A Fettered Mind
The Psychological Clinic Copyright, 1917, by Lightner Witmer, Editor. Vol. X, No. 9 February 15, 1017 :Author: Lightner Witmer, Ph.D., University of Pennsylvania.
I recall my first impression of Marie,?a small slight figure with prominent shoulder blades, the muscles of her face contracting and twitching constantly, the eyes rolling back, the mouth drooling, the feet dragging as she walked. The hands were never quiet, the whole frame in fact appearing to be strung on wires,?wires which were hopelessly tangled and crossed. Her speech was almost unintelligible, thick and indistinct, and she seemed to understand nothing of what was going 011 around her,?constantly saying, “What?
What was it?” in a puzzled way to her aunt and mother. In consultation with a neurologist of New York City I first examined this little girl when she was just seven years old. She was the fourth and last child of parents who had reached the age when they ceased to expect an addition to the family. Her mother was forty-two, and was ill before Marie’s birth with what was diagnosed as kidney trouble. She was too ill to nurse the child, who was nourished on prepared foods under the direction of the family physician. Three older children were all of normal mental and physical development, but Marie, from the time of her birth, had been afflicted with what several specialists diagnosed as an incurable disease. At the age of one year she could not crawl or even move from the reclining position. When placed upon her belly on the floor she could move her arms and legs about, but she was incapable of coordinate progression. At the age of twenty-six months she began to walk without having previously crawled. Somewhat later she began to talk. Her intentional movements had always been incoordinate. The mother called her nervous and spoke of the child having jerking and tremulous movements. The severity of her symptoms may be judged from the fact that when about three years of age a specialist on children’s diseases diagnosed her condition as dystrophy. This naturally involved an extremely unfavorable prognosis.
At about the same time a neurologist diagnosed the case tentatively as infantile cerebral palsy. The condition of her motor system is shown by the fact that she could not walk upstairs without holding on to the banisters, that she stumbled easily, that she could not help herself to rise if she lay on her back. If rolled over on her belly and lifted gently by putting a hand under the abdomen she got up. There was nothing in this that suggested dystrophy. The leg muscles were well developed, but not hypertrophied; the knee jerks normal; the pupils responded normally. Her eyes were Mongolian, the internal canthus being adherent. Rickets was excluded in the diagnosis.
The child had always suffered from constipation. She was tall for her age, and her parents thought her mentally up to the other children who have all been normal.
Marie was seen again by the neurologist six months before my first examination. The most important symptoms then were the choreiform movements, and the over-activity of purposive movements. In the four years she had been given exercises under the neurologist’s direction, looking to the removal of the incoordination. She could walk up and down stairs. She even skipped a little. There was no pronounced spasticity in her gait, but rather an overactivity of the muscles. When the limbs were tested separately, there was no spasticity apparent. The symptoms were much worse when the child was tired or excited. A few months later she was again brought to the neurologist, after she had been taken to one of the most distinguished physicians in this country, who pronounced her case a hopeless one and advised that very little could be done for her.
At the time of my examination Marie possessed a fairly well formed body; her head was normal in formation, the face slightly asymmetrical, the right side being plus. The physiognomy suggested adenoids, and the palate was high, the teeth irregular. The mother admitted that the child was susceptible to colds, but denied that she had ever been a mouth breather, even at night. There had been no ear symptoms.
She was able to stand erect, and to take the normal sitting posture. There was manifest awkwardness in her gait. The hip joints, and to a somewhat less extent, the knee joints appeared to be stiff. The toes turned in badly. There was no true spasticity, either in intentional walking or in the manipulation of the limbs. In walking, the arms made an associated flail-like movement, being bent at the elbow and the hands moving about on the fore-arms, approximating the horizontal position. She could pick up a coin with the right or left hand, but she had trouble in picking up three coins at a time with one hand. Her coordination was very imperfect, and was associated with excessive flexor movements. When asked to extend the arms in front of her with the fingers fully extended, the arms were held out fairly straight, but the back of the hand was overextended and the fingers flexed and spread apart. When the hands were supported complete extension was possible. The incoordination appeared only 011 intentional innervation of the arm muscles.
Associated with all her movements, even present when the child was seated, were contractures of the facial muscles, producing a continual grimacing. She was able, however, to sit quietly, and at these times the movements almost disappeared. The mother claimed that when sitting at table the most that she observed was a nodding motion of the head.
