James
A Study of a Post-Encephalitic Child. :Author: Rose Wimenitz, University of Pennsylvania.
It was Friday morning. James had come for his lesson and was waiting for his teacher to call him. Sprawled out carelessly on a chair, he was the very picture of dejection. His small head was hanging, an obstreperous tuft of the coarse, sandy hair standing defiantly upright on the crown of it; his complexion was sallow and pasty, and not in any way enhanced by a sparse scattering of tiny yellow freckles, plainly visible at close view; his generous mouth drooped, like his head, the lips pale, but firmly closed. In his small faded blue eyes, set just a little too closely together, there was no spark or twinkle, no vivacity or intelligence; but there was determination in his chin, despite just a suggestion of femininity in its tendency to recede; yet withal his expression bespoke nothing in particular. Never a whimper escaped him, never a sign of ill-humor at having to wait. He seemed quite content to sit there indefinitely, scrutinizing the floor or his shoes.
James was always very neat in cheap but scrupulously clean clothes, yet he had a rather slovenly appearance. His clothes never seemed quite to belong to him. Something was always awry. His feet, especially, were very awkward, and hung like dead lead weights on thin bean-poles of legs. There was nothing healthy in his appearance. Beside him sat his mother, a well-built, somewhat plump woman of about thirty-five, with a kindly face and quiet, patient air?too patient to dispel a suspicion of something bovine in her make-up, but not at all displeasing to the eye or judgment. Griselda and her son, was the inevitable mental comment of the spectator, waiting for the call of Fate, in the guise of the teacher. ‘’All right, James; you may come in now.”
At the sound of these words James lifted his head. A light of something resembling understanding come into the pale eyes, already so seemingly weary of life. He smiled; and his face resumed the blank, wooden expression as he slid off the chair and shambled toward the door, as if the matter of walking required infinite energy. Such was James. He had been referred to the Psychological Clinic by the family physician, to whom he had been brought by his mother, who could not see why James should have been placed in a special class. Ever since he had had a bad attack of influenza, with frequent hemorrhages from the nose, he had not been able to get along in school. Both his work and conduct in school had been so poor that he was finally placed in an orthogenic-backward class. He did not like this class. He did not like either his teacher or his associates. He was anxious to be placed in his regular grade that is, the regular second grade.
James was nine years four months of age when he first came to be examined, and his pedagogical history was not very hopeful. Nevertheless, he came through the examination surprisingly well. He passed all the tests, not very well, but fairly well, showing some degree of trainabilit}r. He showed some trouble with analytic concentration of attention, in his work with the Witmer I ormboard, and gave a very stupid performance with the Dearborn Formboard, but he passed the tests within the specified time limits. In his work with the Witmer Cylinders, when asked to hurry, he did not lose his self-control, but failed to respond, and his memory span was found to be slightly deficient, being a very uncertain 5, both auditory and visual. In his reading, however, he showed excellent proficiency, which enabled him to pass the Terman revision of the Binet mental test with a score of 100.3 and a mental age of nine years eight months four months above his chronological age. 1 his was very surprising, when his pedagogical history and personal appearance are considered. According to this, James should be diagnosed as Normal, yet there was obviously something wrong with him. It required no specialist to show this. Consequently, diagnosis in his case was deferred, with a brief notation that the picture he presented at the time of examination was greatly suggestive of pre-senile deterioration; and clinic teaching was recommended to determine his educability and retention. And so James came regularly every Friday morning for a period of about four months. In his lessons he displayed several peculiarities, of which the most noticeable was a habit of stopping suddenly in the midst of his work, as if his blood had congealed and left him in the exact position in which it then was?his arm raised above his paper, his pencil in his hand in position for writing, but no movement whatever. With his pencil in this extraordinary position, he would nod incessantly over his work, much in the manner of an old man in his dotage; then he would come to with a start, and resume his work?but he no longer remembered anything he had been doing before. He did not even recognize a problem he had been working on only a few minutes previously and it was then necessary to begin all over again from the very beginning. These lapses of memory (which is the only explanation his teacher could give for this display) occurred several times in the course of a one-hour lesson, the frequency depending very largely upon his state of health and degree of fatigue. His fatiguability was unusually great; after half an hour’s work in the clinic, at work which should not have taxed him at all, he became so tired as to make all further work with him absolutely useless. Any questions put to him at such a time would bring forth answers showing a state of complete confusion. It was further noticeable that his confusional states were very much aggravated when James was working with arithmetic or spelling involving words of more than one syllable. In his reading he showed remarkably good proficiency. He could read a story once, with an understanding quite good for a normal child of his age. He could paraphrase the story and then write it out in such a manner as to show that he not only knew, but appreciated what he had read. His grammar was atrocious but that is not surprising. The puzzling point was that he could read, understand and retain anything in the way of reading matter, but became hopelessly confused with his arithmetic and never could learn anything at all in it. He was accordingly recommended to the Neuro-psychiatric clinic of the Philadelphia General Hospital, for examination to discover the cause of his confusional states. The report of this examination showed some very interesting statements. He was found to be poorly developed and undernourished. It was stated that he showed marked emotional instability and his case was diagnosed as probably post-encephalitis, following influenza. The poor state of his health and the possibility of post-encephalitis accounted entirely for the ease with which he became fatigued; but there was nothing in his behavior in the clinic, during his lessons, that might suggest emotional instability. In fact, James was always very docile, very obedient, very patient, even when, in the early days, his teacher tried to reprimand him, gently, into concentrating 011 his arithmetic. Certainly, James presented no disciplinary problem whatever.
