The Outlook for James: A Clinic Teacher’s Report
- Author:
Sarah Warfield Parker, A. B.
Graduate Student, University of Pennsylvania. It was a few months before his seventeenth birthday, when we first saw James. He stood awkwardly, with his right hand fussily buttoning and unbuttoning the bottom button of his coat. He seemed of normal size, without conspicuous stigmata, a boy who might have passed in a crowd for nothing more than a poor-spirited “sissy.” An offensive breath, a malodorous body, and a dirty eruption spreading over his face, made him unattractive, but, sad to say, not abnormal. The bovine mildness of his expression shifted to something a shade less open as his brown eyes feebly refused to meet ours. The mouth was not wide, but the lips were thick and the tongue slipped over them constantly, leaving them moist and red. To add the finishing touch to this unprepossessing appearance, the boy lifted his hand weakly and dragged the fingers through his short, oily hair, so that straight wisps stuck out untidily at every angle.
James walked across the room with a queer, shuffling gait, thumping as though he walked in clogs. The right leg dragged as if it were weaker and possibly shorter. The grip of his hand too was weak, especially of the right. When he spoke the words came hesitatingly, often with a forced facetiousness that was vacuous and ineffective.
“Right hemiplegia; right hemiparesis remaining; apparently about 80 per cent of development and 60 per cent of power on right as compared with left.” This was the diagnosis of James’ physical condition. He came of a respected and well-to-do family, of parents apparently in good health. The meagre family history yields but one interesting item,?dysthyroidism in the mother’s family. From the incomplete birth history, the hemiplegia would appear to be either natal or prenatal, or the result of uremic poisoning in the first two weeks after birth. James was the third child, the first being lost at seven months through a miscarriage, the second at the third month. In the third period of pregnancy, the mother was again threatened with a miscarriage at the third month, but carried the child over to the seventh month, when James was born prematurely. After two weeks, it was found that the child was suffering from uremic poisoning, and possibly from Bright’s disease. At that time also, he had frequent convulsions. It was with great difficulty that he was made to take food. The description of the baby in these first weeks is consistent with the symptoms of diplegia or hemiplegia, although a physician who examined the child at the end of the third week, stated that there was nothing organically wrong with him.
The convulsions did not leave him with any perceptible paralysis, but he was slow in walking and talking. When he was two years old, he began to walk, with great difficulty, however, in the use of the right leg. The trouble was ascribed to a shorter Achilles tendon, which was spliced when the boy was four or five years old, an expedient which only partly alleviated the difficulty. After a mental examination by Dr Lightner Witmer, James was referred to an oculist and a neurologist. The oculist reported: “His optic nerves, choroid, and retina are perfectly healthy, not even suspected of being pathological. There are no changes in the pupils, or extra-ocular muscles. He has binocular vision and the vision of each eye is practically normal.” The neurologist reported a slight heart murmur and low blood pressure. James was brought to Dr Witmer shortly after the end of his sixteenth year, because he was not “getting on” in the second form of the Boys’ Academy in his home city. The second form probably corresponds to the seventh or eighth grammar grade. In reality James would not have “got on” had he been in the third, or even the first grade. His mental deficiency was a result of the cerebral condition which produced James’s hemiplegia,?”a defective development of the cellular elements of the cortical, and particularly of the pyramidal cells?not restricted to any one part of the brain but involving all parts of the hemispheres about equally.”1
A review of some of the cerebral changes as indicated in Professor Eugenio Tanzi’s chapter on “infantile cerebropathies” may help us to interpret James’s defective reactions. Professor Tanzi2 agrees with Dr Sachs that in the greater number of cases, the pathological condition in infantile cerebropathies is not confined to the area immediately adjacent to the lesion, but spreads over a wider area by the effusion of blood throughout the cortex. He summarizes the anatomical disturbances as “atrophy of the nervous elements and excessive proliferation of the neuroglia.”3 He ?Sachs, Bernhard, M.D. A Treatise on the nervjus diseases of children. New York J William Wood & Co., 1895.
