However, when he started college the following year he had become confused, apparently had groped or somehow molested a woman on campus, and had been hospitalized. For some time he had been on neuroleptic drugs and was receiving psychoanalytic psychotherapy with much focus on his preaccidental relationship with his parents.

The judge knew that he had raised a son who was a winner, academically proficient, a school leader, and a happy person whose problems arose from a severe head injury. He had researched what was available to him and found very little except neuroleptic drugs and psychodynamic psychotherapy.

The judge handed me Luria's useful book and my own skills as a therapist soon took a quantum leap.

Our own approach to brain injured patients until that time had been supportive, existential, and humanistically insistent on full functioning. We did not engage in systematic training, and gave no practical drill. We did use systematic desensitization, biofeedback and other forms of operant conditioning with heroic psychokinetic interventions.

Our instructional methods deliberately avoided school models and were aggressively multimodal and strongly motor and visual. We were getting acceptable results compared to psychodynamic psychotherapy; however, we were not pleased with our uneven results.

Luria's concept allowed us to formulate what had been intuitively but dimly grasped in our program, and reinforced our opinion that diluting skills to kindergarten or preschool level and practical drill are useless wastes of time.

The following notes are organized in the same structure as Luria's case notes and in some cases are composite descriptions of patients to match his scheme. They represent 20 (now 33 years, GvH 8/2/99) years of replication of Luria's work.

While we have added many other features the basic Lurian insight remains:

the brain is highly plastic and is engaged actively in an attempt to survive - injury results in dynamic systems which are actively goal seeking - the brain is not merely broken.

If we ask ourselves what good is depression we get some insight into what to do about depression. Why should animals have the capacity for profound depression? Why should the capacity for depression be well preserved? Neuropsychologically, we know that the right hemisphere is strongly activated in depression. We know in general that the right brain is, broadly speaking, the defensive brain. That is, the right brain has the task of remaining globally alert generally assessing the environment. It deals with novelty and new skills as well as being the center of rhythmic and other nonverbal skills.

When a musician becomes adept it is the left brain which carries the major load. You and I sing right brainedly.

We all have seen the right stroke or right injured hemiplegic who simply ignores the left side disability and good naturedly asks us when we are going to let him out of the hospital - there's nothing wrong with me, Doc!

We have also seen the left stroke victim who exaggerates his deficit and the right side of his world and complains bitterly all the time.

Animals under stress begin to produce large amounts of ACTH which causes learning to shift from a neophilic, positive reinforcement model, to a neophobic, escape conditioning model. Habituated routines reappear, timing becomes very precise and the animal becomes conservative, and reduces exploration to a minimum.

Well rehearsed routines become the most frequent form of behavior. This strategy permits a heavily predated population to survive, while the species carries the chemical plan for a neophilic, exploratory strategy to use in better times.

While depression has evolutionary value, it may be disastrous to the individual.

In the same way the brain's response to injury is a dynamically structured response which is disastrous for the conscious individual. The response is probably not evolutionarily useful since the events leading to survival after severe brain injury are relatively rare in human evolution. Hemiplegia is not at all like the dysfunction resulting from severed nerves, and is not like a broken part of a mechanical system at all. Hemiplegia results from excess activity in the brain and this activity is organized and purposive.

This insight permits us to conceptualize interventions which respect the sophisticated integrity of the injured brain. For example, in hemiplegia it is often sufficient simple to flood the paralyzed limb with sensation (electric shock, or painful extention) and obtain restored function. On the other hand, rest and relaxation exercises usually lead to atrophy.

Luria taught that brain systems which do not ordinarily carry out a particular function can be induced to take on different tasks. This insight is not qualitatively different from the educational insight that multimodal instruction is more robust than ordinary practice. Luria specifically notes that his scheme for restoration is based on insights derived from studying mnemonics where multimodal memory models prove to be very stable.

