medicines for this boy. They won’t do him any good. Take him out into the country, or send him to a private kindergarten, where they will humor him a good deal.” Another expressed the opinion that by the time he was eight or nine years of age he would be uncontrollable. The family physician is reported to have said that if the boy were an adult, he would say he had locomotor ataxia. A neurologist, in whose judgment I have the greatest confidence, and who has been kind enough to furnish me with a transcript of his notes, made a tentative diagnosis of hereditary or congenital ataxia.
There is no doubt in my mind that at the age of four or five years this boy presented symptoms which warranted a diagnosis of mental and physical degeneracy. There is also no doubt that most of the physical symptoms had subsided by the time he was eleven years of age, but the mental and moral symptoms continued, and the boy was an object of extreme anxiety to his parents, the mother, a naturally strong woman, being on the verge of nervous prostration from worry.
*See also an article entitled “The Hospital School” in The Psychological Clinic, Vol. I, p. 138 ff. Also called “The Orthogenic School” to emphasize its aim at restoring normal development through individual training.
On October 12, 1907, he was entered in the Hospital School. On January 15, 1908, I entered him in the third grade of a Philadelphia public school. In June he was promoted, by exemption on his term record, from this grade, to the fourth grade of the Philadelphia school. During this time he lived at the Hospital School, and his work was under my supervision. In the early summer he returned to A , his native town, with the recommendation that he be entered in the fourth or if possible the fifth grade, as intellectually he was ready for this higher grade. He was given some private tuition during the summer, and this fall he was entered in the sixth grade of the public school at A . If he advances at a normal rate of promotion, he will enter the high school in three years time, at the age of fifteen. At the present time, therefore, he manifests no intellectual retardation, nor has lie moral symptoms which in my opinion deserve to be considered pathological.
The history of this case presents many points of psychological and medical interest. I shall give in order, (1) the results of my first examination; (2) his previous history; (3) his condition on entering the Hospital School; (4) his record of progress in the Hospital School; (5) his present condition.
(1) First examination. On August 9, 1907, Mr. C wrote to me from A , a city in the state of iTew Jersey, saying that he had been recommended by Dr John K. Mitchell to consult me in regard to his son, who was a case of arrested development. I told the father I was about to leave the city on my vacation, and recommended that he wait until my return in the latter part of September. He wrote me again, however, requesting me to stop off in A , to see the boy on my way north. I mention this fact to show the urgency of the case from the father’s point of view. I saw Edgar on August 18, 1907. I dined with the parents and their two children, and spent a couple of hours in the physical and mental examination of the boy. He was a stocky, well-built, healthy looking child. He had red hair, and the expression of his face suggested an unsteady temper. The brow was low, but not of a character to awaken a suspicion of mental deficiency. The shape of the aperture of the eyes indicated a possible arrest of foetal development, but this was the only suspicious symptom. The teeth were in good condition, the mouth closed, the nose undeveloped, the nostrils small. A hasty examination showed the necessity of consulting an oculist, and the appearance of the nose and nostrils called for an examination of the naso-pharynx. The chest was fairly well developed, the voice was good, but he had a lisp, and his speech was a trifle thick. Hearing was normal. His manners at table were good. His gait was normal, the knee jerks were present on both sides, the co-ordination of the hands was good. In his conversation with me and with his family, he seemed to me to be a normal child of eleven, rather alert mentally, a selfcontained, independent sort of boy. If I had visited the family casually, I would not have observed anything wrong with him. My first brief examination was therefore negative, and excepting for the history which the father and mother gave, I should have pronounced the boy normal, but probably suffering from some optical defect and from naso-pliaryngeal obstruction.
(2) History. The father and mother were apparently healthy, and of normal mentality. I considered them capable of exercising more than average judgment in the management of their children, and in the enforcement of home discipline. I could obtain no history of degeneracy in either the father’s or the mother’s family. There was one other child younger than this boy, a girl who had never caused the parents any anxiety and whose history was that of an unusually alert and vigorous child. The birth of the child had been in every respect normal. He had been healthy as an infant, and for three or four years they had observed nothing unusual in his development. As time went on, however, they observed that his gait in walking and running was defective, that his speech was thick and slow of development, and that he refused to associate freely with other children. These facts led them to look back with suspicion on an occurrence which took place when the child was two months old. The mother had left the child in charge of a woman acquaintance, during an absence of from fifteen to twenty minutes. When she left the child he had just awakened from a nap. When she returned, the child was apparently sleeping soundly again. He slept until midnight, a very unusual occurrence for him, and he awakened screaming. During the evening, the woman in whose charge he had been left, kept coming up and asking after the child, as though she were worried concerning his condition. Shortly afterwards she moved away and ceased to visit the family. They recalled that she was jealous, and they suspected that she might have struck the child on the head or injured him in some way, either purposely or accidentally. They reported that the child was unusually fretful the next day, and vomited once violently. They also noticed that when bathing him the arms and legs hung pendant, although previously the fingers had been tightly grasped into a fist, and the legs drawn up on the body.