2 Tanzi, Eugenio. A Text book of mental diseases. Translated from the Italian by W. Ford Robertson, M.D., and T. C. MaoKentie, M.D. New York: Rebman Company, 1909. (Reprint 1911.) Pp. 444-471. 8 Ibid. p. 445.
states as his opinion, that the “associative centers are those most exposed to the first assault and to the further diffusion of the disease, for the reason that they present a mark which is more widely dispersed and collectively larger.”1 Prof. Tanzi describes the condition of the mental processes and the effect upon the character of cerebropathic patients. “The active army of the mind is composed of an abnormally small number of cells, which at the same time are poorly supplied with dendrites, badly nourished by an impoverished organism and poorly stimulated by a sense of bodily need; ideation is scanty and slow and has neither the occasion nor the power to increase its strength.”2 As a result, the majority of such patients “seem to be dominated by a profound apathy.”3 They, “more than any others, exhibit characters of a negative nature, or of deficiency, such as want of affection, anideism, alalia, and inactivity. Their violence, tempers, and misdemeanors have an origin that is visceral, reflex, or instinctive rather than psychical.”4 James’s history would indicate that his is the type of hemiplegia in which the paralysis is slight and the psychical cerebroplegia very much greater. The physician admittedly can do little to remedy this. “As we have to deal in these conditions with morbid processes that profoundly damage the brain, which compromise the development of specific and irreplaceable elements, which destroy one part of the brain and arrest or prevent the development of the whole organ, it is obvious that medical intervention cannot effect much of value.”5 It therefore devolves upon psychology to analyze the reactions which are the symptoms of this pathology, especially in relation to the learning process, in an effort to determine by what steps and to what extent, special training can repair the inefficiency of the cerebral mechanism. James entered a small home school in the country, January 7, 1915. At that time his behaviour corresponded to the description of the typical case of infantile cerebropathy,?apathy, delayed transmission of impulses along the sensory and motor tracts, defective association, and symptoms of slight alalia. These characteristics of behaviour had a common mechanical basis in the defective apparatus for sending the nerve currents from one cell to another,?i. e. ill-nourished cells without adequate energy and adequate receptive dendritic processes.
Apathetic James certainly was. He had no “spunk.” He i Ibid, p. 445. a/Wei. p. 461. ?Ibid, p. 461. * Ibid, p. 460. ? Ibid, p. 469.
knuckled under to the strongest, and he did it meekly, meanly. A boy might taunt him, call him “coward,” “sissy”?there was no retort; but let that boy touch James in the merest good-humored tussle, and James trembled with hot, futile fury?that “visceral, reflex, or instinctive” anger of which Tanzi speaks. I have seen him thick-skinned, indifferent, under the coldest snub, and I have seen him trapped in the children’s sand-pit at the seashore, wild, flushed, with teeth set. He rested in complacent satisfaction with his own clothes, his own family, his own mind, his own work. The cruellest thrusts of his teacher, directed in an effort to sting him into energetic action, did not stir him from his meek quiescenec. Twice, when a sharp quick rap across the knuckles was tried as an experiment, James turned crimson and set himself to his work with grim energy No amount of training can lift him out of the sluggishness which is the direct symptom of his diseased brain. Thyroid extract given to him, three grains a day, for several months during 1915, produced a slight but yet perceptible quickening of energy. Hours of work in the garden with a hoe stirred him physically with the same minute but favorable result. These two factors can reduce but cannot cure his apathy. The value of attempts to stir James through his irritability to even slight physical stimulus is open to question. On the one hand, such access of energy is only momentary and may have no developmental effect. On the other hand, the sum of such stirrings may break the habit of mental inertia and contribute its quota to an awakening of energy. The signal of really hopeful effective improvement must be an impulse self-initiated. It will never come solely through the factors which we have in our control. All we can do is to stir his physical and mental organism to as much activity as we can stimulate, while we await, meanwhile, a more potent ally in the natural recuperative energy of the nerve tissues. Speed is to be considered quite apart from apathy or lack of initiative. James’s motor reactions are slow. It took him half an hour, working steadily and attentively, to fold and place on the table the scattered sheets of two Sunday newspapers. No test, nothing more than a minute’s observation, is needed to convince one that he is painfully, distressingly slow. Here, however, there is chance for improvement under discipline. His purely motor reactions cannot be quickened, nor has he sufficient energy to be trained into alert readiness for a signal. But to his slowness is added deliberation. By insistent drill he can be made to eliminate some of the stupid useless movements and comments which delay his reactions… . I am sorry to keep you so long, I had to turn this page. You see it had to go this way instead of that way.” He will stand slouching in the middle of the floor, muttering: “I’m going to try to hurry now ?I shan’t be long this time?I’m sorry that I’m so slow.” James’ slowness is a functional disability, but this deliberation is a habit which should respond to training.