In restoration the important issue is to discover which facilities and systems still work relatively well. This focus is quite different from the usual practice of therapists who typically catalog all those things which don't work well. The therapeutic planner has to figure out how to use the functions which still work to proceed around the specific defect.

Since defects resemble each other, in the way one fever looks like another, it is important to understand the underlying structure of the system which maintains the defect, and it is essential to know what is still working.

For Luria the key to restoration is to make the patient conscious of the defect and to engage as much of the brain as possible in the analysis of the defect and the methods by which the goal can be reached using different systems and subsidiary systems. The patient may not be be able to comprehend the ultimate goal, so restoration has to proceed by analysis of the components of the skills which remain and can approximate the goal of speaking, reading, locating in space or other skills.

Luria taught us that the brain is wonderfully plastic. He restored the idea of consciousness to psychotherapy. The patient is done no harm by being made conscious of the defect, on the contrary, until consciousnes is achieved progess is impossible. The patient has to be made consciously to analyze the process of the skill and the way in which progress toward a goal is blocked.

The analysis, of course, is carried out by using all the intact or partially intact systems.

Finally Luria demonstrated that practical drill is of no value whatsoever. While a great deal of repetition is necessary in restoring function to the injured brain, the purpose of the repeated actions is to make the patient become aware of the defect and the methods of analyzing and reaching the goal. This process is not always accessible where there is frontal or extensive injury; however, the basic approach is valueable to some degree in all but the most severely injured patients.

HEAD INJURY: SUCCESSFUL CASES OF REHABILITATION

TOM: Simple Sensory Feedback

Six months after Tom was in an automobile accident he was still paralyzed on the right side. His senses were disordered, his movements were deranged and his speech was badly slurred. When I asked Tom to raise his right hand he was grossly uncoordinated and his muscles were very tense. Repeated practical training and drill had not helped him at all.

I attached an electric stimulator to Tom's ring finger and the back of his hand. Tom could not tell me when I had switched the current on. However, if the current was on and I asked Tom to raise his right hand he immediately lifted it without wavering and without tensing or the spasms which ordinarily characterized his movements. He was able to function almost normally when the current was on.

Alexandr Luria told of a similar case where he put a rubber band around his patient's middle finger and a tight rubber strap around his hand. When I did this with Tom if his eyes were closed he could not tell if the rubber bands were in place or not. But he could easily move his hand and arm.

DICK: Sensory Feedback and ReLabelling as Feedback

Nine months after Dick fell on his head from a tree he was paralyzed on his right side, his senses were disturbed and his speech was markedly slurred. Dick could barely move his hands and lower arms or feet and lower legs. His hands and feet spasmed into a spastic contraction whenever he attempted to use them.

When I put tight rubber bands around Dick's fingers or arms he was able to move his hands and arms. If I shocked him, or gave him electrical stimulation which was not painful he could move. Dick said it hurt when he forced his hand open; but, when I forced one of his fingers open and held it open Dick could then easily open his other fingers. After I forced the finger open for a few minutes Dick could move freely for about 20 minutes.

I put a splint on the hand for several days which forced Dick's fingers open. When I removed the splint Dick was able to use the hand. He was able to use his hand freely for a longer time after each subsequent use of the splint.

When Dick could use his fingers after I forced open one or all of his fingers I trained Dick with physical routines in which I gave new names to his hands.

I chose labels that had some important meaning like "the money hand", "the greeting hand", "the sick hand" to the right hand and arm. The new names were accompanied by complicated and rapid movements in increasingly difficult routines. This combination of electrical stimulation, tactile stimulation, forced motor extension of the hand and fingers and the psychokinetic exercises was effective. Dick moved flexibly and spontaneously without using external aids after six months of training.

HARRY: Sensory Feedback

Harry was severely paralyzed on the right side after an abcess behind his left eye. Harry's tactile awareness was faulty, especially in his right upper arm, and he suffered a loss of coordination. He had trouble making simple movements like putting his right index finger to his nose. Extensive practice seldom helps people like Harry and he was no exception. He had no spontaneous improvement after the first three months following surgery.