Marie’s articulation was very imperfect, slurred and rapid. Her voice was weak and rather toneless. All vowels and consonants were more or less affected, but even in my first examination she was able to repeat by imitation most of the articulate elements of the English language. She was unable to narrate the simplest occurrence in coherent form; she was invariably substituted for he, many words were left out and connecting links in the narrative were apt to be missing. At home she was treated in many ways like a baby; everything was done for her and nothing but obedience was exacted in return. She was entirely untaught, but she knew money, could count to twelve, and subtract one and two from numbers up to ten. She did not know her letters, or how to read.
To the trainer who was sent into Marie’s home, the task seemed indeed Herculean. How could this strange, incoherent, grimacing, stumbling child be helped, altered, made? For if the training was to be successful she had to be remade; it must be a new birth, only to be attained after months of painful effort on the child’s part, of endless tact and patience on that of the trainer. The treatment suggested was examination of the eyes, and of the naso-pharynx for adenoids. The following corrective measures were prescribed: (1) diet, baths, and general hygienic rules of life and exercise; (2) special training (a) to produce a quiescence of the over-active muscles, (b) to produce intentional movements without associated movements, (c) to confine the essential motor activity to the performance of simple tasks, walking, and running, and stop the involuntary movements of the face and tongue; (3) articulation exercises; and (4) the beginning of mental training, teaching the letters and simple problems in addition, subtraction, etc., in conjunction with the articulatory exercises. Care was taken to guard against over-exertion. It seemed to me that at the beginning Marie could stand little more than a few minutes of work with any intense application of attention. Two kinds of exercise were therefore recommended: (1) those in which the child was required to give a maximum of attention and was held rigidly to an assigned task. These were to be performed at frequent intervals during the day. The intermission and frequency of such exercises were to depend upon the observation of signs of fatigue in the child. (2) Free exercise in the form of games and play in which the child’s attention was relaxed or was gained through interest and held without effort.
Three years from the date of the trainer’s entrance on the work, she and the child lunched with me at my home. That day the contractions of the face were not present (though at some other times they persisted). This enabled one to appreciate the beauty of the soft, fair hair, the dark blue eyes, and darker lashes, the delicate contour of the little face. She was the life of the party. Her enunciation, quite clear and distinct, was easy to follow while she told anecdotes of a recent wedding in the family at which she had been present?anecdotes which revealed unusual quickness of observation, insight and humor. She handled her knife and fork well in spite of the fact that at times the contractions and jerks in the arms were very noticeable. Her mind was alive, she heard and understood all that was said, laughed gleefully at the little jokes, and added her quota with keen delight. After luncheon she rested on the couch and at my request she dictated to Mrs. Witmer the following anecdote, one of a number which had greatly entertained us at table and which I desired, if possible, to get word for word as she told them. She interrupted her narrative at intervals to interject special directions or remarks which I will put in parentheses. ” I suppose you know who Mr. and Mrs. Black are. Well, they always ask me if I am glad to go home or if I like the place I am in. The other day at table Mrs. Black asked me, ‘Are you glad to go to Atlantic City, Marie?’ (Spell it without the a; she always pronounces it M’rie.) I said, ‘Yes, but there is some other place I want more to go to.’ ‘Where?’ she asked. ‘To Philadelphia, to see Caterina,’ I answered. She looked at Mother with an inquiring gaze, and Mother answered, ‘She becomes very much attached to everybody who is with her and is nice to her.’ (Please underline race!) I said, with a spark in my eye (Is that too fancy?) ‘Caterina is not everybody.’ (Please underline everybody.) And I did not speak to her nor look that way through the meal. After dinner, I said, ‘Mother, I want to speak to you in private about that everybody.’ When I got her alone I said, ‘ I want you to understand that Caterina is not everybody.’ ‘Who is nice to you, I said,’ repeated Mother, ‘I wouldn’t like you if you were not that way.’ ‘Everybody?’ I repeated. ‘Oh, well, it is taken for granted you would be with nice people,’ protested Mother. ‘That may all be, but if you think you can take Caterina away from me and that I will be just as happy with some one else, you will be very much mistaken.’ ‘What would you do if Caterina married?’ Mother asked. I said, ‘Caterina is not a hired girl to marry and let me go out of her life.’ ” Later when she went down town with the trainer, her walk was like any other child’s and in the street car she attracted no attention whatever. Apparently she had only a step to take to join the ranks of normal children. Little of her former self remained, except the muscular contractions, and these varied with her physical and nervous condition.