A pack of eighty cards, consisting of ten suits of eight cards each, having printed on each respectively one of the ten form-board geometric figures, was used to determine by test this trainability of motor reactions. Duplicate figures were arranged in a given order and James was required to sort the cards as rapidly as possible upon the corresponding positions. This procedure was repeated ten times, the time of each sorting being recorded. The practice curve obtained is in a measure an index of how much increase of speed we can stimulate in James by motor training. This practice curve indicates that though of course, his gross rate is higher throughout than that of a normal adult, he responds markedly to practice. Therefore we may infer that discipline and drill will accomplish something to speed up his motor reactions. Reactions which follow processes involving simple psychic functions come less slowly than one might expect. James’ reaction time has been tested only roughly, but the results give an impression of his responses.
Speed Tests.
Test 1, February 15, 1915. Woodworth and Wells,1 Number Checking Test, a blank on which are printed 500 digits in ten rows of fifty each, so arranged that each digit occurs with equal frequency in each row. The subject is directed to draw a line through each cipher on the blank,?a test involving simple recognition and motor response.
Comparative Time Record. James?no errors 185 sec. Imbecile (probably H. G. I.) (14 years) 157 ” Moron (15 years) 85 ” Range for six university students tested by Woodworth and Wells 50-100 ” Average for six university students tested by Woodworth and Wells 66* ” Test 2, February 14, 1915. Woodworth and Wells, Color Naming Test,2 a blank’ on which fifty squares of red, yellow, blue, green and black are arranged in rows of ten. The entire blank is exposed and the subject names the colors in sequence as seen. This test involves recognition and voco-motor response. ‘Woodworth, R. S., and Wells, F. L., Association Tests. Psychological Review (Reprint), Vol. VIII. No. 5, December, 1911, pp. 24-29. 2 Ibid, pp. 49-52. Comparative Time Record. James 45 sec. Moron (15 years) 35 ” Low grade imbecile (with verbal faculty highly developed) 75 ” Range for Woodworth and Wells’ graduate students 22-41 ” This test, repeated on May 30, 1915, when James showed an access of energy after a month at the sea shore, gave nearly the same result, 43 seconds. Test 8, February 17, 1915. Woodworth and Wells’ Form Naming Test, a blank similar to above with five geometrical forms substituted for color squares. Comparative Time Record. James 80 sec. Moron (15 years) 60 ” Imbecile (probably H.G.I.) 50 ” Range for Woodworth and Wells’ graduate students(14) 31-60 ” A repetition of this test on May 30, 1915, showed a drop to 70 seconds?a gain of 10 seconds. Test 4, May 31,1915. Cylinder Test, a set of twenty wooden cylinders of graduated depth and diameter, to be replaced as rapidly as possible in their respective recesses in a circular wooden frame. Comparative Time Record. 1st trial 2d trial 3d trial James 70 sec. 43 sec. 80 sec. Moron (15 years) 74 ” 53 ” 50 ” H. G. I. (15 years) 113 ” 52 ” 89 ” Adult 1 53 ” 33 ” 30 ” Adult II 40 ” 32 ” 35 “
James’s practice record for ten trials was (1) 70 sec.; (2) 43 sec.; (3) 80 sec.; (4) 99sec.; (5) 73 sec.; (6)74sec.; (7) 66sec.; (8)61 sec.; (9) 49 sec.; (10) 55 sec. This record is significant in its unevenness and surprising in its occasional success in attaining normal speed. Test 5, May 31, 1915. Peg Board, a wooden board in which are thirty-six round holes, and a tray containing in one compartment four dozen white pegs and in another compartment one dozen each of red, blue, green, and yellow pegs. The subject is first directed to fill the holes with white pegs as rapidly as possible.