The parents reported that he began to walk at one year, and to talk at about three years of age. When he began to talk, he lisped. He was a healthy child, the only children’s disease from which he suffered being measles. When between four and five years of age, he got up a great deal at night, crying and seeming to suffer pain. He lost the power of walking and for a while could not stand. His legs went from under him. He had nervous movements which looked like chorea. He stumbled a good deal, and often fell sprawling upon the floor. One leg was not noticeably worse than the other. He was said to be awkward in the use of his hands, and could not dress himself. He was careless at table, eating noisily and “slobbering.” He was very hot-tempered, could not be corrected for anything without flying into a passion, but when angry he never broke or smashed anything around the house. When he was a small child he would strike back at his’ parents or other children, but later on he became somewhat easier to manage.
From the beginning he did not play like other children, and differed from them in many ways. When a little over four years of age, he was entered in a kindergarten. Here the teacher complained that he could not be managed with the other children. He would not join in the games, and would lie upon the floor, refusing to stand or march in line with the others. The kindergarten teacher thought he had spinal trouble, and said he lacked concentration. It was after this experience in the kindergarten that the father, on the advice of the family physician, consulted a number of specialists, from whose opinion the parents arrived at the conclusion that the boy was mentally deficient and likely to develop moral symptoms which would make him dangerous to himself and other children. A neurologist whose notes, made at the time, I have been given the opportunity to consult, reports him “fairly well developed physically, but with a kyphosis of moderate degree due apparently to muscular habit rather than any bony condition. His gait was simply rather ataxic and awkward, but he could walk and run fairly well. He stumbled in walking, would hold the head forward, but had no distinct Brach-Romberg… . The speech was thick, although he talked fluently. The main defects in the boy were his mental backwardness and his stumbling gait, and I take it to be a case of hereditary or congenital ataxia, cerebellar or spinal. I only saw the boy twice and could not follow him up.”
As a result of the boy’s condition and of the medical opinions which they had received, the parents sent him to a small private school in the neighborhood, where it was thought the teacher would be able to give him individual instruction. When he came to us he had evidently been taken through fractions in arithmetic, and had been taught to read. But the mother reported that he did not know his multiplication tables. When she tried to teach him, he would forget one day what he had learned the day before. lie had never been able to tell time very well. If the parents or the teacher, in their efforts to teach him reading, had asked him to close first one eye and then the other, they would doubtless have discovered that he was nearly blind in one eye. The early correction of this optical defect would probably have led to the amelioration of much in his condition.
The parents complained that the boy was unable to stand up for himself, that he would allow strange boys to take things away from him, damage his bicycle, or pummel him without making any resistance. The mother talked with him about this, and both father and mother impressed upon him that when a boy hit him he must hit back.
They also complained that the child giggled and laughed inordinately. When a joke was made, he would laugh to an immoderate extent. They also observed that he was unable to play ordinaiy children’s games with cards, and that he complained very much of fatigue. He vomited frequently.
In view of this history, I felt I could only suspend judgment, and I therefore advised the father that I must have the boy in the Hospital School for at least a month before I would be willing to express an opinion as to his condition and the treatment required in his case.
(3) His condition on entering the Ilos-pital School. Accepting my advice, the father placed the boy under my care in the Hospital School on October 12, 1907. He appeared to be a bright, observant boy, manifesting considerable intelligence in conversation. Our tests showed him to be possessed of a fairly good memory. His mental retardation was not of a character that could be revealed in a brief examination. I therefore left the discovery of his mental defects to be made in the course of his training, which was in the hands of Miss Tierney, the trainer and nurse in charge of the school. From her report and my observation of his work Ave found that his retardation in school work appeared to be the result of two factors, (1) his own deficiency and (2) the improper teaching that had been accorded him up to this time. For example, in arithmetic lie would attempt fractions, but in the first days that he was with us he did not perform a single sum even in simple addition correctly. The following is a sample of his work in substraction:
6273 ?1425 4847
A single instance of this kind means nothing. When an error like the one made in subtracting 5 from 13 creeps into every operation there must be some cause for this deficiency. Is it a defect in the boy or in the educational methods ? There seemed to be no reason why a boy of his general intelligence could not have been taught to add and subtract with accuracy. There were also apparent gaps in his educational equipment. Thus, in division he worked as follows:
3)17415 585 We could find no evidence of his ever having known that a cipher should be placed in the quotient to represent the division of 1 by 3. lie was tanglit this in two days and never seemed to lose n afterwards. Tie also failed to understand how to multiply by a cipher, lie did not know his multiplication tables. In reading he left out words and put in others which were not to be found in the text. lie also misread many words. Thus, he would read was for were. The comprehension of what he read was excellent, and despite his many errors with simple words, he was able to read very difficult words. In reading he was hasty, rushing quickly at the succession of words. He seemed to be fond of reading, but he mumbled a great deal to himself when reading a book.
His spelling was exceedingly deficient. He could not spell words that were taught in the first grade. Thus, he failed to spell correctly all of the following words: fruit, picture, taking, liking, making, ever, kneel, fright, knitting, and never. His writing was extremely poor and unformed. Apparently he had never written with pen and ink until he came to us. The physical examination made by Dr Ludlum* and myself was negative, so far as revealing severe somatic or physiological stigmata of degeneration. His circulation was poor, but was *Neurologist to the Hospital School, who had charge of the medical treatment of the case.
rapidly improved by hygienic baths, massage and exercise. His appetite was poor and his nutrition below par. lie fatigued rapidly both at work and play. He was ready to go to bed right after his supper, which he had at six o’clock in the evening. To improve his health, he was given a tonic.