We used a number of devices to restore Harry's feeling. We used electric current, pricking rings and bracelets, severe massage, painful constriction by rubber bands or copper rings, and vigorous, complicated exercises. Harry would say "my finger feels alive again" when current was applied. At first, his movement and sensation were restored only when one of the device was in place and being operated. After using several different devices for several days Harry could move, feel and coordinate movements for increasing lengths of time. Harry seemed to need aggressively applied psychokinetic exercises for good functioning to be maintained.

TOM, DICK AND HARRY, had lost primary skills because of damage to their senses of location, movement, touch - essentially damage to the interaction of movement with touch and the sense of location and change of location. These dysfunctions are relatively easy to restore when no verbal, symbolic or abstracting and projecting skills are lost.

ROBBIE AND CHARLES not only had serious loss of sensation and movement; but the internal map and speech were also scrambled.

ROBBIE: Relabelling to Reestablish the Internal Map

Robbie had just entered his freshman year of college. He was the only child of high achieving parents and had been an honor student and class officer. He was in a coma for seven weeks after his car hit a telephone pole. He lost all movement on his right side until the fourth month after the accident. During the first month after recovery from coma he could not speak and could not understand speech.

Robbie came to us two years post accident and had improved very little after the first year.

When we first saw Robbie he was euphoric. Robbie had been getting treatment from a psychodynamic psychiatrist who had him on neuroleptic drugs. We discontinued the drugs; but his euphoria persisted. Because he had lost fine coordination he needed help to eat; but he could dress himself and go to the toilet without help if he was guided to the toilet.

Robbie could not tell the difference between right and left. Even though his bed was against a wall, he could not remember on which side his roommate slept when asked to point while he was lying in the bed. He could not imitate positions of the hand. He mistook horizontal for vertical, his knowledge of direction was completely confused. He seemed to have lost his sense of the meaning of prepositions. "Above, below, upon, under, beneath, through" and so on were meaningless to him.

Robbie could not locate himself in space and his concept of time was oddly distorted or missing. He could not indicate by movement the meaning of prepositions and could not define them verbally.

Robbie mistook horizontal for vertical. He could not tell you on which side of him his roommate was if he was sitting between the beds and answering questions.

The young man had difficulty locating the parts of his body if you said "touch your head ... arm ... knee...". His knowledge of direction was confused. He could not recognize basic shapes when he felt them with his fingers, nor could he imitate any position in which the examiner put his own hand.

Although Robbie's speech was stiff and mechanical he spoke with relative ease and was entirely comprehensible. However, his grammar was scrambled. He could not do arithmetic problems if there was more than one digit and fractions, multiplication and divison were impossible for him to comprehend.

Robbie wrote from right to left in mirror images. When we showed him pairs of letters where one was a mirror image he picked the mirrored letter as correct. He rejected printed material as a trick of the teacher trying to confuse him by showing him "stuff printed backwards".

Robbie could not locate his room in the school on a plan, and he could not follow a simple map. Robbie could not describe the path he had to travel to go to the toilet or to the dining room.

Robbie transfered to my care from a center where intensive practical drill for eighteen months had resulted in little or no improvement in Robbie's abilities. Our own initial attempts to make him consciously aware of his inability to orient himself in space were also useless.

Robbie had no prepositional sense at all and could not notice the skill that he had lost.

Fortunately his tactile sensation was better preserved than in many cases of head injury and I was first able to make Robbie remember his "well" side from his "sick" side. Everyone who transacted with Robbie was trained continuously to refer to his world in terms of "sick side" and "well side".

