DISABILITIES AND PROGRESS IN DYSPHASIC UNIVERSITY … · M. B. ELVIN AND R. C. OLDFIELD Such disabilities became evident in writing long essays, thoughnotinthetestinterview.Hedescribedhismemory

J. Neurol. Neurosurg. Psychiat., 1951, 14, 118.

DISABILITIES AND PROGRESS IN A DYSPHASICUNIVERSITY STUDENT -

BY

M. B. ELVIN and R. C. OLDFEELDFrom the Department of Neurology, Radcliffe Infirmary, Oxford and the Institute of Experimental

Psychology, Oxford

The relations between language and thought inthe normal person, and the connexion between theforms of their disturbance in the dysphasic, arequestions which have aroused much discussion andlittle conclusion. But at least it would seem clearthat the nearer an individual's daily occupationapproaches to the purely intellectual, the more itis likely to be impeded by even a mild degree ofdysphasia. It is tempting to suppose that if anintellectual occupation were nevertheless pursued,the study of its products in the form of writtenmaterial might contribute to an understanding ofthe relations of thought and language, at least inrespect of their modes of breakdown. So uncom-mon is it, indeed, for any degree of dysphasia,however slight, to leave the patient still capableof attempting to lead a chiefly intellectual lifethat little has been reported of such cases.* Apartfrom the accidents of war dysphasia is a conditionencountered chiefly among those of establishedoccupation, or those whose days of active occupationare over. The significant problems of prognosisand rehabilitation scarcely go beyond the questionof whether or not the patient can maintain andexercise skills long since acquired-skills whoseprogressive aspects may for some time have falleninto abeyance. And the analysis of intellectualdeterioration and its relationship to linguisticbreakdown is much complicated by the existenceof ingrown habitual practices, whose disentangle-ment from constructive adaptations is not easy toeffect. The case of a healthy and highly intelligentyoung man, destined for one of the learned pro-

*In Head's (1926) series, for example, one patient is reported tohave had a university education, and one to have been a medicalstudent before injury. In neither of these is there any suggestion oftheir return to intellectual occupations. In one other case (No. 2)it is reported that the patient re-learnt Hindustani, and in generalshowed a remarkable power of re-acquiring knowledge. Headremarks that he might superficially have passed for a normal man.Alajouanine (1948) gives an interesting account of three cases ofdysphasia in elderly people who had followed intellectual or artisticvocations. Only one of these (an artist) was able effectively to con-tinue his previous activities.

fessions and educated accordingly, who becomes thevictim of dysphasia between school and university,is, however, a very different one. He presents, forinstance, prognostic and rehabilitation problems ofgreat delicacy: if encouraged and enabled topursue his earlier plans Qf becoming a universitystudent, he will be engaged for at least two yearsin work that is continually novel and constructive,and almost exclusively intellectual. Moreoverit is work which demands the written expression ofthought upon a succession of occasions. Thestudy of this written material, in conjunction witha clinical assessment of his condition throughoutthe period, can scarcely fail to be of interest. Notthe least interesting is the relation of thought tolanguage, especially the question of how far thereis interaction, and how far mere parallelism, orindependence, in their breakdown and recovery.

Case HistoryLieut. K (Case No. 16134), who came of a professional

family, was educated at a public school and won anopen scholarship to the university before joining theArmy in 1942. His chief interest at school had been inclassics, and he had intended continuing their study atthe university, though he had actually won his scholar-ship in history. After sustaining a head injury he founddifficulty in recalling Latin and Greek, especially thelatter, and this fact made him decide to read history.On September 7, 1944, at the age of 23, the patient

sustained a deep penetrating injury from a shell fragmentin the left temporal region. The wound was excisedand sutured on September 8, 1944, when 2-3 oz. ofpulp and blood clot were removed. The wound healedby first intention. , The x-ray tracing in Fig. 1 shows theextent of the resulting bone-defect which measured10 x 4 cm. approximately. Retrograde amnesia wasmomentary. Post-traumatic amnesia lasted for aboutfour weeks. On becoming aware of his surroundings hethought that he must be in a foreign country as speechhad no meaning. This only lasted for a few days. Healso failed to recognize his mother at first, and thoughtshe must be a social worker.

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D YSPHASIA IN A UNIVERSITY STUDENT

FIG. 1.-Tracing of lateral skull radiograph showingsite of post-operative skull defect.

He sustained a complete and permanent homonymoushemianopia to the right. He had two fits (in December,1945, and July, 1946) beginning in the right hand andprogressing to a generalized convulsion. He is still(1950) taking phenobarbitone. For a brief period afterthe injury he suffered from complete right hemiplegia,but this had cleared up by December, 1944. The availableevidence suggests that he was predominantly right-handed, though he had played tennis with the left hand,and was in the habit of using it for a few other activities.By the time he entered the university in the autumn of

1945, the paralysis and the speech were much improved.He was able to row in his college boat and to take afairly normal part in university life. In December, 1946,however, he still used a stick in walking, partly becausehe was not fully adjusted to his hemianopia (and com-plained of a wandering right eye), and partly because hisright foot was still troublesome. Speech in December,1946, was rapid (as it had always been, he said), and veryirregular in tempo. He felt difficulty in framing what hewanted to say, and this was increased by any delay orany attempt to think over the expression of his ideasbefore utterance. The urgency of his speech decreasedduring the two and a half years that followed, but wasstill noticeable in June, 1946. The hemianopia remainedessentially unchanged. He appeared eventually to makea good adaptation to the difficulty. By the time he leftthe university, the complaint of a wandering eye hadceased, and he was able to move about normally.He remained at the university for seven terms, and

was placed in the second class in the final honoursexamination for the shortened war course. For aboutsix months afterwards he worked in a museum as astudent, with the idea of looking for a job in a local his-tory museum later. Difficulty in being accepted for insur-ance cut short his efforts to obtain such work under alocal authority, but in the autumn of 1948 he wasawarded a research studentship in London seventeenthcentury history. The award was for one year and hasbeen renewed once.