He had spells of vomiting,?two or three a week. When his field of vision was tested he became dizzy and vomited. The examination of the eyes revealed a marked defect in one eye. With the right eye alone he was able to read better than with the two eyes open. With the left eye he could not make out a single word, and a line of print looked like a black blur upon the page. Iiis mouth was closed; he was not a mouth-breather, even during sleep, but the nose was undeveloped, the nostrils small, and blood often appeared in the nasal passages.
He settled down to work in the school, quite happy and contented. The parents were greatly worried about the result of my examination, and kept imploring me for an expression of my opinion. It was a long time, as our work progressed, before I was able to convince them that there was nothing seriously and permanently wrong with the boy. Some of my letters to the father help to develop the case, and I therefore print some extracts from them here. On October 16, 1907, I wrote:
My Dear Mr. C.: I liave been observing your boy’s work, continuing my examination. I wish that I could write with such positiveness as to disabuse Mrs. C.’s mind of all cause for worry. I am not able to do this, but I can assure you that there is no reason to worry greatly. I have not as yet been able to observe from my examination of Edgar, that there is any reason why he should not be able to take a full public school education and develop into a perfectly normal young man.
Edgar is an extremely nervous boy. His mind seems to me to be very quick and alert,?so quick that he does not give sufficient attention to detail. He ought to have been trained very early to do some of his work with great exactitude. In all ordinary matters he seems to be quite bright. He can repeat a story that he has read quite well, perhaps a little bit better than the average boy of eleven years. I may come to the conclusion that Edgar is a boy of a peculiar mind, a mind that may perhaps be cultivated to some work above the average. I must observe him somewhat longer. We must undertake to teach him some simple things, and see how well he grasps and how well he retains. We have already found that he grasps quite readily. It will take me a week to see whether he loses what he has once been taught.
I find that he fatigues very easily, growing tired and nervous. His circulation is not as good as it should be. We shall strive to improve this with baths, exercise and massage.
I want you to assure Mrs. C. that on the whole the result of my examination is favorable. Dr Ludlum and I are not able to convince ourselves that there is any mental defect. We are convinced, however, that he is seriously in need of a training which will, in some directions, go all the way back to the beginnings of school work. I will write you again in the course of a week, or if anything is discovered by me which forms my judgment positively one way or the other. I shall be very greatly surprised if I should discover Edgar to be permanently a mental defective. Very truly yours, Oil October 18th I wrote: My Dear Mr. C.: Edgar’s right eye is practically normal. His left eye is quite defective. It is very astigmatic and his vision is very much reduced. He has about one-tenth normal vision for distance. If this condition is substantiated by the examination of an oculist, the condition of Edgar’s eyes would account for a great deal of his difficulty in progressing in school work. It is necessary for us to have Edgar’s vision corrected immediately, as it is very disadvantageous for him to iise his eyes in their present condition.
Very truly yours, Following this letter he was sent to Dr Burton Chance, who refracted his eyes.* On October 23d I wrote to the father as follows: My Dear Mr. C.: I have found one cause of Edgar’s inability to progress in school work. His left eye is quite defective, while his right eye is very nearly normal. My diagnosis of deficient vision has been substantiated by the examination of an oculist, to whom I sent him. Edgar’s eyes will now be refracted and glasses will be prescribed for him. I will then see how he progresses.
An inequality in the capacity of the two eyes, such as Edgar has, is usually attended with somewhat serious consequences. Edgar complains of headaches, which are undoubtedly from the eyes. Moreover, I believe that we must attribute to the eyes alone his inability to learn to read *The findings were a slight inward deviation of the axes, associated with a hypermetropia of the right eye and a myopia of much greater degree of the left eye. The vision of the right could be made to equal the normal in spite of the hypermetropia, while that of the left equalled onetwelfth the normal and was practically amblyopic. with exactness and his difficulty in some of his work in arithmetic.
Outside of this defect of vision I have not been able to discover anything seriously wrong with the boy. I believe now that at the end of this month I shall be able to report to you with confidence that the boy has normal mentality, but that he has been backward in school work owing to his defect of vision and owing to poor training at school. I also incline to the belief that much of his irritability may have arisen from the eyes producing nervousness. Very truly yours,
On October 29th I wrote the following letter: My Dear Mr. C.: It is very necessary for Edgar to remain with us until a full month has been completed. I have sent Edgar to an oculist, who has made a very careful examination of his eyes and will, I expect, finish to-morrow by giving him a prescription for glasses. It will be necessary for Edgar to wear these glasses always. When there is one very bad eye and one nearly normal eye, it is very hard to get the two eyes working together properly. I shall want to see that his glasses are satisfactory and shall want to discover what improvement he makes in school work from the wearing of the glasses.
The question of where Edgar shall go to school is an important one. I am beginning to encourage myself with the thought that if Edgar is given special instruction he ought to be able by Eebruary 1st, the beginning of the second term, to enter his proper grade in a public school and progress normally with the other children. The schools in A are good schools, at least that is their reputation. If he were entered at the present time, he would undoubtedly have trouble, owing to the fact that there are many curious gaps in his knowledge, especially concerning arithmetic; certain simple things which he ought to comprehend and would have comprehended if he had been taught, he appears not to know. I think that Miss Tierney could do a great deal for him between now and Eebruary 1st. I am very much interested in the boy, and as I have a small fund at my disposal for looking after a few of these children, I should, I think, be glad to make a special arrangement with you, keeping Edgar at my school on such terms as you feel you could afford. I do this because I want to continue my experiment with him until -I can return him to you with his backwardness entirely made up.