We reinforced the concepts with electric current to the sick side, bells on a bracelet on the sick side, and weights attached to the sick side as well as rubber bands and tight bracelets. We left a red light burning on the sick side of the bed. We affixed pricking devices to the sick arm. We drew lines with cold metal rods from midline to the sick side constantly describing what we were doing. We lightly scratched arrows from well to sick side in the skin of the abdomen and chest; we painted arrows in the same fashion. We slapped the sick side, tickling and poking so that we were constantly reinforcing the concept of sidedness.

We put all money, food, and any other things Robbie might want into the right hand while identifying it as the "sick side", "sick hand", "money hand" and so on.

Right was red, left was green. We painted Robbie's hands appropriately as we worked, keeping always a sense of fun, enthusiasm, rapid pace and positive orientation. As soon as Robbie had a stable grasp of red/green we stopped using "sick/well".

In similar cases we have used "Kermit's" side, "Mickey's" side and identified the frog as green, the mouse as red. Any vivid character in the patient's world may be used.

After two weeks Robbie could distinguish his right from his left, the right side of the room from the left, and he could follow plans, sketches and maps. He began to use "left" and "right" without prompting. We continued to use red/green, money hand, Kermit's hand and similar constructs even after Robbie was using "left/right".

I limited Robbie's psychokinetic exercises to right/left discrimination at first. All his massage, all his assistance with daily living and other activities were carried out in a constant barrage of verbal codes for right/left.

When Robbie began spontaneously to use "right" and "left" accurately I began to add exercises which permitted him to analyse all the locative prepositions. "Up/Down", "Under/Over", "Above/Below", "Around/Through", "On the table/Off the table" and other spatial relationships were associated with physical movements. All the prepositions were analysed and given multiple meaningful associations. Strong physical movements were associated with direction.

Using the parts of his body which he could move fluently I taught him a repertoire of coded prepositional associations. As he laboriously drew lines across paper he was encouraged to analyze the direction of the drawing "from sick to well" or from "red to green", from "the side closest to me to the side farthest away". Loving detail was lavished on every turn and line of every drawing.

Robbie learned to write from the green side to the red side. He could then begin to add and to subtact by putting the unit on the sick side and the tens on the well side. After eight weeks of reeducation Robbie could write with mirrored capital letters from left to right and to add and subtract using mirrored numerals.

I used Ashton-Warner's method (see her book, TEACHER) to develop Robbie's preferred vocabulary. I taught him Hulda Clark's method for vivid imprinting of letters. Then I used Anan'ev's method for conscious analysis of letter structure. (Davis has refined and replicated Anan'ev's method as "Ball Stick Bird").

In the same manner that Ashton-Warner instructed Maori children learning English I asked Robbie to tell me a word or sentence he would like to have as his own. I lettered each word in large strokes with a large felt marking pen. As I lettered I described what I was doing slowly and in tedious detail.

I associated each letter verbally with a visual or auditory image using Clark's system. "N", nnnnn, a nose, see the mosquito bite on it? "M", monkey, mmmmmmm, see the monkey's thumb? "L", leg, llllll, long, long leg. "U", uh, underpants hanging down.

I identified each stroke as one of three basic forms. "O" a big big Orange, "o", oh!, a little bitty orange." We used capital letters with Robbie since he retained mirrored capitals.

As he drew them we taught him to analyze how he was drawing the letter in terms of "V" vanilla ice cream cone, "l" a long stick, "O" an orange.

I used brown crayon to draw the cone, orange for the orange, and green for the stick. I described all of the parts of the letters as a cone, an orange, or a stick, or parts of a cone, orange or stick.

Robbie learned that the letter "A" is drawn by "take a cone and turn it upside down and use a little piece of the stick and put it in from Mickey's side to Kermit's side." "B" is drawn by "put a stick on the well side, and an orange on top, and an orange on the bottom on the sick side."

When patients have lost all capacity to write and cannot read any printing at all, or when I am teaching children or adults to read for the first time I begin with lower case letters. In these cases it is often enough to emphasize small differences in the serifs, adding hooks or curls and associating them with menmotics.