By what process was this metamorphosis attained? How had it been accomplished? Against what odds? Imprisoned within this jerking, delicate little body, cut off from all the joys of childhood, there was a mind which for seven years had waited to be set free. And bit by bit, tearing down here, building there, strengthening, replacing old with new, the trainer under my direction had rebuilt the house, let in the doors and windows, set free the imprisoned ego, ?and to her surprise and delight this ego was artistic, fanciful, imaginative, humorous, charming.
The first year the greater part of the time was devoted to articulation, and to exercises for improving the gait. These would have been practically valueless without the correction of each step taken and of each word uttered. It was through countless commands of “Lift your feet, turn them out. I do not hear you; say it again plainly,” that after three months a slight but distinct improvement was manifest. Very soon she was able to articulate all sounds with the exception of ng and th, but these she mastered in six months. From the beginning the trainer taught her singing, and it proved of the greatest value. It was found that she could articulate correctly; it was combining sounds which proved most difficult. The drill therefore was on sentences, or verses, and she had to repeat one line at a time after the trainer. It must be remembered that all the time she had allied against her the motor disturbances of face and limbs, and her extreme frailty, which prevented the lessons being longer than a few minutes at a time?then rest, or play, then another lesson. It is not to be wondered at that at first, though very sweet tempered, the child rebelled over and over against the constant battering at formed habits, against the deadly tedium of correction. This showed itself in bursts of tears, in tearing and clawing at the trainer’s clothes like a small enraged animal. Three years later she was able to talk to the trainer about this period and confessed that then she hated one whom later she learned to adore. Very soon she was taught to play cribbage, and this alternated with her work in articulation and later in writing, as it proved a pleasant way to introduce a little arithmetic.
After a year’s work, the gait was much better as a whole though there were lapses owing to bodily weakness. Dancing was begun with good result. She was taught the simpler fancy dancing with arm as well as leg movements. The rolling back of the eyes had almost ceased, and the enunciation at its best was understandable. She had learned to use her voice in the singing of scales and old French nursery songs. In the beginning she could not even control it sufficiently to call any one’s name so that the sound would carry. She was taught French as part of her articulation work, for the value of its lip training and also with the idea that in a new language she would not have the old speech habits to combat, and this supposition proved correct. She learned to read a little French, her accent being unusually good.
Adenoids had been discovered when the child was two years old but the mother had refused to have them removed. It was only through my insistence after she had been in my care for two years that it was finally decided upon. The surgeon who removed the tonsils as well as the adenoids is reported as saying that it was one of the worse cases he ever operated on. No immediate effects of the operation were observed but the following winter was the best she had ever had.
Marie was bored with the toys most children love. This was especially true of dolls. When the trainer arrived she found Marie’s chief pleasure and excitement had been in dressing up. She never wearied of it, and when one of the little girls of the neighborhood came to play with her, she pressed her into the game also. There were several reasons why the trainer thought it wise to discourage an excess in this one direction. It was always rather exhausting, and left the child over-tired; then all her peculiarities of look and manner seemed to be accentuated by the silks and laces and ribbons in which she was decked, and it was thought best to limit this indulgence to once a week. Instead, the trainer encouraged the dramatic instinct dormant in the child by telling her fairy tales. Then, when these palled?principally it appeared because “they lived happily ever after”?she read aloud Charles and Mary Lamb’s
A FETTERED MIND 247
“Tales from Shakespeare.” Here certainly there was no surfeit of happy endings, especially as Hamlet, and Romeo and Juliet were the favorites, and were called for again and again. The quarrel between the two great Houses made a deep impression. It was straightway related to the cook?a firm ally?who must have thrown new light on it,.for the next question to greet the trainer was?”Didn’t you say Juliet was a cantaloupe? Well it commences with a K anyhow.” She learned by heart parts of these two tragedies and the contrast between the frail, shaken, little figure and the force she threw into such lines as, “As thou’rt a man, give me the cup; let go, by Heaven, I’ll have it,” made the recitals memorable. This dramatic appreciation was shown also in her drawings, which made up in boldness of conception what they lacked in correctness of line. The small trembling fingers had always loved to draw, the sense of color being extraordinarily good, and most of the stories told were forthwith illustrated on paper with colored crayons. Even at the time of the trainer’s advent the child could pick out in a moment not only every separate color but could differentiate between a pink lilac and a blue lilac and other delicate gradations of tone.