In December, 1946, he was given a number of psycho-metric tests. On the Wechsler-Bellevue scale his vocabu-

E

lary was at a very superior level, and there was noimpairment in arithmetical computation and reasoning,in immediate retention for digits, or for visual-construc-tive tasks. His weighted scores were: vocabulary, 18;arithmetic, 17; block-designs, 16. On the digit-symbolsub-test his performance was relatively poor, his weightedscore being 8. Immediate retention for verbal materialwas above average, though, presumably, relativelyconstricted for his general intellectual level, and he foundconsiderable difficulty in learning digits or verbalmaterial beyond his immediate retention span. Immedi-ately after reading a passage through he could recall anumber of items nearly as great as the norm, but he feltthe task to be difficult, and his performance was poor inrelation to his general ability. He could reproduceargument more correctly than narrative. For boththese types of material reproduction was more coherentafter five minutes delay than immediately after presenta-tion, although some points might be forgotten in theinterval. On neither the sorting (Vigotsky) nor Rorschachtests were there any marked peculiarities, though on theformer there was some tendency to abandon one princi-ple for another before completing the sorting, and onthe latter his drive to organize his ideas tended to bepoorly maintained. In verbal reasoning (Burt-problems)he was generally quick and correct, but would some-times overlook a detail in the longer problems and thenfind it difficult or impossible to spot his omission onre-reading. He was also inclined to become too involvedin his own view of the problem, either as regards formor matter, to be able to return to the facts as stated,despite a real effort and intention to do so.At this time comprehension of speech in ordinary

conversation seemed normal. When required to sortobjects according to a verbally formulated dichotomyhe made no errors that he did not himself correct in 70choices, but obviously found the task exhausting. Hisspontaneous speech was rapid, though punctuated withmany hesitations, some a-a-a-ing, and some repetitionof initial s's. In answer to specific questions speechbecame more hesitant and awkward. Pronunciation wascorrect, and there was no actual misuse of words inconversation. He showed some hesitation in namingobjects. Finding the word he wanted when trying toexpress an idea of any complexity, as in giving a defini-tion, was a task of some difficulty. Reading aloud wasaccurate except for a slight tendency to drop or alter theendings of longer words, and to confuse short wordssuch as " to", "the", "for ", errors which he generallycorrected. Hesitations were conspicuous and wereassociated with an inability to see what lay ahead, theconsequence of his hemianopia. Difficulty in compre-hension only appeared in dealing with long and involvedstatements where visual and retentive disabilities seemedto be of considerable consequence. His speed of com-prehending visual symbols briefly presented seemed tobe normal, although the right half of the field wasfrequently missed. Given the time to think of eachword, spelling was good, though he was apt to bedoubtful of double letters. Writing was rapid, legible,and grammatical. When tired, however, he was stillapt to misuse words, and commit grammatical errors.

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Such disabilities became evident in writing long essays,though not in the test interview. He described his memoryfor events in the recent past as vague, and found itdifficult to recall much of what had happened during theprevious summer holiday which had been spent abroad.He complained of a liability to make conflicting appoint-ments, and then forget both.

In the past, his interest had quite largely centredaround verbal activity. Words amused him, and he wasgiven to playing with them in epigram and rhyme. Hemet his linguistic difficulties in good spirit, created socialcapital out of jokes about his speech errors, and madeconsiderable efforts to adapt his ambitions to his nowrestricted capacities. (He had originally intended to readfor the Bar.) He entered into all the social, intellectualand athletic activities of which he was still capable. InDecember, 1946, however, he was very conscious of thedifficulty he was finding in learning and remembering,and in writing satisfactory essays. He became somewhatdistressed by his inability to use notes made on hisholiday reading on account of their incomprehensibility.And in general he was wondering in an anxious way abouthis prospects. After a careful clinical and psychologicalassessment, however, he was encouraged to continuereading for his degree. At this time he very kindly agreedto submit for study some of his written work.

The Written Material Submitted for AnalysisThe written material selected for analysis was the

following: (1) an essay written in his last term atschool before joining the army; (2) two letterswritten in November, 1944, three months afterinjury; (3) eight essays chosen from those writteneach week between October, 1945, and June, 1947;(4) two trial examination papers; (5) an essaywritten voluntarily at our request in January,1948, six months after taking his degree.

Analysis of the MaterialGeneral.-The following quotation from his school

essay is given as an example of his written workbefore his injury. It was written at the age of17 on " The Conquest of Egypt ".