"Apple, a, see the stem curl to the well side." "Finger, fffff, see it hook to the sick side." "Glasses, guh, see how the two oranges are joined by a stick and make glasses, guh."

Within three months Robbie could write fluently. He began copying drawings which at first were also mirror images. He corrected this mirroring spontaneously without direct training. His orientation in space improved substantially. Robbie began to make free drawings.

Robbie could not read for another six months. We worked hard to find material Robbie enjoyed and which kept his interest, and then we read to him a great deal. I read aloud to Robbie and he listened to a great deal of spoken recordings. I did teach Robbie consciously to analyze the acoustical properties of speech but I felt that intensive analysis of speech was not necessary as Robbie was immediately fluent at this task. Robbie's speech was consistently accurate.

CHARLES: Movement and Coordination

Charles was a normal 15 year old boy when he was assaulted in school and was hit with a hammer on the left side of the middle of his head. We first saw Charles a year after the injury and he still suffered partial paralysis of the right side. His movements were disturbed overall and his sensation was diminished.

Charles had a very weak grip, and he could not move his wrist, elbow or his shoulder simultaneously. He could not move any of these joints while he was moving any finger. Charles could not do such tasks as hammering, sawing, using a plane and so on.

Charles did not recover deep muscle sensation, and when surface feeling came back his coordination did not improve in the way this ability recovered so fluently for Harry.

We took Charles to the shop and told him to watch another student planing. We told him to tell us what the 'model' was doing. He watched the model from every possible angle. He watched TV tapes of the model working. We drew cartoons right in front of him as he watched the model. We used arrows and other aids to show the efficient movements for the task, planing, sawing, or hammering. We drew on the wood itself. All during this observation Charles worked with wood, tool and himself in a jig which forced correct stance, trajectory and relationships of the three. Charles was rewarded with food, drink, tokens, ratings, and praise as his work improved.

Within a month Charles used his right hand and within two months he was able to work with only about l in 4 errors and he worked adequately at other tasks.

FRANCES AND FRANK: Two Similar Cases of Loss Treated Differently

Frances and Frank seemed to be cases of identical dysfunction; however, the underlying damage was very different and required two contrasting strategies for successful tactics to result in rehabilitation.

FRANCES: Kinaesthetic Loss of Movement and Rhythm - Novel Associations-

A gifted 16 year old who was assaulted at school. Frances had complications after invasive damage in the center of the right side of the brain. Frances could not write smoothly but she could quickly spell out words to dictation. She could no longer play the piano although she could recognize and strike the notes from a sheet of music. Frances could not play any piece although she had already practiced and played well before the injury. Frances said it felt as if "I'd never done this before, my fingers just go off on their own."

Frances could sew by hand but she could not sew with a machine although she had been a proficient machine seamstress before her injury and had used a foot treadle powered machine. Frances could hammer and saw, she could tap a telegraph key on signal; however, she could not tap out a rhythm with the key and she could not play rhythmically. She did not improve with practice. Her bodily movements were jerky. She was perseverative - she would strike the same piano key over and over again. At other times she would strike the key once and be unable to do anything other than tremble on the one key.

I used psychokinetic exercises with Frances first establishing codes for particular movements. "Right Front" meant extend the right hand as far as possible straight forward, "Right Stretch" extend the right hand as far upward as possible, "Out" move the arm horizontally away from the shoulder, "Bowl" backwards as far as possible as though bowling a ball. In a similar fashion, "Saddle" indicated a movement of the leg to the side, "Point" move your foot to the front, and "Reach" point the foot backwards as far as possible. Codes for more dynamic movements were also used.

The codes were made up to have at least some meaning naturally related to the act.

Frances learned the codes and movements readily if somewhat jerkily. She had no perseveration until the commands were given quickly in sequence.