Comparative Record.
James used left hand, placing one peg at a time; coordination scarcely fair; attention persistent; energy 1 (lowest) on a scale of five; planful in that he placed pegs in an orderly way, row by row. Time 78 sec.
Moron (15 years) used two hands, taking up several pegs at a time; coordination fair but broken by nervous excitability; twisted the board, dropped pegs and wasted much energy; planful but not consistent; energy, nervous. Time 45 sec. H. G. I. (15 years) used left hand 94 sec. Adult 1 36 ” Adult II 42 ” The subject is then directed to put in a row of red pegs. After carrying out this direction he is directed successively to put in a row of each one of the remaining colors.
James showed no defect in color discrimination. He understood and followed directions, and displayed more initiative than we were accustomed to expect of him, suggesting another color as soon as he had finished with the preceding one.
Test 6, May 9,1915. Association Test, Carl G. Jung Association Blank,1 a series of 100 words arranged by Carl G. Jung. The subject, seated with back to experimenter responds with any word suggested by stimulus word, and the reaction word is recorded. The time between pronunciation of stimulus word by experimenter and hearing of response is taken by stop watch. Time Record. Mean reaction time 3.4 sec. Average deviation 1.5 ” Range 1.0-10.2 ” This reaction time is surprisingly normal. There are no comparative statistics available but I have the statement of a professor of psychology who has used this blank with several classes of university students, that the normal adult range is 0.8-3.2 with the mode at 1.4. It is especially remarkable that James does not show a wider deviation. Test 7, January 23, 1915. Number of words pronounced in three minutes. James 74 words Moron (15 years) 159 ” Imbecile (H. G. I.) 47 ” Passing mark for 12 years (Binet) 60 ” Binet record 218 ” James’s record is slow but passable. Test 8, May 9, 1915. Fifteen Minute Test, number of words written in fifteen minutes. ?Woodworth and Wells, op. cit., pp. 50-51. 78 THE PSYCHOLOGICAL CLINIC. Number of Words. 12 5 8 10 15 min. min. min. min. min. min. James 7 13 33 64 80 114 Moron (15 years) 44 112 168 203 293 The slowness of James’s thought expressed in motor reactions shows a bit more significantly here, but there is no startling evidence of the retardation of his mental activity until we find him grappling with a more complex problem. The nine tests described above are either simple free association tests, or tests involving simple recognition and association with a single motor reaction. In such tests James falls a little below the lowest average. In a controlled association test, such as the “easiest opposite” series of twenty words, arranged by Woodworh and Wells,1 James fails. Out of twenty reactions, only four were correct responses. And in failing he was so slow that his reaction time is approximately five and a half times that of the middle or high grade imbecile with whom his record is compared, and eight times that of the moron mentioned above. It is thus, when we come to the association of simple sequences and the purposeful selection of a correct response, that we come to the serious obstruction in James’s mind, the psychic seat of his slow response to the problems with which he is daily confronted. Tanzi states that the association areas are open to the most insidious attacks of hemiplegia. It is precisely in this function of association that we find James’s most serious deficiency. To discuss understandingly the evidence of this defect, and to determine just what is the effect of this deficiency upon the learning process we must attempt a tentative analysis of that process itself.
There are probably three processes of mind fundamental to the learning process,?attention, imagination, and memory. Under the caption of attention, we must consider analytic and persistent concentration, and distribution of attention; under imagination, intensity and associability; under memory, trainability as measured by the number of repetitions necessary to fix an image, and retentiveness. These, subject to the direction of the volitional elements of mind, control and initiative, are the fundamental factors in the learning process.