Unless you are confident that the military academy to which you thought of sending the boy is a better school than a public school, I would not send him to it. If he returns to school immediately after his first month with me is over, I want to be put in communication with his teacher, as I can tell her some things that will help her to understand him. Very sincerely yours,
The first month’s work clearly demonstrated that Edgar was not intellectually defective. His extreme retardation in school subjects, an intellectual deficiency for a boy of his age, appeared to be difficult to explain. Undoubtedly the defect of vision had made his school work difficult, and may perhaps have been solely responsible for the backwardness. Children with eye strain of the sort from which Edgar suffered, cannot concentrate their attention on their work. They also fail to form clear visual images which are essential for the acquisition of satisfactory memories, and thus they experience a very serious handicap in the learning of reading, spelling, and arithmetic. Moreover, eye strain of this character produces in some cases a state of mental confusion. There can be little doubt that much of the boy’s nervousness was due to eye strain, for this ceased shortly after his eye defect had been corrected. Tie had been troubled with vomiting, and the prolonged testing of his vision always brought on a fit of nausea. After he had been given glasses, he had but two attacks of vomiting, one following immediately upon first wearing them. The wearing of the glasses also resulted in greater mental alertness, and a greater accuracy in reading and writing. They probably also assisted in the improvement which took place in his health, though this was brought about in large part by more hygienic food, baths and a tonic.
The moral symptoms displayed by this boy are of great interest. By the end of the first month I could not make up my mind whether these symptoms were pathological, the result of an earlier diseased condition of the brain, or whether I should view them as normal traits of character. Fortunately the father determined to leave the boy with us until June, in order that we might overcome the backwardness in school subjects. This gave me an opportunity to study the moral features of the case.
The first symptom worthy of note was obstinacy. Edgar could not be forced in any of his school work, nor could external discipline be exercised without producing a resistance which was certainly excessive, and might be viewed as pathological. It was necessary to treat him in a very different manner from the ordinary boy. The trainer could not say,?”do this,” with any hope that the command would be obeyed, but if the boy were invited or requested in a mild manner, especially if he were allowed to reason the matter out, he became entirely amenable to the discipline of the school and home. Tie at first refused to take the tonic prescribed for him before each meal. When brought to the breakfast table, and told that he could not have his breakfast until he had taken the tonic, he refused to eat a mouthful. The same procedure brought about the same result at dinner, but when Miss Tierney put before him the solicitude which his father and mother felt for his welfare, and their desire that he should get an education, and how necessary it was for him to take the medicine, he” finally yielded and never afterwards made any objection. This kind of treatment made him more and more compliant to tho demands put upon him by the Hospital School. I have no doubt that if at the outset we had employed the ordinary school methods, the obstinacy would have developed instead of diminishing. By the time we considered him ready for an ordinary public school, the middle of January, he had become thoroughly interested in his work, and this element of his character was no deterrent to his school progress.
A second trait of character amounting to a pathological symptom was the uncontrolled and apparently unreasonable outbreak of temper, at times resembling an insane rage. Without a sufficient cause, he would rush down from the second floor and violently assault another boy in the school. These outbursts of violence and temper appeared to be periodic. They were ushered in by two or three days of irritability. Their frequency diminished very rapidly during his stay with us, and on Jannary 10th he had his last attack. Undoubtedly his general improvement in health assisted in causing their disappearance, but they were made to disappear largely because we finally reached an understanding as to their origin and nature. In what manner I shall proceed to relate.
Edgar had one trait of character which cannot be called abnormal per se, but which in his case was undoubtedly excessive. Tlis parents never mentioned it to us, and doubtless they had never observed its presence. He was intensely jealous. Even after he had been with us for several months, he would be unpleasantly affected for two or three days if another boy was shown some favor by even a relative or outsider. He was extremely ready to claim that one or another of his associates was the “teacher’s pet.” He was always on the lookout for favors shown to others, in which he did not participate. Naturally, this was accompanied by intense selfishness. He never offered to share a penny, or a bit of candy, or a cake with another child in the school. If he could not immediately use what he had, he stored it away for some future occasion. Rather than use a postage stamp that belonged to himself, he would borrow a postage stamp from some one else and forget to return it. Ill my judgment the selfishness was not excessive for a boy, but -the jealousy was certainly present to an inordinate degree, and yet I am not willing to consider what at times I called an “insane jealousy” a pathological symptom. I view it now as a trait of character which he will have to struggle against all his life. Miss Tierney’s influence upon him was for the good, and this influence increased after we discovered the relation between his jealousy and his outbursts of passion,?for example, he probably ran downstairs and assaulted the other boy for what appeared to us to be no cause, for the reason that he had been brooding for a day or two, or three perhaps, over some chance favor that had been displayed to this boy, which he considered unfair. His jealousy made it impossible for him to win a game of checkers or cards from a child who had much less intellectual capacity than he. lie was always fearful that the other boy would cheat and get the better of him in some way. lie therefore did not watch his own hand. The first game he ever won in his life he wron some time during the spring, after he had been taught how to control this passion of jealousy.