The work with James continued, with a few periods of absence, from February to May, during which time he had succeeded in learning very little indeed, although he put forth genuine effort. It seemed that he had excellent use of the material he had learned before he had had influenza, but that it was impossible for him to retain anything new. At times he seemed to understand what he was doing?and then he would have a lapse of memory and all that he knew would disappear. In almost four months of comparatively regular teachJAMES. 147 ing, he did not learn to make change for a problem such as the following: If you were given 25 cents and sent to the store to buy apples for 5 cents and sugar for 10 cents, how much change would you bring home? If given a long enough time, he could finally arrive at the answer, after a terrific struggle and much confusion. If he could only have remembered what he was doing long enough to complete the problem, he might have been able to learn the process; but the veiy processes of addition and subtraction were causes oi the utmost confusion to him, especially subtraction; and their use in correlation naturally assumed greater proportions and complexity than was necessary. The same kind of confusion was displayed when a word of more than one syllable was put before him to spell.
At times he would become quite talkative and talk in a very sensible manner?so sensible, in fact, as to make one wonder if there really was anything wrong with the boy. He always talked about his family?what his father did, what his sister eained and the increase she had just received, and the latest happenings with his other sister, who was crippled. A visit to his home in Kensington explained much of his prattling. James comes ot a ‘ poor family a workingman’s family. The house is a tiny, ramshackle affair, but kept immaculately clean and neat. His father has a milk route and he has a sister who works in a factory. These are the sources of support for the family. The other sister has osteomyelitis of one leg and is in a home for cripples in Atlantic City. James is the oldest boy and has one younger brother, who is, to all appearances, a normal child. He also has an old grandmother, who is constantly bewailing James’ condition, and who insists that James knows he will never amount to anything. James’ mother reported that he wanted very badly to be taken out of the special class and that he had a reputation for tormenting the other children in his class. He never protested against going to school, however, and was more than willing to go to the Psychological Clinic for his lesson on Friday. He felt, as did his mother and grandmother, that this would eventually lead to his being placed in a regular second grade. They were very anxious about the boy and very willing to co-operate. The wholesomeness of the atmosphere in little house spoke very favorably for James’ chance of improvement at home?at least, in the way ol affording no obstacle.
Early in May, as a result of his second Neuro-psychiatric examination, James was diagnosed positively as a case of Post-encephalitis and sent to the same home in Atlantic City where his sister is. Since he was so easily fatigued and showed so little retainability with new material, a life in the school-room would avail him very little. The school authorities immediately acceded to the request that lie be excused from school indefinitely so that he could build up physically by leading a life in the open air. The clinic work was therefore closed; and James passed on to another experiment… .
What are the prospects for a boy like James? If you were his parent, what would you do with him? He never had much, to begin with, in the way of personality. He evidently inherited his mother’s rather apathetic disposition as well as her capacity for patience, and his general picture must have been, at best, nondescript. Nevertheless, he must have been at least as alert, mentally, as any ordinary six~3rear old, judging from the clearness of his reasoning during his short periods of lucidity and his proficiency in reading. Postencephalitics are either emotionally unstable or depressed. James’ one display of noisiness and tearfulness, at the time of his first neuro-psychiatric examination, and his reputed habit of tormenting the children in his class in school might put him into the emotionally unstable group; but his customary appearance leans more in the direction of depression. His great fatigability is also typical of his condition, and it may be that his states of confusion are due to no more than excessive fatigue. In this event, improvement of his physical condition would likewise improve or correct this defect and he might even be able to retain new material in an acceptable manner. In this case, he could be made into a normal citizen, although there is no evidence to lead one to believe that he would ever have achieved intellectual attainments, even under the most favorable of conditions. If, however, his lapses of memory and confusional states are due to some defect in the brain itself, he will have a well-nigh unsurmountable task before him in trying to cope with society in a manner sufficient to earn him his bread and butter. What, then, is the prognosis in this case? Is he a normal child temporarily handicapped by a physical defect or a child with a damaged brain? And, in either case, since he is decidedly backward on the educational scale, must the stamp of imbecility be placed upon him?
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