Now the Cabinet was faced with the decision ofleaving Gordon to his fate, or sending a large army tosave him. They had not the courage to do either. Atlast public opinion forced them to send Wolseley toget him back. Wolseley reached Egypt, battled hisway up the Nile, sent forward advance guards andpushed on for all he was worth. A minor reverseheld them up for three days. They reached Khartoumtwo days after Gordon was killed.No spelling or grammatical errors occur in this

essay which is easy to read, intelligent and coherent,though not brilliant. Language is used withfacility and some dramatic effect. At the same timeit ought perhaps to be noted that a few minordefects of expression are shown, and these are ofa kind which occurs in a much more severe formin the later material. It would be more correct

in the last sentence to say ". . . after Gordonhad been killed." And, in the two precedingsentences, there is a certain confusion of numberwhich leaves the meaning rather imprecise.

Extracts from two letters indicate the degree ofdifficulty he experienced in written expression threemonths after the injury.

I hope this will come to you for the right address Iam attempting. I do want to hear fo you and howyou are making as it is ages since I heard of you sincethe last I spoke to you.As you bullied me to promise a letter, I will do so

and do youself as good as mine will be. A Very crypticremark ? I'll have to get on to you. How are you ?Do you answer? No? Well the answer doesn'tmatter.There are examples here of the use of omnibus

words (e.g., " do " and " make ") to cover limita-tions of vocabulary, of the misuse of prepositions(e.g., "for the right address "), of repetitions andomissions, and of a change of grammatical structurein the middle of a sentence.The first essay was nearly incomprehensible

without much re-reading, interpolation, and inter-pretation on the part of the reader. For thefollowing six months essays continued to be verydifficult to follow. Nevertheless, from the beginningthey were shapely. A basic pattern of introduction,argument, and conclusion could, with sufficienteffort, be seen to emerge from the matter, althoughthe proper connexions between paragraphs, andoften between phrases and sentences, were notexpressed or were expressed incorrectly. Somemeasure of real comprehension and planning musthave been applied in writing the essays fromOctober, 1945, onwards, even though the patientfelt that he had not " really understood the subject ",and that his own essays were of little use to himip refreshing his memory. The difficulty he foundin using his essays and the notes he took on readingduring the summer of 1946, was, however, onlyin part due to their " incomprehensibility ". ByJune, 1946, the essays were, in fact, moderatelyclear and coherent despite errors. But in re-readingsuch essays, though he found the opinions expressedclear enough, he was disturbed by the apparentvagueness of the facts, and by the failure of whathe had written to bring them to mind again.Consequently he had to re-study each subject forexamination purposes. By contrast, he foundhimself able to recall opinion, but in December,1946, he could never be sure whether it was his ownopinion or somebody else's. By 1950 he was surethat it was in fact always his own opinion thatwas so recalled.

Essays written up to the end of 1946, and indeedinto 1947, were written quickly in order to put his

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ideas down before he lost the gist of what he wantedto say. On the whole he felt that they were themore coherent the quicker he wrote, and the lesshe really had to say. On the other hand spellingmistakes and minor omissions were more likelyto occur with speed. When reading the essaysaloud to his tutor he could, and would, makealterations and corrections. Nevertheless, it wasnot until the late spring of 1946 that his tutorfelt that he began to see " what the essays weredriving at ". During the autumn of 1945 he waswriting two essays a week on different periods ofhistory, one on the Restoration in which he wasinterested, the other on the Anglo-Saxon periodin which he was not. The periods were aboutequally new to him. The first group of essaysare the harder to follow, but have more substanceand show more evidence of thought. The latterare simpler, shorter, more factual, and are expressedin a rather juvenile way.

Length of Essays and Errors.-Table I shows thelength of the representative essays, together withthe types of error. Though there is no steadyincrease, and it would be unreasonable to considersuch an increase to be in itself a sign of improve-

ment, the last essay of the university group is infact nearly twice the length of the first. The last,also, has fewer errors than the first, and the majorityof the minor errors occur towards the end, possiblyindicating fatigue.

In order to allow comparison throughout theseries, the original numbers have all been convertedinto the number of errors per 10,000 words (tothe nearest whole number). An interesting pointwhich emerges from Table I is that the trend ofimprovement is marked most clearly in the fewerwrong prepositions, and in the decreasing numberof awkward, indeterminate expressions, and spellingerrors. In other cases, those for instance of theuse of the wrong verb, and of a shift of grammaticalform, no clear trend is present at all, unless itconsists in a tendency for performance to be atits worst in the middle of the series of essays. Totalerrors are shown graphed against time in Fig. 2,and prepositional errors in Fig. 3.