Once Frances learned the code and could repeat the movements fluently I recorded a sequence of commands at a pace slow enough for Frances to succeed without many errors. I used a male teacher with the lowest bass voice and a woman with a soprano voice to give the movements randomly but in 4/4 time with the male representing four beats and the female two beats.

Once Frances learned these associations I added a tuba with the bass and a piccolo with the soprano. While the bass was giving commands I flashed a slide of a tuba in yellow on a screen, and a picture of a piccolo when the soprano was speaking.

Then I gave Frances cartoons of tuba and piccolo and I asked her to type the rhythm they represented. At first I asked her to type "ffff" for the four beat signal (male, tuba, bass, yellow) and "jj" for the two beat signal given by the female soprano with green piccolo. Then I asked her to use the dual telegraph keys which turned on a yellow light on the left and a green light on the right. I asked her to hold the key down for the full beat of four, or for two, as signaled. Then I flashed the slides for the exact time of the beat as well as using the recordings, the slide of the instruments and lights. I asked her to 'play' from cartoons on paper. Then I switched keys - right = yellow, left = green.

When Frances could maintain correct rhythm with either her left or her right hand I had her practice with five signals given dysrhythmically before she tried to reproduce them. A slide was shown for three seconds with yellow and green dots, or tubas and piccolos. Frances played the rhythm after the slide was turned off.

I made electrodes so that a large electrode attached to the back would give a diffuse sensation and a tiny electrode attached near it would give a sharp sensation. I experimented with Frances until we found a level at which she distinctly recognized a signal but felt no pain.

The diffuse signal was associated with tuba, man, bass, and yellow, while the sharp signal was associated with piccolo, soprano, and green. I used all four signals to train Frances to repeat rhythms very quickly. Then Frances learned the signals when they were shown to her in no particular rhythm or on paper.

Frances quickly learned to play a cartoon of a man as 4 beats and a sketch of a woman as 2 beats. Frances was equally successful in reading a broad symbolic lightning stroke as 4, and a thin stroke as 2. She had a bit of difficulty translating green and yellow dots appropriately but soon was fluently responding to colored dots.

We prepared sheet music with notes drawn appropriately for 2 or 4 beats (all on F) with the half notes in green and the whole notes in yellow. We added the left hand. When Frances was fluent at reading 4 and 2 we taught her to associate orange with 3/4 (the half note with a dot) and blue for the quarter note. When Frances recognized and played these time values well we started her on simple tunes. Frances continued in this manner for about three months and played the piano smoothly while reading or from memory.

Frances had a problem which was fairly simple to correct. I probably indulged in overkill with the added signals in the beginning of training. However, for many other patients these added stimuli are essential. This is especially true for electric stimulation and the use of hand pressure, taps, hot and cold, pricks and other tactile signals. Tactile reinforcement of symbolic or abstract signals seems very important in restoring writing or other rhythmic tasks that previously were overlearned.

Frances spontaneously generalized her ability at the piano to other rhythmic tasks like machine sewing.

Unfortunately the spontaneous improvement Frances enjoyed does not happen in many more severely injured patients. In many severe cases this training does not seem to help.

FRANK: Kinetic Loss of Memory and Rhythm, and of Novel Meaning and Arrangement

Frank seemed to have the same problem as Frances had; however, the reeducation approach needed to be quite different.

Frank was a 20 year old soldier in Viet Nam and received a bullet wound in the right temple. We saw him 13 months after his wound. Frank had dysrhythmic movements. He had been able to type at 80 wpm before the injury and could not type at all after the injury. He had been a gifted guitarist but he could no longer play the guitar at all.

Frank was not helped by psychokinetic exercises. When we used auxiliary signals he could not remember the rhythm. Frank apparently could not build an association with the signals through conditioning. Of course, verbal drill did not help him remember. Frank could passively repeat a rhythm on the telegraph key if it was sung, tapped on the opposite hand or on his back, or signalled by electric stimulation. He could not repeat the rhythm. He could not copy from a paper any repeated series.