From a pedagogical point of view, attention is the first to be considered, because it is the active element in education. When we say that a child must be prepared for school work, we mean that his attention must be trained. It is to that function of mind, that we either consciously or unconsciously direct our efforts. James needed ? Woodworth and Wella, op. pp. 59-60.
no such preparation for study. His attention was good. He had the capacity for analytic concentration,?that is to say, he could separate into component parts the sensational elements of his perception. This conclusion is based on daily observation; the quickness with which James singled out birds and flowers in the fields, the adequacy of his observations of pictures and maps. Perhaps to quote his descriptions of two pictures which he had observed minutely for sixty seconds, will indicate something of the evidences in behavior on which this inference is based. “I saw a large man and a little boy. The man’s hair was dark and rough. He had a little twist on the top of it. His face was white. He had a blue coat on. You could not see his hands because they were in the pockets. He had a black vest under his coat. His trousers were black and white dotted-white with black dots. He had black boots on. The man was looking towards the little boy. The little boy was looking toward the man. The little boy’s hair was dark and rough. His face was white. He had a blue suit on. His shoes were black.” “I saw a boy who had Scotch clothes on. He was holding up a cat in one hand. He had a Scotch plaid on?blue with white waist. His stockings were Scotch. His cap was Scotch, too?blue. His shoes were black, and the upper part white with buttons down both shoes. His hair looked shaggy. The back-ground was dark. I saw a thing which said Valentine in blue. Right across from the Scotch boy there was a little boy looking at the Scotch boy. His hair was dark. He had a blue suit on, and shoes. They were standing still. The Scotch boy was looking at the little boy and the little boy was looking at the Scotch boy.”
To be sure, his pathological lethargy often prevented the volitional element of initiative from acting so as to use effectively this capacity for analytic concentration. He was lacking likewise in the ability to follow analysis with synthesis,?that is, to pass again from the state of concentration to the state of diffusion. That, I believe, however, is a process of associating part with part to form a whole and comes rather under the caption of association.
James’s persistent concentration was equally good. He stuck to each task perseveringly without flagging of effort or interest. In distribution, likewise, there appeared no observable defect. He therefore had all the qualities of attention which are fundamental to the learning process.
Imagination we have chosen to discuss from two points of view, intensity, and associability. The intensity of James’s images, especially visual, seemed to be normal. He remembered readily birds and flowers which he saw. He remembered accurately the map which he studied. He could reproduce from his image simple designs made out of four design blocks.
The intensity of visual images was apparently of relatively high order. Auditory images were probably normal. He remembered and recognized bird calls without effort. Response to practice in motor training which we have discussed would indicate normal motor images. His voco-motor images, too, in all probability, were not defective, since he had no particular difficulty in remembering words and names. There was no evidence of defect in the intensity of imagination.
The subject of associability is to us the most important. We have to consider it in three divisions, although the third somewhat overlaps the first two:?(1) sequence in association, (2) logical relation in association, (3) recall. Sequence in association involves what we commonly call memory span. It is the linking of images in simple series. In this first and simplest element of association James is deficient. The following shows his memory span to be approximately that of an eight year old child.
Presentation Visual Auditory Digits 5 5 Letters 5 5 Monosyllables (disconnected) .. 4 ? Syllables in sentence .. 10-12 Colors 3 5 Symbols in sequence as (H? AO) 4 Logical relation in association is emphatically ” controlled association.” James’s fairly good reaction time in the Jung Association Test and the ease with which he responded to the Kent and Rosanoff series of one hundred words,1 would indicate that in relatively free association he is not conspicuously defective. We would conclude that his association areas are not so much inert as chaotic. When an ordered response is required, James’s lack of control over his associations is striking. The time it takes to establish or attempt to establish such a control is shown in his extraordinarily long reaction time in response to the “easiest opposite” association test. The frequent failure of effort to establish that control appears in the character of the responses which follow: 1 Kent, Grace Helen, and Rosanoff, A. J., M.D. A Study of association in insanity. American Journal oj Insanity, Vol. LXVII, Nos. 1 and 2, 1910. THE OUTLOOK FOR JAMES. 81 I Easiest Opposite Association Test. Stimulus Reaction High High?height Summer summer?hot Out out?in White white?”I can’t do it.!; Slow slow?not slow?fast Yes said Above above?I can’t North south Top top?tip Wet wet, damp Good good?worse Rich poor Up up?out Front side Long long?along Hot warm East west Day short Big high Love love?”why, just love.”