Spelling errors decreased, on the whole, duringthe year and a half covered by the essays for tutorials,but there was a sudden increase when limited timeconditions were imposed as in the trial paper(No. 9). This seemed to indicate lack of time forcorrection, rather than renewed breakdown due

TABLE IPROPORTIONAL ERRORS IN A SERIES OF ESSAYS

0 9E"' 0

0 :tl- cdoo > 12-.24

~~~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - * .0 E

1Oct>ber,1945 1380 72 7 22 7 29 7 O 7 2 |7 - )72 |8 3

2) - .-153

E 0 > 0 0 Z 0 5 50 19 38 10

4~~~~~~C-Jue194 220 23 '"18 O 4 O 5 93 0

5Oor142400 24 > E5 14 0 018 5 510100

1 October, 1945 13807273220 29 7 0 72 7-728t {03326

2 January,1946 149534 7 7773 7 13 06 0 70 136 0229

3d Ma,96 20010 0 0, 01 10 01 13 04 un,4 220023 .018 0. 0 0 05 4 5 320SOctoer,194 21140 0 24 051E 0 1 5 510 1 0

6 December,194 1651 6 6 0 6 6 0 6

7 January, 1946 1605 04 0 13 6 6 25 03 6 0 0 13 07 25 294

8 February,1947 253720 4 20 0 12 8 0 4 20 0 8 4 20 120

9 January, 1948 1500 7 0 14 0 0 7 0 0 0 0 0 14 7 49

Total 189 18 124 26 75 84 13 38 85 30 50 201 272 1205

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to fatigue or strain. The errors appear scatteredthroughout the paper, as they do in the essays written

300

250

200

150)

Errors

100

ED

0 5

FIG. 2.-Graph of total e

80

60

40

E-rors

20

FIG. 3.-Graph of prepos

Vocabulary.-Table II shows the number ofdifferent words used in the first 994 words of essays1 and 8, analysed according to parts of speech.These figures show a 67% increase of vocabularyover this period, and this is in keeping with thegreat decrease in verbal repetition noticeable inthe first essay.". . . changes were made to make the Castles underRoyal Control . .. soon to make Pitt in control"."... consummation was consummated ".... parties were continually pressed by the continual

pressure of the Crown ".Secondly it appears from this table that nouns

and adjectives show the greatest absolute, as alsothe highest percentage, increase. The relativenumbers of parts of speech, however, remainremarkably constant. The more precise denota-tion possible with the greater range of nouns andadjectives brought into play is reflected in the abate-ment of confusion caused by the use of over-generalwords. Conjunctions also show a high percentageincrease, doubling in number during the year anda half, and this allows a much more explicit relationof ideas. A considerable increase in adverbs,many of them temporal, had the same beneficial

15 20 25 effect.Months The actual misuse of conjunctions was com-

rrors in the series of essays. paratively rare: the relations between sentencesand clauses were more commonly left unexpres*d.In this respect conjunctions differed considerablyfrom prepositions. The latter increased onlyslightly in variety (they were rarely omitted evenin the earliest essays) but their misuse was constantat first, tended easily to recur with fatigue later,and was not entirely eliminated even by 1948 inthe voluntary essay written at leisure. The reasonfor this difference is not clear, though it mightperhaps be suggested that omission of conjunctionsis not so destructive of the formal structure of thesentence as is that of prepositions.

It must not be supposed, in analysing the patient'svocabulary at a given stage of recovery, that hisrestricted use of words was who-ly the productof their loss or unavailability. Perseverative ten-

M0 5s 20 25 dencies, both in respect of words and of phrases,may prevent the employment of words which would

;itional errors in the series of otherwise play a part in his expression.essays.

at leisure, but in the latter they would generallybe corrected on re-reading. The only uncorrectederror in the voluntary essay of January, 1948,is " dependant " for " dependent ", one so commonas to be of little significance. In any case, thepatient provided written evidence that his spellingbefore injury had not been flawless.

Major Factors Causing Incomprehensibility.-Thechief factors which make the early essays difficultto understand are the following.The Misuse of Single Words.-The construction

following such a word is often not anticipated bythe reader.

" The State church became not under State control."

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TABLE II

VARIETY OF WORDS USED IN ESSAYS 1 (OCTOBER, 1945) AND 8 (FEBRUARY, 1947)

Essay 1 Essay 8

Part of Speech No. of No. of Absolute PercentageDifferent Percentage Different Percentage ncrease ncreaseWords Words

Articles.. .. .. 3 3 0 0

Prepositions .. .. 19 5 22 4 3 16

Pronouns .. .. 11 3 15 3 4 36

Nouns (Proper) .. 25 7 43 7 18 72

Nouns (Common) .. 115 31 197 32 82 71

Verbs .. .. .. 70 19 95 16 25 36

Adjectives .. .. 77 21 160 25 83 108

Adverbs .. .. 33 9 52 9 19 58

Conjunctions .. .. 12 3 24 4 12 100

Total .. .. 365 611 246 67

" . of its negative attitude, the most importantproblem arose"The Commons had long been at issue over theCrown on matters of finance."

Failure to State the Main Point of a Paragraph.Comment and criticism are given without adequateindication of the subject.Lack of Verbal Precision.-Too often " general"

words are used, when a wider vocabulary wouldhave provided the right word in the right place."The negative aspect of Parliament .

"He was in all things supreme."". . . failure of negociations encouraged Cromwell tolet the matter turn into war."" Yet he brought about an even more powerful dis-rupting factor to the Whigs."A similar fault is the failure to qualify a reference

sufficiently:" Whig theory " (referring to the Whig theory of anaristocratic Junta)."They fell back on the 1640 attitude."

Inappropriate Use of Words.-This seems inpart to be simple perseveration, affording a solutionto the difficulties of a restricted vocabulary, butthe patient's delight in epigram perhaps alsoencourages the tendency.

parties reversed in their attitude to externalaffairs . .. systems of electoral representation was notreversed."" . . . not examine details [i.e. to judge the value of

Wolseley's later work] but the results. Then later. . . the details of his work had more effect."

In the second example the logical failure is onlyapparent. In fact the second " detail" is short for"the effect on detail ".

Telescoping Ideas.-There was a tendency totelescope ideas, and their logical connexion eitherof content or grammar was omitted.