If I asked Frank to copy "_._._._._._._." he drew ....... or _ _ _ _.

Frank was able to notice his defect. He made an effort to correct himself but failed in every attempt. When we asked him to draw _/_/_/_/_/_/ he would draw //////// or _ _ _ _ _ . When he tried to copy () () () () () he would produce )))))) or ((((((. If he tried +=-+=-+=-+=- he would get =-=-=-=- or === or ---.

When I asked Frank to draw a triangle and then a circle he would draw circles endlessly without noticing his failure for some time. When I pointed out to him that he was only giving me circles he would draw one or two triangles and then fail again.

I began to tell Frank to draw figures as objects rather than asking him to copy geometric forms. For example, I asked him to draw a series of pen holder sets, like this _/_/_/_/_/. He copied accurately straight away. Draw these six tweezers, like this ()()()()()(), and again he was successful. Giving a new meaning to the figure enabled him to retain the image and draw it.

In some drawing tasks all I had to do was to draw any colored sketch around the figure and Frank could draw it again and again (+=-). So long as I was able to give some meaning to a figure Frank could draw it. When I asked him to draw a sun and a tent he did so and then drew a series of them.

Kirscher's tasks include a problem where meaningful names are given to circle, cross, square, triangle, and horizontal curves. When I asked Frank to copy the figures he could not copy them. When I told him to copy the box, tent, orange, crucifix and lake as I showed him the shapes he did so immediately. He was able to copy again when I gave new meanings to the sketches such as picture frame, house, sun, crossroads, dangerous curve.

I taught Frank Hulda Clark's method of presenting a semantic alphabet so that each letter is associated with a vivid mnemonic (monkey, mmm; pistol, puh; toe, tuh; etc.). Then I had him type letters to a tape recording. The letters were spoken rhythmically and I dictated the mnemonic of the letter rather than the English name of the letter, ie., "monkey, mmmm" rather than "EM".

Frank continued to type more efficiently if a metronome was playing. He typed better from dictation than by reading sight copy. He never did recover his old 80 wpm ability. He was able to maintain a respectable 30 wpm without external aids for considerable periods. His ability to type fell apart when he was tired or under emotional stress.

Guitar playing presented a more complex problem. I put vivid geometric designs around each chord but this would not work for whole measures or pieces. I substituted mnemonics for notes and he did better, but this method was cumbersome to use and hard for Frank to learn.

Frank's difficulty may have been because of my own lack of imagination. I found it hard to think of semantically vivid images for duration. My codes of hippo (whole note), cow (3/4), goat (1/2), and cat (1/4) may have worked as associations for the durations but may not have had enough semantic weight. In my mind, duration and size and strenghth are associated but they may not have been in Frank's mind.

I made up a code using a bomb, artillery shell, grenade and a bullet for 1/1, 3/4, 1/2 and 1/4 notes. This code was also cumbersome to draw. Frank learned the code quickly, but he did not make the transfer to standard notation. When I indicated the rhythm by pressure or with light, sound, or electric stimulation he could play acceptably. His reading of notes used both mnemonic schemes for the scale. The auxiliary signals served as vivid reinforcers of the symbols and he could not remember rhythms presented only with these added signals.

My experience with patients with this kind of injury (as well as frontal and prefrontal injury) is that they seldom recover fluent skill without the use of external aids or through very self conscious use of internal schemes.

ASSOCIATION VERSUS EMPHASIS

Frances represents a case of damage in the ability to sense movement, while Frank represents a case of inability to form memory traces and associations of movment. Despite their similar deficits the underlying operations are very different.

Frank and other patients with temporal or other injuries which derange rhythmic ability have a kinetic dysfunction where semantic emphasis or kinaesthetic emphasis is successful. The patient can produce a rhythm presented more vividly either by added signals, or by semantically enriched signals. They cannot build associations.