He was a child fond of nagging and teasing. He would knock another boy’s hat off, or give him a gentle pinch. If the other boy retaliated, he went him one better, then when the inevitable outcome of this occurred, he was the one who blamed the other boy for teasing him. After the Christmas holidays, the father brought him back with the report that Edgar had been struck by another boy in the school, and that Miss Tierney had not allowed Edgar to hit the other boy back, as, according to the father’s advice, he ought to have done. It required a great deal of diplomacy to convince the father that this kind of admonition was not appropriate for his boy. While he loved to tease, and had the elements of a bully, he was, like most bullies, a coward. When it finally came to blows, I never knew him to make a stand-up fight with some one whom he had been nagging. While these traits are unpleasant, they are not sufficiently unusual to be called pathological. The boy also had certain habits which might awaken a suspicion of a pathological origin. He would pick his nose and sores on the body, and then put his fingers in his mouth. He also chewed his food at table with his mouth open, and made a great deal of noise while eating. But I scarcely consider these habits pathological, for they are of frequent occurrence in boys who awaken no suspicion of mental defect. Of course it must be borne in mind that this child came of parents to whom these habits were disgusting, and that they had tried to break him of them, and failed, but we must not suppose that they failed because they necessarily had a pathological character to deal with. It may have been that they were not gifted with sufficient psychological insight to train a boy who presented just this combination of character traits, each in itself normal.
If, for example, we had failed to discover early in our treatment of him that there was one trait of character to which we could always appeal,?a reasonableness, combined with an ambition and pride in accomplishment,?it would have been impossible for us to have solved in the easy way we did, the difficulties presented by the emotional and moral characteristics of this boy. It was always possible, except during the actual occurrence of some outburst of temper, to appeal to Edgar’s reasonableness, his desire to get on in the world, his wish to please his parents, his pride in outdoing his fellows. Indeed, I am not at all convinced that the exaggeration of his jealousy, of the nagging and teasing, may not have come in very large measure from the observation of his own inefficiency, when he compared what he himself was able to do, with what other boys were doing. Consequently, in a double sense his eye defect may have been responsible for the exacerbation of his moral symptoms, in the first place because the eye strain induced a hyperexcitability of his nervous system, and in the second place because the defect of vision made him ineffective, despite the fact that he must have been aware of his mental superiority to boys who far outdid him in the elements of school work. He certainly showed signs of shunning competition with other boys. In our Hospital School, they vied with one another as to who should ran the talking machine. He sat by, apparently uninterested. The complex of emotional and moral symptoms which I have just passed in review, presents the picture of a pathological condition often found in children recovering from an injury to the brain, at birth or in the early years of life. Associated with these symptoms was the intellectual deficiency. The motor symptoms which are apt to be associated with the pathological emotional and intellectual conditions, were not present in this case, unless we view the marked inefficiency in writing and drawing, which showed itself during the entire course of his training, as a survival of an earlier motor disorder. It appears to me to be quite within the realm of probability that this boy at the age of five years was in an acute condition as the result of some, perhaps slight, injury to the brain; that in tlie course of liis development from five to eleven years of age, tlie injury to the brain was recovered from, and the motor symptoms gradually subsided and to all intents and purposes disappeared by the time he had reached his twelfth year; that the brain, however, remained in an unstable and irritable condition, and hence the retardation in intellectual development and the emotional symptoms. There is certainly no evidence, in view of his rapid intellectual and moral development, that his condition in October, 1907, or at any time, rested upon an incurable defect of the brain. On the other hand, why need we believe that there remained any trace of this supposed injury when the boy had reached his twelfth year ? Why, indeed, may we not assume that the brain had become entirely normal at an even earlier period than this, by the time he had reached, let us say, his sixth year ? Then we should view the mental deficiency and the defects of character, which he presented in his twelfth year, as the very natural result of the failure by the parents to provide for the proper training of a normal boy, because they had come to look upon him as abnormal, presenting as he did traits of character which rendered him difficult to manage. A simple arrest of mental and moral development, the result in the first instance of some cerebral injury but later on due solely to lack of training and a defect of vision, is my interpretation of the emotional and moral symptoms which in my opinion do not suffice to remove him from the class of’ normal children. If, then, the picture I have painted is that of a normal boy, it may appear to many that I have drawn a very unlovely character, presenting as it does extreme irascibility, jealousy and selfishness. But it must be taken into consideration that this boy was induced during the eight or nine months that he was subjected to our training, to make a manly and successful effort to overcome his defects of character. This must be placed on the credit side, when we form an estimate of the worth of this child’s character. Indeed, it is my opinion that children of strong passions and impulses are better material to work with than those who are merely indifferent, and that an excess of temper and obstinacy is more easily dealt with than excessive amiability. Under proper guidance, children of strong impulses, even though these may in themselves be objectionable and likely if let alone to lead on to a perverted and practically hopeless moral condition, possess the materials upon which may be built an adult character of fine quality as well as strength.
Edgar was under training in the Hospital School from October 12, 1907, to June 25, 1908. In the record of progress which follows, I have eliminated all but the essential features. With reference to the development of emotional stability and moral character, my notes are given in greater fulness of detail than with reference to the methods and other particulars of the intellectual training and improvement.