" . . . final outbreak of disturbance that caused Henryto submit was his own contact with foreign affairs."

Such telescoping may apply to an alteration inthe writer's point of view, and will then ofteninvolve a change of grammatical structure.

" The long eclipse of the Whigs only emerged when aWhig Party under Grey was built up."

In many cases, especially in the first term's essays,the awkwardness was composite in origin, and couldbe subsumed under more than one of the aboveheadings.

" The existence of James as a Roman Catholic intensi-fied by his marriage . . ."(Shift, telescoping, ? omission.)" It made pressure of the Crown brought to a headbut it did not clear the issue."(Omission, misuse of word, ? shift of approach.)" The final failure of North made the King to surrenderat last" followed by ". . . by refusing to allow aParliament to be held in his absence he at once madeany such Parliament to be obviously rebellious."(Over-general words, ? shift in construction.)

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Minor Errors.-In addition to these major sourcesof confusion, there are other types of error. These,though less- confusing to the reader, demandalertness if they are not to be allowed to disruptthe meaning. Among these minor errors are theomission of minor words, the ambiguous relationof pronouns, word repetition, the use of anincorrect grammatical form or of a wrong tense,failure to make verb or pronoun agree in number,and minor shifts of grammatical constructionnot in themselves very confusing.

Condition at the End of the Essay SeriesIn March, 1948, the patient was given the digit

symbol test again. He made six more substitutions,and the same two half errors as he had in December,1946. Though there had been a great change inhis general adjustment to the field defect duringthis time, it probably still handicapped him on atest of this type. By this date, his immediate reten-tion span for verbal material had increased so thathe could repeat the appropriate Babcock sentencewith ease. Verbal learning beyond this span,however, still presented difficulty. He no longerhad the trouble in reproducing a moderately com-plicated grammatical structure that he experiencedin December, 1946. At that time he was apt tointroduce alterations of a mildly confabulatorynature which were based, apparently, upon theuse of visualization to surmount verbal difficulty.In March, 1948, these were no longer evident.But omissions of structurally important wordsoccurred, as did the introduction of synonyms.These errors tended to recur in a perseverativefashion. He was, however, able to reproduce thecontent of verbal passages more coherently andfully. An increased capacity for rote retentionassisted him in this, but he was still liable to relyupon a word sequence rather than upon retentionof the trains of ideas expressed. When this ten-dency led him into absurdity he would correcthimself. He showed an improved capacity tocarry out verbal reasoning tests of the type devisedby Burt. He clung less tenaciously to his firstincorrect conclusion, and on re-reading the problemmore quickly grasped relevant data previously over-looked and so was able to consider its implicationswithout getting confused with his previous line ofreasoning.

In February, 1950, he reported some difficultyin learning new technical terms. He complainedthat he constantly forgot the sources of his informa-tion, and had in consequence to make frequentfresh starts. Dates, even when he was constantlyusing them, slipped easily from his mind. Asregards day-to-day memory, he found that he was

still inclined to forget appointments, though lessfrequently than three years before. He had a" permanent uncertainty about the date and theday of the week ". His memory of the past was,he said, more complete and accurate than it hadbeen, though recall did not produce much" emotional excitement ", perhaps because thework he had been doing was unexciting comparedwith his activity during the war years. The contrastbetween war and peace made comparison difficult,but he thought that he lived ' very much from dayto day . . . with little sense of anticipation in thatI do not make any advance plans, and the factthat I am going to do or see anything new does notproduce any excitement". Events during thewar " have a far sharper photographic impressionon my mind".He was seen again in November, 1950, and there

appeared to have been little change in his condition,in so far as it could be elicited by interview and afew psychometric tests. His speech was still subjectto blockages demanding the introduction of circum-locutory and redundant material if the flow ofexpression was to be preserved. Object-naming wasnot free from error and circumlocution. Thewritten expression of material just studied by readingwas very adequate, but was carried out at a furiousspeed. He made a few spelling errors, mostlycorrected, chiefly of substitution of phoneticallysimilar consonants. Grammar, syntax, and logicalform might be regarded as normal (if sometimesslipshod), considering the haste with which thetasks were carried out, and the written versionsshowed evidence of intelligent compression of theoriginals. He again noted greater ease in reproduc-ing argument than narrative, and this was borneout by his performance. On the digit-symboltest there was evidence of a further slight improve-ment, his weighted score having risen to 11.On questioning him regarding his present life

and work, much the same points were elicited ason the previous occasion, and indeed it seemedthat he had reached a stable attitude towardshimself and his affairs, so that he confines hisactivities to those in which he can reach an adequatelevel of adjustment or achievement without drawingupon the finer points of skill which are now impaired.How successful he is in carrying out his historicalwork it is impossible to say, but it is certainly of acharacter which intellectually would have madebut slight demands upon a person of his intelligenceif unimpaired. He himself feels that his presentcapacities are adequate to his work, but acknow-ledges that his overall rate of working is probablyno more than a third of what it was previous toinjury. He is frequently constrained to break off