Recall is itself nothing but controlled association?the ability to produce at will two or more images linked by sequence or logical relation. James was consequently distinctly weak in recall. A stimulus word seemed to be flung into a chaos of images, and it was only by happy accident that it met its mate. The answers to such a question as, “What body of water is south of Europe?” are typical. Sometimes it hit the group of images linked under the caption “body of water,” and the response was Black Sea, or any other ocean or sea that immediately came to mind. Sometimes it penetrated to a smaller subdivision of ideas,?”body of water south of”?and the answer was Indian Ocean. Not until after many days of drill could one have any reasonable expectation of a correct answer. In every phase of controlled association, James was extraordinarily weak. In memory there is no corresponding defect. A simple image is fixed without a great number of repetitions. It is the association of images that must be fixed by drill. In retentiveness, there is the same situation. James remembers well what is taught to him, but his mind seems a vast chaotic store of images linked in very elementary sequences, which are practically unassociated with each other. It seems very probable that James has no fundamental mental defect other than that in the process of imagination which we call associability. That function is so essential, however, to the learning process, and his deficiency in it is so great, that our reduction of James’s mental defects to a single process does not contribute to a hopeful prognosis. Only physiological strengthening of the brain cells will establish the stability of association tracts which can correct this condition. In training James, the most we can do is to attempt by drill to fix certain associations.
If this defect of association interferes so gravely with the simple acquirement of facts, it is only to be expected that it would affect even more gravely the higher phases of the learning process involved in reasoning. Probably analytic concentration of attention and controlled association, especially that type which we call logical relation are the chief constituent processes leading to the conclusion which we call reason. In the solution of every problem, there must be analysis and there must be synthesis?that is, constructive association.
We have presented certain instances of behavior from which we infer that James had the first element?analytic concentration ?at least in relation to concrete perceptions and images. This type of concentration of attention varied inversely, as the material presented to consciousness became more general and abstract. The major part of the boy’s defect in the faculty of reason, however, was due to his defect in constructive association.
In the description of the pictures, which have been used for illustrative material, we find a rather unusually minute selection of details, but not a sentence that describes the picture as a whole. He made no spontaneous effort to interpret the situation. In answer to questions he never showed that he understood what was happening. He could not construct the unit-details into a significant whole. In the same way, he failed to interpret the Binet pictures, receiving credit only for a type of description acceptable from a seven-year-old child. He could not construct a single sentence containing the three words,?Paris, fortune, stream, but presented instead three sentences:?”Paris is the capital of France and there I had my fortune told. There is a stream of water in France.” Of course he could not reconstruct the jumbled sentences in the Binet test. James was given in May the Trabue Language Scale A, which is essentially a completion test, consisting of sentences with omitted words to be filled in by the subject. He attempted sentences up to the seventh grade, but failed in one fourth grade, one fifth grade, one sixth grade, and one seventh grade sentence. This performance gives him a mark of sixteen points, which according to Mr. Trabue’s figures, ranks him with third grade children.
Woodworth and Wells, in their book on “Association Tests,” publish three interesting and rather amusing blanks designed to test the ability of a subject to understand directions.1 On one of the two simpler blanks (in which the reactions were based on relatively simple processes of association), James did very well. On the more difficult blank, where more of the element of selective attention and constructive association entered in, James’s mark for comprehension was not above 50 per cent.
In the same way, James failed on all the Binet tests that depended upon an effort of reason, except in the simple problems of behavior, which a nine-year-old boy is supposed to pass. A record of his responses speaks for itself: Ten Year Old Test III, Detecting Absurdities. Q. “An unlucky bicycle rider fell on his head and was instantly killed; they took him to the hospital and fear that he cannot get well.” What is foolish in that? A. Why didn’t they bandage his head as soon as he got there? Q. “I have three brothers, Paul, Ernest, and myself.” What is foolish in that?
A. He could have one more brother without counting himself. Q. “The body of a young girl cut into eighteen pieces was found yesterday. People think that she killed herself.” What is foolish in that? A. How could she kill herself without a gun or a knife or there would be some man coming along that would kill her and be a little out of his head. Q. “There was a railroad accident yesterday but not a serious one. Only 48 persons were killed.” A. There couldn’t be a railroad accident unless the train ran over the bank or off a track. That might have killed 48 persons. That’s all unless somebody wanted to kill them. To the final question about the ill-luck of suicide on Friday, James could give no response. The whole series shows an effort to reason combined with inability to reconstruct effectively the situation indicated. He failed also on the series of five problems of action for the ten-year-old child, and was of course unable to explain the situation indicated in the final fifteen-year-old test: Q. “My neighbor has just received some significant visits; one after another, a doctor, a lawyer, and a priest called. What is happening at my neighbor’s?” 1 Woodworth and Wells, op. cit. A. Doctor there to help her, priest there to a dinner and lawyer because she wants to make some new laws.