(4) Record of Progress. On October 30th, he began to wear glasses. On November 3d, he had an outbreak of temper, in which he lost control of himself. On November 4tli, he complained of headache and vomited. On November 11th, he again complained of severe headache and vomited and had an outburst of temper.
His school work, in which he had begun to make some progress, before he put on glasses, now showed marked improvement although he still continued to make his characteristic mistakes. He complained constantly of being tired, lounged in his seat, rested his head on the desk and usually had to be urged to take any kind of exercise. On November 21st, he began taking a tonic. By December 1st his physical improvement was beginning to be noticeable. He no longer lounged in his seat and he sat erect when studying. He did not seem to fatigue so easily, and his attention was more steady.
On December 12th he again had an outburst of temper in which he attacked another boy without any apparent cause, running downstairs and assaulting him. He also tried to bite the assistant trainer. He was irritable for several days at this time. While in this state he pulled the bedclothes from another boy in the school and annoyed him so much that he was obliged to leave the room.
He returned home for the Christmas holidays. In his report the father commented on the fact that he seemed to play more naturally than usual with the other boys, that both he and his wife had remarked that the boy played a game of cards with a cousin thirteen years old in quite a normal fashion. He complained that the child continued to giggle inordinately. Edgar had no outbursts of temper while at home. The father observed that the boy told time better than he used to. His disposition was much improved. Pie read a great deal at night, having been given five or six books for Christmas which interested him greatly. The father reports that he noticed before he came to the school that he would often have severe headaches and would go to bed early. During the Christmas holidays he had no headaches and had to be driven to bed.
On January 7th he was operated on for adenoids. Following this operation he was irritable for three days and on January 15th, he had another outburst of temper, but much less violent than heretofore. Miss Tierney reports that he tells her now when he feels the attacks coming on and by talking to him she is able to check the active outbreaks. This was the last violent outbreak of temper that he had during his stay at the Hospital School. On January 15th he was entered in the third grade of a Philadelphia public school. The normal age for children in this grade is nine years. Measured by his classmates, Edgar was two years behind in his school studies. ITe presented his first school report on Monday, March 21st. He had received excellent in conduct, excellent in spelling, excellent in geography, good in reading, good in language and poor in writing and drawing. I had rather feared that he might not be able to stand the strain of the school work and of association with other boys, but his teacher expressed very great satisfaction with the excellent work he was doing, and spoke of him to Miss Tierney as one of the best pupils in her room. He prepares all of his lessons for the next day before going to bed. He has to be sent to bed. I have myself observed him come in from the street, where he had been roller skating, in order to get his lessons of an afternoon. He seems to be able to work at odd moments, showing very excellent concentration of attention. He had some difficulty with a boy at school on one occasion, claiming that the boy ordered him out of the hall, and that he kicked the boy and then ran home to report. The boy followed him, but he escaped by getting into the house first. He had to be coaxed to go back to school the next morning, but he finally consented. Since the operation for adenoids a marked improvement has been noticed in his physical health. He is now unusually obedient and does with the best will in the world whatever he is asked to do. He has no more nausea or vomiting. His improvement in spelling and arithmetic is most remarkable.
The boy is ambitious in his school work. On March 11th his name was placed on the roll of honor for the week, for the first time. He exhibited his record on this occasion, and also on subsequent occasions when he had achieved this honor, with the greatest pride. He realizes that he has a bad temper, which is apt to get him into trouble with the other boys, and he remains at home until nearly school time, so as to avoid getting into trouble with them.
His inability to control himself is shown in his temper in games. He is not good at any game. In fact, he always loses. This is to some extent due to selfishness and excitability. He seems to be in such fear that someone will take an advantage of him, that he watches his antagonist rather than his own hand. When he loses his- game, he becomes very angry. Thus on March 15th he ran down stairs to Miss Tierney and said that he could not win a game, and would not play any more. He was greatly excited, but calmed down after being talked to, and admitted that his temper was due to jealousy. The next eveninghe was told to play a game and see if he could not carry it through without losing his temper. He played with another boy in the Hospital School, and lost as usual, but he did not lose his temper this time; he came to Miss Tierney and reported with some pride that he had controlled his temper, although he had again played and lost the game. When jealousy leads him to resentment, he will torment another child in every way possible. Thus on the evening of March 27th, he kept striking another child with a strap in a teasing manner, pulling his hair, and otherwise worrying him. When he was talked to by an assistant trainer in a kindly way about this, with a view to persuading him to stop, he refused to obey, and simply said “I don’t care.” Miss Tierney was then called, and when she went into the room he said he would stop teasing D?, but as soon as she had left the room he began again, claiming that D? was her pet, and had everything. He said he hated D? because he had everything, and made the remark, “If I had two aunts living in Philadelphia I could go anywhere too.” (This was apropos of the fact that D? had two aunts who.occasionally took him to the theatre.) He said he hated everybody in the house. He continued to bother D ?so that they could not be kept in the same room for that night. When in these spells of anger or jealousy his eyes become very small and bright, and the cornea seems to redden. His face gets very red, and his whole expression changes.