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work and turn for a time to a distraction such asThe Times crossword puzzle (which he finds himselfquite competent to tackle). In short, he appears tohave reached, at least temporarily, an adequate, ifconstricted, adaptation. Whether this phase willbe succeeded by one of fresh expansion remains tobe seen.

DiscussionWe have already remarked upon the meagre

fruits of theory about the relations of thought andlanguage. John Dewey (1933) has said: " Theconviction that language is necessary to thinking(is even identical with it) is met by the contentionthat language perverts and conceals thought ",and, he continues, broadly three different viewshave found their supporters. The first is that thetwo are identical. .The second that words are neces-sary only for the communication of thought, notfor thought itself: the third that language, thoughnot identical with thought, is yet necessary to it.This last, commonly upheld, must at once raise thequestion of the precise manner in which languageplays its role in the processes of thinking. In thespecial field of linguistic breakdown, this questionbecomes, " In what way does a disturbance of thelanguage mechanisms impede thinking? " and," Is the disturbance of thought capacity in dys-phasics thus only secondary to the language break-down ? "To these questions, Henry Head offered one

possible answer. For him, whatever is worthy ofthe name of thought is not an act of " simplematching ", but demands the intervention of sym-bolic processes between stimulus and response.Aphasia is basically a disorder of these symbolicmechanisms. That it manifests itself chiefly in thelinguistic field is but a reflection of the predominanceof language among the other symbolic systems usedby man. The patient is " lame in thinking " becausethe mechanisms by which he thinks are out of order.In somewhat similar fashion, the economic life ofa country would be very gravely disturbed if itsmonetary and banking system were largely destroyedovemight. The movements of currency and creditdo not constitute trade. Barter operations, thoughclumsy and limited in scope, are possible withoutthem. But in practice a monetary and bankingsystem is necessary to modern commerce as weknow it. Without it, too, payments in actual coinbecome meaningless. So, for Head, both disturbanceof thought and breakdown of overt language alikearise from the destruction of the more basic sym-bolic mechanisms. His conclusion is, perhaps,chiefly of value in its emphasis upon the immensecomplexity of the processes which underlie both

thought and language, by contrast with the relativesimplicity of the verbal transactions we observe.Sentences, like payments in actual coin, are limited invariety by the available material. Neither revealsthe richness of the organization behind them.*

Other writers, of whom the outstanding example isArnold Pick, have approached the problem of therelation of language to thought in somewhat differ-ent terms. They have asked by what sequence ofprocesses the thought is formulated into a sentencesuitable for overt expression. As expounded in hisearlier work (1913) these comprise four stages:(1) the mental attitude, diffuse if intellectuallyinformed; (2) the thought-schema, in which thematerial is psychologically differentiated; (3) theschema of the phrase, in which the syntactical andgrammatical form of what is to be uttered is present;and (4) the choice of words to fill in the phrase-schema and complete the sentence. Pick's justifica-tion for the adoption of this kind of frameworktlies in his conviction that clinically the varieties ofaphasia are in accordance with it. Certainly itemphasizes the difference between those disorderswhich manifest themselves chiefly in a disturbanceof content, and those, such as agrammatism, wherethe disruption is one of form.

Useful as conceptions such as these may be in theanalysis of language disorders, they are clearlyincomplete inasmuch as they offer little in the wayofhypotheses regarding the manner in which thoughtitself takes place. The views of Selz (1922, 1924),who obtained from experiments on the thought-processes themselves independent evidence of thepart played by schematic frameworks, go some waytowards extending Pick's findings in the requireddirection. Bartlett's (1932) extension of Head'stheory of schemata is perhaps equally relevant.

But, apart from the shortcomings already noted,current theories in this field suffer from anothergrave defect, and it is this which observations on ourpatient throw into relief. " As soon as we attemptto express our thoughts even to ourselves," writesHead (1926), " we re-arrange them and drasticallyprune away redundant and incoherent features. Forthe purpose of articulated speech or writing thisprocess is carried out still more ruthlessly . . . theresults of unrestricted thinking are refined andordered in accordance with logical canons." Cer-tainly this is one essential aspect of the formulatory

*It should, perhaps, be made clear that Head did not employ thiseconomic analogy, but it seems not inappropriately to express theessence of his view.

tPick is at some pains, especially in his later writings (1931), tomake it clear that this sequence of stages is tlexible, and by no meansalways fully followed. There may, for instance, be condensation, andthought may proceed at levels other than the first. Van Woerkom(1921) has proposed. a similar set of stages, which places greateremphasis on the active-synthetic and analytic-nature of the secondstage.

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process. But there are others, less comforting intheir implications, which have not received theattention of which they are worthy. At these Headhints when he remarks: "The superb logicianmay have difficulty in expounding his ideas and weare familiar with the practised speaker whose wordsare jejune of thought". The introduction ofcoherence and the pruning of redundancies are toooften not the sole outcome of formulation. Some-thing may be lost from the thought itself. Habitualverbal forms, and conventional syntactical schemes,eagerly offer themselves, as Delacroix (1924) andothers have pointed out, to spare the pains ofthought. The element of originality or profunditythe original shadowy thought perhaps possessedmay be beyond the skill or patience of the speakerto formulate. Instead a compromise completion ofthe task is reached, in terms of empty and conven-tional, if sometimes elegant, expression. Thistendency will be reinforced where, as is frequentlythe case with expressive dysphasics, continuity ofutterance is imperative if breakdown and blockageare to be avoided. Alternatively, something of theessence of the thought may be preserved only atthe expense of obscure and complex verbal guisewhich, even in the normal individual, may amountto syntactical error. There is a basic antagonismbetween thought and expression which alwaysdemands some compromise. There may be conflict tothe extent that the individual's aspirations becomeinvolved on one side or the other.When we consider the series of essays written by