After Shakespeare’s tales, came the stories of the operas, German and Italian, which the trainer told with as few necessary changes as possible. The stories of the German operas took the strongest hold on her imagination and were each illustrated in turn. The meeting of Vanderdecken and Senta was especially beloved and on this she tried her hand again and again. A phonograph and a playerpiano which she pedalled herself made many of the leading motifs familiar. Thus, little by little through these various channels, there came to the child, light, color, music, people who did and said interesting things, a new and fascinating world. In the fall of the second year she was practically unable to read, but only one year later she was reading “Cranford” aloud to her trainer, and laughing at Miss Mattie and Miss Deborah. Sewing she loved. She would outline patterns in various colored silks, sometimes, owing to the motor disturbances, making ten trials before she finally hit the right spot with her needle.
These muscular contractions were a subject of much thought and discussion between her and the trainer. They were known familiarly as the “gorgons” and it was understood that as far as it lay in her power they must be fought and ultimately conquered. In time the child herself entered intelligently into the work with a better understanding of what the struggle meant to her. Marie differed more from other children in her mental life than in her outward appearance. In Scotland she would have been called an “innocent,” and here probably was the key to her unlikeness. For the little girls of her own age who came and went were in no sense innocents. They were their mothers, aunts, grown sisters in miniature with the standards of the little town in which they lived. Beside them Marie shone out as one who knew no evil, lived in a dream world, loving, unselfish, tender hearted. Take an instance of these early days. The trainer had been painting her a future of glorious color, the reward of her patience under the rigorous training. “And what will you be doing, Caterina”? “I do not know. Does it matter”? “Why, yes”?a little shyly?”I want you to be happy too.”
Up to the end of the first year of training, Marie had rarely, if ever, gone through the process known as thinking. All that the child’s clouded mind could grasp had been instantly retailed to the family or servants. It seemed to the trainer that to make Marie distinguish what ought to be and what ought not to be repeated was in the nature of an intellectual exercise, and had a marked educational value. Therefore in their daily intercourse this discrimination was exacted, with the result that by the end of two years the trainer found herself out-distanced in the difficult art of discreet repetition.
Marie had always been subject to outbursts of weeping which left her exhausted. Her family had taken the attitude that when these fits of crying were over, the child was to be praised and petted, and given something she liked as a reward for stopping. The trainer attacked these emotional out-breaks at once, and used very different methods. The tears were referred to as “turning on the water works,” and in time Marie was made to see that the injured person was not herself but her teacher. She grew to take pride in narrating how she had fought and conquered one of these fits of crying. When left alone with her family for several months, this emotional weakness would reappear, together with other bad habits which were held in check by the trainer’s influence and watchful care. Marie never saw anything as she walked along the street, never in her own house heard any of the conversation which went on around her. When questioned on these points, she said, “I seem to be off somewhere.” As soon as her gait had been noticeably improved, she was taught to bow to the people on the street who spoke to her, and to notice persons and objects on the road. In the beginning of the third and as it happened, the last year of training she was taken to a well known aurist who pronounced her hearing defective. This accounted in some measure for her inabilA FETTERED MIND 249 ity to take in general conversation, and also for her constant ” What? What was it?” After her deafness was known, the trainer always spoke very distinctly but never repeated her remarks or answered the child’s frequent ” What? ” In spite of this Marie could invariably repeat what had been said to her, showing that inattention and absent-mindedness played a large part in her failure to comprehend. She ceased in time to say “What?” to her trainer, finding it useless, but in her intercourse with her family it was constantly on her lips. She included these petitions in her morning and evening prayers,? “To speak plainly, to be as quiet as possible, to pay attention to what goes on around me, to sit up straight and be brisk.” The “quiet” referred of course to the motor disturbances. She had always been allowed an indefinite time to make up her mind about anything. This had grown into a torpidity of thought, hence the petition to be “brisk”. She understood that it was her thought and not her body which was being hurried up.
By the following spring it had become increasingly evident that the work could not go on much further under the existing conditions. The child’s famify were holding her back, through ignorance as to the physical requirements in the case, as well as through inability to grasp the value of the work and to assist in its progress.
The proposal was therefore made to them that they should allow the child to come to Philadelphia with her trainer and be under my direct supervision and in the care of certain physicians for a trial experiment of six months. This they absolutely refused to do and I was therefore reluctantly compelled to give up the case and recall the trainer.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.