On the following day he kept up this tormenting of D?, because D? had been taken to a lecture the previous evening, and he (Edgar) had been kept at home in punishment for his bad temper of the night before. With the assistance of another boy in the school, D?’s hands and feet were tied, and the two culprits walked off without permission. “When they came back, Edgar kept on teasing D?, calling him the “pet of the school,” was irritable all day and very unkind to D?.
On March 29th he was still in what Miss Tierney had taught him to call his “mean mood,” and sulked all Sunday morning, refusing to go to church. In the evening he was a little more agreeable, and sat on the porch. By April 4th he had overcome his mean mood, was in a pleasant humor, and ashamed of his behavior of the past few days. On this day he came voluntarily to Miss Tierney and asked her if he had not been behaving himself better in the last day or two, admitting that he was jealous of D?. When Miss Tierney talked to him about his faults, he promised to do his best to keep his temper down, although he said it made him mad, because D? had everything.
By April 6th his outbreaks of jealousy, like his violent outbursts of temper, were beginning to be under control. By this time also his articulation was noticeably improved. I had him read from a history which was far beyond his ordinary reading lesson, and he read extremely well. He lisped on a few words, but when I asked him to pronounce them carefully, he pronounced them without any lisp. He lisps more when talking than in reading. The lisp is undoubtedly a persistent habit. The grade teacher reports on April 6th that he is one of the brightest pupils she has in her class. His average for a test in arithmetic made about this time was 67. This branch is now his most difficult study. Excepting in arithmetic and writing, he is doing excellent work. He has caught up to and is perhaps beyond the average of children in his grade. On April 8th, Edgar reported that his teacher said that his language work was the best in the class. The story was about George Washington, on the rendering of which she complimented him, saying that he knew more facts than any other boy. On April 9th, he came home with a language lesson marked good. He claimed that another boy was jealous of his mark, and had torn up his own work, because it was only fair. He frequently makes remarks of this kind about the other boys, seeming to think that they are jealous of his good work. He also volunteered the information that one boy in the class was marked excellent, but this did not bother him as this boy was the “teacher’s pet” and she would have marked him high anyway.
Perhaps because of this boy’s mark, Edgar sat down to dinner sullen and irritable. Miss Tierney was absent, and an assistant trainer was in charge. When asked if he would have some butter, he said, yes, but when another boy refused, he said he did not care for any either. When his attention was called to the fact that it might be well for him to develop a little originality, and not copy others, lie said, “Well, I will have a little butter after a while.” The assistant trainer said, “No, if you don’t take it now, you can do without.” lie retorted that he did not want any dinner anyway. lie was advised that he would be the chief loser by going without his dinner, and that he was spiting only himself. When dinner was brought in, he helped himself liberally. But he was still irritable towards D?, and when he was told to let D? alone, he grew cross and wanted to leave the room, but he was compelled to sit still. When the trainer told him that D? was really too good-humored to associate with a boy like himself, that when he went out into the world, he would be shunned by everyone and have no friends, as other people would not take his nasty remarks so nicely, he made a face at the trainer, stuck out his tongue, and said he did not care what other people thought of him. But during the rest of the meal he was in a reflective mood, and after finishing his dinner, when D? asked if he might skate, Edgar asked if he could go on the porch and watch D?. The rest of the evening he appeared to be in a good humor. On April 10th, he brought home an arithmetic paper marked 100, and his average in review was 91. This kept him in the best kind of humor all day. He asked the trainer what she thought of his general behavior during the week, and when she told him it was not very good, he said it would be better next week, as he was trying hard. On April 11th, he was in good humor, played a game of marbles and won the game. He came in very delighted to report the fact, saying that this was the first time in his life he had won any game. He also asked “Don’t you think I am getting along well ? It has been a long time since I quarrelled with anybody.” He was out of doors playing the greater part of the day, and had no outbursts or quarrels.
On April 12th he attended church in the morning, and spent the afternoon with D? and his aunt in the park. In the evening Miss E. invited him to attend a special service. He made ready to go, but when he got as far as the door he said he had changed his mind and would not go. When coaxed, he continued to refuse, and ran upstairs. Miss Tierney called him down, and said, “Edgar, that does not look as if you were improving or getting along well.” It was pointed out to him how very unkind it was to act in that way when people were good to him, and that it showed an ungenerous disposition. After being reasoned with in this fashion for a few minutes, he said, “If I run, I will catch up with them and go.” lie ran out, caught them, and went to church with them.
On April 14tli he again had 100 in arithmetic. Three dollars was sent to him in a letter from his father. The receipt of this money delighted him. ITe is always pleased when he gets money. He wanted to keep it, and was not willing that the trainer should take charge of it. He said he knew a place where he could hide it. On April 27th he obtained an average of 75 for a review.. He apologized for this low grade on the ground that he should have had a higher mark, but that a boy sitting near him defaced his paper. When the paper was brought home, however, this was found to be an untruth. The work was all his own, and the corrections on his paper were made by the teacher. The mistakes made in the review lesson were in new work in arithmetic.