our patient, we may ask how far defects of expressioncan be distinguished from those of thought, and towhat extent both can be seen to be the outcome ofsome common failure of intellectual organization.As improvement takes place, do the two types ofdifficulty clear up in parallel fashion ? It may beremarked at once that, while the evidence pointsto a general parallelism of progress, there areoccasions when his thought appears to be clearerand more adequately structured than his faultylanguage allows him to express. On others a decep-tive clarity of expression may conceal an underlyingwoolliness of thought. That thinking was oftenclearer than expression was demonstrably true whenprepositions were misused and conjunctions omitted.He was frequently prepared during 1947 to defendhis misuse of prepositions, at the same time indi-cating in other ways that the idea was perfectlyclear. He could explain the relationship of phrasesand sentences which he failed, by omitting a con-junction, sufficiently to relate. Similarly the denota-tion of many over-general nouns and expressionswas in fact more precise to him than might appearto the reader, as would become clear from his

amplifications in conversation. The same could besaid of some telescoping and shifts of grammaticalstructure. Confused expression at any particularpoint, in fact, did not necessarily indicate a corre-sponding confusion of thought. It was often simplythe outcome of the inadequate linguistic resourcesavailable to him at that moment. The actualexpression achieved would then be a compromisereached by lowering his standards of correctness,and even by the acceptance of pathological tenden-cies such as perseveration. On the other hand,expression could superficially be clearer thanthought. The clearest of his early essays were thoseabout subjects in which he was not strongly inter-ested. According to his own account he would, insuch cases, take the leading ideas from his readingand reproduce them glibly without much comprehen-sion of their implications and relations. Somethingwhich did not engage his personal intellectualinterest equally did not evoke the repressive criti-cisms and linguistic inhibitions which few normalwriters escape. In his own words:

" I could see that there were ideas A, B, and C. Icould use A, B, and C in an Euclidean way, finishingup with a Q.E.D., without really knowing what A, B,and C implied. For instance, I might have knownthat growth of the powers of the thegns was an impor-tant fact, and that this led to the success of Williamthe Conqueror. But I would not have seen why itwas important, nor would I have any idea how, whenand why the thegns had become important, nor evenwhat I meant by thegn. I don't now. But I could putdown correctly A+B+C= D. It certainly meant thateven at the time of reading my sources I didn't reallyunderstand the point, though I could see that it wasone."

Clearly some comprehension is needed to makea sensible selection of points, and to follow a planA+B+C==D. But his understanding of the situa-tion was superficial, hardly going deeper than acommonplace acceptance of the verbal terms ofthe argument and of their logical outcome. Expres-sion was coherent but simple.

It is not without interest to compare the peculiari-ties of the patient's verbal expression with thedifficulties of thought which he experienced, asjudged by the quotation. A number of parallelssuggest themselves.

There is a correspondence between the tendencyto use words of over-general meaning in expression,such as " matter" and " thing" (associated with asmall number of substantives and adjectives in theearlier essays), and the lack of specificity andstructure in an idea; for example, the lack ofexplicit understanding of what thegns were and did,notwithstanding the appropriate use of the wordthegn in argument.

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The inadequate articulation of sentences, clauses,and paragraphs which results from a paucity ofconjunctions, the wrong use of prepositions, andthe omission of connecting statements, may perhapsfind a parallel in the incomplete connexion of ideaswhich he describes when, for instance, he remarksthat the importance of the growth of the power ofthe thegns was not evident to him. His thinkinglacks the formal precision which in expression isafforded by the words " therefore', now"because of", and " on the other hand ".The changes in grammatical structure which are

apt to occur part of the way through a sentence(" forgetting how a sentence started ") might beheld to correspond with the difficulty experienced inkeeping a total problem in mind while still con-sidering the implications of part of the data. Thisdifficulty was shown in his performance on theverbal reasoning tests. It is also indicated in hisfeeling that much reading was a bad preparationfor writing the essay (" The less preparation andreading I do, the better the essay ", 1946).

Speed, both in achieving expression and in under-standing a situation, were of great importance tohim. Fear of forgetting the beginning, whether of asentence or of a train of thought, was one elementin his desire for speed. Another was the avoidanceof interference by the search for appropriate wordson the one hand, and by the seduction of intellectualred-herrings on the other. The structure of bothspeech and thought was to some degree evanescent.In thinking he sought for structures; for instancehe complained of the lack of a clear chronologicalframework in Anglo-Saxon history on which tohang events. In the effoYt to replace the insight whichhe lacked, he would adopt an artificial structurenot really grounded in his thought, and this wouldoften prove inadequate to the solution of theparticular problem he was engaged on. In the sameway, the grammatical structure of the beginning ofa sentence was apt not to anticipate its end appro-priately.