The persistence of this inability to reason showed itself particularly when James was confronted with the simple problems of arithmetic. He is seventeen years old. He cannot make change. He cannot count the cost of three two-cent stamps and three onecent stamps. On the morning of February 23, 1915, James was given four stamps, a number of pennies, and the problem,?”How much will four stamps cost at two cents each?” He was directed to draw four stamps and under each stamp to draw the number of pennies he must pay for it. This simple problem was given after six weeks practice in writing out solutions. This was the result:?”If I have 4 stamps then to make four stamps I will have to put with 2 stamps the difference between 4 stamps?2 stamps =2 stamps. Ans.” On February 25, one half hour was taken to explain to him this example, with stamps and pennies before him. With the pile of eight pennies still on the desk in front of him, James wrote: “If I have 4 2-stamps then I must divide 4-f-2 = 2 pennies. Ans.” The explanation of James’s failure to “get on” in the second form, lies in this lack of control over association, showing itself in a grave defect in recall and in reasoning. It is easy’ to summarize exactly the extent of the consequent pedagogical retardation by outlining his school status. According to the diagnosis of the clinical examiner, according to the Binet tests, and according to his general school progress, James has, in the main, developed no further than the nine-year-old-child.
James, since he has normal kinaesthetic and visual images, has learned to write legibly but carelessly a handwriting worth perhaps 40 per cent by the Ayres Scale. He has learned to spell certainly no better than the third grade child. When he was first tested, January, 1915, with twenty words chosen at random from the first five years of Rice’s Spelling Book, he made the following records. Grade 1 95 per cent ii..: 80 ” ” III 80 ” ” IV…. 65 ” ” V…. 50 ” ” The types of error were four: (1) confusion, as “rageages” for wages; (2) omission, “conveent” for convenient; (3) phonetic, “exsalunt” for excellent; (4) inversion, “Adiartic” for Adriatic; “Scandinvania” for Scandinavia. This last was the prevailing type of error. James can learn to spell readily, especially if he sees the words. It takes constant drill, however, to fix the letter order so that it will persist in spite of the confusion of association. This recurrence of inversion of letters is typical. All the letters are there, but you can never be sure in exactly what order they will come out. Leonard P. Ayres’ “Scale for Measuring Ability in Spelling,” which was published in April, 1915, offers a more accurate measure of James’s efficiency in spelling. The Ayres Scale has a practical basis in the “thousand commonest words in English writing.”
According to this scale James has ability in spelling somewhat greater than that of the average fourth grade child. The following table compares his ability on June 2, 1915 with Mr. Ayres’ standards for the Fourth Grade: Column Fourth Grade. James. 100 100 100 100 C j D 100’100 100,100 100 100 100 94 H 100 94 R 50 i 53’ 43 James’s reading is atrocious. It is not that he doesn’t know words. He has a good reading vocabulary, and with allowance for his defect in reasoning and in reconstructing the elements of a situation, his comprehension is good. But it is here more than anywhere else that we see the evidences of hemiplegic alalia,?that is, difficulty in articulation. In January, James’s reading was almost unintelligible; he hesitated, repeated at least three-fourths of the words, and miscalled more than half. The slowness of the association of the word seen with muscular coordinations of speech is true alalia?a pathological condition beyond the boy’s control. The major part of his bad reading, nevertheless, is a habit. In his effort to go faster than is physiologically possible, he jumped to the first idea that came, and more than 50 per cent of the words were miscalled. In his efforts to fill in the gaps, to gain time to make his coordinations for the next articulation, he repeated the words immediately preceding. Four months of drill, in which his teacher has sat through many painful hours listening to his halting, stuttering voice, have quite markedly improved his reading through the elimination in part of these long-established habits. There is nothing that pleases him more than to be allowed to read aloud, so that his interest is a positive ally in establishing by practise steadier habits of reading. James’ status in arithmetic is not encouraging. In fundamental processes he is slow but fairly accurate. The association sequences involved are simple enough for him to learn, and he knows them satisfactorily, subject however to an occasional characteristic slip of association. In reasoning, obviously, his mark is zero. In January, the Courtis Arithmetic Tests were given to James but his motor reactions are so slow that his grading in the mechanical processes was scarcely a fair index of his capacity, though doubtless placing him justly on the efficiency scale. Of decimals, he knows something; of fractions, less.