On April 28th he went to school as usual and was in good humor until evening, when he and D? went out skating. Edgar came home angry, claiming that D ?had made fun of him, and that D? felt too proud because he could skate better than he. He would not go out again, saying that he would rather study anyway, as he had more to study than D?. He is by far D?’s intellectual superior. When D? was questioned, he said he had not made fun of Edgar, but that Edgar had become angry because he could take longer strokes and skate faster. Edgar remained in the house and studied his lessons, and went to bed about nine o’clock. On April 29th he came home from school, claiming that he had been compelled to write certain words ten times, whereas another boy who was the “teacher’s pet” had written them only five times. When asked how he knew this, he said he had picked the boy’s paper out of the waste paper basket, and found that his words were written only five times each. He said he was never going to write his work more than five times in the future. He seemed very jealous of this boy. This is an illustration of what jealousy will lead him to do. On May 1st, D? was taken to the circus. Edgar did not go, but this did not seem to affect him to jealousy, as it always had heretofore, and he even asked D? to tell him about what he had seen at the circus. But in the evening, when he played a game with F? and D? he lost the game and said it was because E? cheated. He teased F? calling her a cheat. He was suffering at this time from a cold, which probably tended somewhat to make him more readily exasperated. On the following day, May 2d, he said, “Miss Tierney, it is a long time now since I had any fits (meaning his outbursts of temper). Do you think I wTill ever have any more?” Miss Tierney told him, “No, not if you keep on trying to overcome your jealousy.” He claimed he was not jealous of anybody now, except of the boy in school who thought himself so smart. He talked a good deal about this boy claiming that the teacher petted him to such an extent that it made everybody mad.
On May 6th his cold continued pretty bad, but his humor was excellent. He brought home a report of 100 in arithmetic, which pleased him greatly. He is always delighted Avhen he gets a high grade. On May 7th he came home very much excited and indignant because he and some others had been searched for money that was lost. It took quite a long time to quiet him down, and until he was quiet he was unable to eat his luncheon. He finally calmed down, but during the afternoon he referred to it frequently. Despite his excitement, he prepared his lessons for the next day, read a story, and played a game in a good-natured manner. On May 8th his name was again on the roll of honor, but he had mislaid his glasses and brought home work from school which he had copied wrong. He had written m’s for n’s and left out letters in a number of words. The following day he wrote a letter to his mother which was very badly spelled, showing the kind of spelling errors that are easily referred to difficulties of vision. His work showed that he could not possibly get along well without his glasses. On May 10th he and D? went with D?’s aunt to gather some flowers. When he came home he requested that his bunch of flowers be kept separate from D?’s, because he had the larger bunch,?another manifestation of his selfishness. On May 11th, he came home from school very much excited. He said he was afraid his teacher would take his name off the roll of honor, but it would be all on account of another boy. This other boy was jealous because Edgar’s name was on the roll of honor, and kept slapping him; and because he told the boy to stop slapping him, he supposed the teacher would take his name off the roll of honor. Tie said another boy also slapped him, and claimed that he did this so that he would have to talk and have his name taken off the roll. His name so far had not been taken off the roll, but he said if he should come home and say it was taken off, Miss Tierney would know the reason why. On May 12th he reported that his name was still on the roll of honor. This put him in a very good humor. On May 13th, he was sent from the dinner table to wash his hands. On leaving the room he said, “I won’t come back.” However, he did come back after washing his hands. When tJtie meal was over, he went to Miss Tierney and said, “I nearly got mad but I just said to myself ‘I will control my temper.’ ” May 15th, he came home from school with his glasses broken. He said a boy at school had broken them, but he did not report it to the teacher because this boy was the teacher’s pet and she might only punish him (Edgar) for it. Miss Tierney asked him why he disliked this particular boy so much. He said, “Oh, he thinks he is so smart,” and then he told about the good clothes this boy wore and that he always carried a flower in his button hole and looked at him with a grin on his face as much as to say “I am smarter than you.”
On May 20th, he reported that all the boys with the exception of three of the teacher’s pets had been kept after school for leaving the room in a disorderly fashion. ITe claimed he had been unjustly punished, but he studied away at his lessons during the afternoon and evening. On May 21st, in the evening, while playing with some other boys, he stopped playing and left the room. After he had gone to his room, he called Miss Tierney and asked her if she thought he had left the boys because he was angry. He said he wanted her to be sure that he had not lost his temper and claimed that he had only left the room because he Avas feeling very warm and Miss Tierney had told him not to get overheated in playing. He asked if she did not think that he had been controlling himself pretty well. On June 5th, Edgar came home from school with a distinguished note signed by the principal, testifying to his good conduct and he asked if he might keep this report and was allowed to keep it. On June 23d, he came to me with his term report from the school. He had been exempted from examinations and promoted to the fourth grade. He was very proud of the record that he had made and said he was glad to go home as “he felt like himself again.” He said to me, “Dr. Witmer, do you think I am cured now ? I liavn’t got mad since the operation. Of course F? came into the room once or twice and bothered around and I chased her out, but that wasn’t like what I used to do.”
On June 25th, he returned home and during the summer was given private tuition to prepare him for skipping one or more grades.
His present condition. No comment of mine can add to tlie force of the following extract from a recent letter of the boy’s father:
October 10, 1908. Dear Dr Wither: Your letter received and would have answered sooner but was waiting for Edgar to receive his monthly report. They have placed him in 6 B, which means he has three years before he enters high school, if he does not miss. He received 8 in history and geography and 1 in all other studies, which we considered fairly good, as we only expected he would be placed in the 5th. We have urged him to do better next month and try to bring home some 10’s on his report. We consider Edgar very much improved. Yours sincerely, C.
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