Coherence in thought and speech had their bestopportunity if deliberation were avoided. Delibera-tion might involve, for instance, search for anappropriate word, or the consideration in greaterdetail of evidence hitherto partially neglected. Inthese cases confusion was likely to arise. But,characteristically, this inadequacy of structureresulted in rigidity rather than in weakness ofthoughtand expression. If, in reasoning, a form grew outof the data, it was difficult for the patient to treatit as tentative. Either it broke down when furtherevidence was noted, or it persisted rigidly andcontra-indications were ignored. In verbal expres-sion, the tendency to rigidity appeared in the form

of stock phrases, of phrases personally favoured bythe patient, or of phrases recently used. Thesewere the alternative to breakdown of expressiveactivity. Both in thought and expression, thepatient seemed to lack normal freedom to manipu-late his own mental processes. The healthy individualcan and does treat each production of his mentalactivity as the object of criticism and refinement,so arriving at an apt response. The patient cannotachieve such smooth convergence upon the appro-priate act. If he is to decide, or to express, at all, itcan often only be done by accepting incompletelyevident concepts, or inaccurate grammatical forms.

Certainly in general the patient gave evidence ofcorresponding difficulties in the field of thought andexpression, but it is at the same time clear that thesetwo skills are to some extent independent of oneanother, inasmuch as the compromise in his per-formance might be reached at the expense of one orother of them. The freer he was from the intellectualdifficulties aroused by his own interests, the greaterwas his capacity to express himself correctly.Where, on the other hand, his more personalintellectual powers were challenged, all his expressivedisabilities were aroused in the effort to do justiceto his thought.These considerations suggest, perhaps, that where

the attempt is made to re-educate the dysphasicby exercise in expression, the subject matter shouldbe chosen so as to evoke interest, but not touch tooclosely the more basic of the patient's preoccupa-tions. Where, on the other hand, it is desired torehabilitate the capacity for thought, too close aninsistence on its formal expression may defeat themain object.Our main conclusions which emerge from the

study of this patient's behaviour are.(1)The common basis, which Head attributes to the

intellectual and linguistic functions is borne out in sofar as both in their breakdown and their recovery theyexhibit phases of a broadly similar character. Itmust be remembered in this connexion, however,that the dysphasia exhibited by our patient was of apredominantly expressive character, and any assess-ment of his thinking is therefore to some extentconjectural. Nevertheless it has seemed to uspossible to distinguish to some extent the respectsin which his difficulties were to be attributed tobreakdown of the symbolic mechanisms utilized inthinking from those more especially connected withlinguistic expression. But it is clear that, accordingto Head's view, no absolute distinction of this kindcan be made.

(2) The implicit, unavoidable, conflict involved inthe attempt to formulate and express the products ofthought is more clearly shown in a patient of this

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kind than in the normal individual. The resultingcompromise is less apt, sometimes doing justice tothe thought at the expense of clarity in expression,at others accepting conventional forms of expressionwhich replace the thinker's individual contributionby socially contrived cliches. In the latter case itis later difficult, as he reported, for the patient todecide whether the views so expressed are his ownor those of others.

(3) Progress in the restitution of expressivefunction, as shown in the essay series, is clearlymarked by a decrease in prepositional errors, andit is suggested that this is paralleled by increasingcapacity to use valid structures in the manipulationof ideas.

SummaryThe case is described of a young, healthy, and

highly intelligent man who sustained a penetratinghead injury producing an initially severe dysphasia,and subsequently took up the open scholarship hehad previously won at the university and obtainedsecond class honours.A number of the essays which the patient wrote as

a student are analysed and his progress traced inrespect both of linguistic and intellectual skills. Hiscondition was also assessed at intervals clinicallyand by psychometric methods.

Linguistic and intellectual improvement showed aparallel course, but the effects of the antagonistic

demands of thought and expression were alsonoted.Some consideration is given to the bearing of the

findings on current views regarding the relationsof language and thought.

We should like to express our gratitude to the patientfor his generosity in making his written work availablefor analysis, and for his ready response toWall ourenquiries. We have also to thank Sir Hugh Cairns andDr. W. Ritchie Russell for permission to make use of theclinical material, and to publish this case.

REFERENCESAlajouanine, T. (1948). Brain, 71, 229.Bartlett, F. C. (1932). " Remembering." Cambridge.Delacroix, H. (1924). " Le Langage et la Pensee." Paris.Dewey, J. (1933). " How We Think." New York.Head, H. (1926). " Aphasia and Kindred Disorders of

Speech." Cambridge.Pick, A. (1913). "Die agrammatischen Sprachstorun-

gen." Berlin.(1931). In " Handbuch der normalen patholo-

gischen Physiologie ", ed. A. Bethe, G. von Bergmann,G. Embden, and A. Ellinger., vol. 15 pt. 2, p. 1416-1524. Berlin.

Selz, 0. (1922). "Zur Psychologie des produktivenund reproduktiven Denkens und des Irrtums." Bonn.- (1924). " Die Gesetze der produktiven und repro-duktiven Geistestiitigkeit." Bonn. ..

Woerkom, W. van (1921). J. Psychol. norm. path. 18,730-751.

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Documents

DISABILITIES AND PROGRESS IN DYSPHASIC UNIVERSITY … · M. B. ELVIN AND R. C. OLDFIELD Such disabilities became evident in writing long essays, thoughnotinthetestinterview.Hedescribedhismemory