The first composition James wrote in the school, January 15,1915, carries in itself the evidence of his status in English composition: “The Boy and the Wolf.
“A Little Shapard was keeping his flocks a little way out of the village. And he came rushing into the village crying a wolf was after one of is had lambs. And he ran for help and twice or three times the work men dropped is work and want to help him but when he got there they were only laugh at and nobody paid any heed to them. And they were though him of his joke and that was how he lost his flock.”
The four months following showed a gradual improvement in sentence structure, the elimination of confused and careless constructions. He could write a letter or a diary, lucidly following sequence in time. There seemed to be little improvement, however, in his grasp of more complex associations and the ability to comprehend and reproduce the elements of a simple plot.
Of history and geography James had learned and retained a great deal, but knew nothing,?that is to say, his mind was stored with a vast number of facts wholly unassociated and all subject to the most amazing inaccuracy of recall. In these subjects, his training demanded not so much teaching as sorting and cataloguing. The attempt was made, first to bring some order into his jumble of geographic facts. This subject was chosen for several reasons. Geography was one of his pronounced interests; it was the subject of which he already knew most, and map study was a method of work which allowed us to use to the full his accurate concrete visual imagery. The work met with a fair measure of success. James gradually came to be able mentally to select units from his very clear image of the map of Europe, and in the simplest way to recombine them with other units. This is the first element in reasoning, and in exercising it he was keeping alive that segment of the reasoning faculty which he possessed. The task of establishing ordered associations was necessarily a slow one because its basis was drill and patient repetition. At the end of four months, James knew thoroughly the most important facts about nine of the countries of Europe. In so far as effective associations could be established in his unstable mind, they were established. There had been fixed a high probability of a correct response to questions reating to this mass of information, yet sometimes scattered through a long series of questions, the drilled association would fail to hold and each sequence would have its turn at failure.
The work in geography served further as a disciplinary exercise. The cholalic habit of repetition was almost entirely eliminated, and the unnecessary factors serving to lengthen reaction time minimized, so that three or four seconds was the standard reaction time in responding to questions.
A conclusion as to wise procedure in the further handling of this case must be based on a review of the situation outlined in the preceding pages.
James is a boy whose mental development has been so arrested by cerebropathic conditions, that in seventeen years his progress in school has been less than that of a normal nine-year-old child. The only functional defects seem to be a general lethargy, evidenced in apathy, a somewhat slow rate in motor reactions, and a lack of control over the association of images, gravely impairing the faculty of recall and reasoning. Such a review suggests several recommendations:?(1) The continuation of thyroid extract and physical outdoor work to diminish James’s physical and mental apathy; and keep him wholesomely occupied; (2) insistent discipline to eliminate faulty habits of deliberation, repetition, and useless reactions which reduce his speed; (3) patient drill to establish as many useful associations as possible; (4) mental work with such material (probably concrete visual) as will give maximum exercise to his partial faculty of reasoning, based on analytic concentration of attention and imperfect associability. The future holds out to James no hope of normality, yet the outlook is not therefore necessarily unhappy. Out of doors, there is an attractive side of his nature,?albeit a bit feminine. To share his enthusiasm for birds and flowers, his pleasure in the sensations of the woods and fields, adds very genuinely to one’s own pleasure in the out of doors. Indeed, I have yet to know the imbecile who has not his bit of human personality, by whom you are not enriched through that exchange which gives relish to every experience. James’s life can be so arranged that he will have every opportunity for these congenial activities. His father owns a farm. The boy can be trained to do simple farm work, and on the farm he will find full enjoyment out of doors.
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