Frances and other patients with premotor injuries have a kinaesthetic dysfunction where new associations must be built up. The associations are auxiliaries and generalize easily. The Franks cannot remember or condition new associations. The mnemonic devices which work are intensifiers and not auxiliaries.

Direct practice almost never helps restore motor abilities which have been lost for more than six months. Luria taught that the key to effective reeducation is to discover what underlying operations are faulty. The operations can be reconstructed by forming new links through the skills which remain intact. For example, when we saw that Frances not only learned the psychokinetic codes, but also generally improved her overall movement through the exercises, we could be pretty sure that associational training would work.

Frank was able to translate a complex meaning into a simple drawing, but he could not repetitively copy. Frank learned semantically vivid associations ("bowl") in the psychokinetic exercises, but had trouble with more abstract associations ("point"). He did not benefit from the exercises. We knew that his ability to extract vivid meaning was intact, but his ability to remember new arbitrary associations was gone.

GEORGE: A Case of Awareness and Analysis

GEORGE was 12 years old when he had a penetrating injury near the middle of the back of his head. Two years after the accident the initial blurring of objects he had first suffered progressed to an inability to recognize objects. George had great difficulty differentiating similar words and letters. He could pick out a second copy of any object I showed him but he could not name the object or recognize it. George could recognize sounds, and knew the letter "H" which was the initial of his last name. He could write from dictation but could copy only with great difficulty.

George's rehabilitation required tedious attention to making him consciously aware of the details of his deficiency. I proceeded by asking George to watch me as I drew letters at a chalkboard. I drew very slowly. I often asked George "where is my hand now?" As I drew he often recognized the more basic letters (viz. o, l, c). I asked George to draw his own letter on top of my letter. Often as he drew he recognized the letter.

I had George handle letters cut out of plywood in a bag so that he could not see them. We took out the ones he recognized. He then copied them on the board and on paper. Those letters that he did not recognize were taken one by one in both our hands, while still in the bag, and analyzed. If he did not recognize the letter I had him take the letter out, touch it while he looked at it. He described and analyzed the structure of the letter. Then he copied it on top of my newly made drawing at the board, and then again on a paper while I repeated the sound and mnemonic for the letter (ie, monkey, mmm).

I do not ever train letter recognition by using the formal name (ie, "em") or by following abcdarian sequence.

I used a similar process with pictures of objects. George often guessed at the meaning of a whole complex drawing by looking only at one or two elements. I had to get George to understand that he must make his search more thorough and more systematic. As he learned not to plunge into a guess at first glance his estimates improved.

My basic role was to make George bring his inabilities into his conscious awareness. As he became aware, I could help him analyze the ways in which he failed, and the ways in which he would succeed. I found it useful to use vivid cartoons of situations with significant meaning. I showed him slides over and over again so that he learned their meanings.

As George got better and better I aggressively trained him in "Fair Witness" reporting. I showed him slides and asked him to tell me exactly what he saw concretely with no guesses or surmises. Whenever he made any abstract or projected comment I would ask him "where do you see that?" I forced him to describe each drawing or picture as concretely as possible without conjectures, projections, opinions, feeling tones or inferences.

Within six months George was able to recognize objects and to copy writing.

HENRY: Linguistic Analysis, Producing Phonemes

At 18 Henry suffered a severe wound at the back of the left center of the top of his head. He was moderately paralyzed and had lost sensation in his right arm and fingers. He could not detect shapes with his right hand. He had difficulty coordinating with his left hand and with switching from one part of a complex movement to another. Henry could not speak a word spontaneously. He repeated isolated consonants and vowels only with great difficulty. He could only write separate letters. He found it almost impossible to place individual letters into words. If he tried to create a word the letters were in the wrong order.

Henry often did not recognize the meaning of words. If I asked him to point to his ear he might point to his nose, knee or some other part of the body.

I found that Henry could respond to commands if I gave them clearly. I had to avoid ambiguous sounds or words that sound like other words. If I established a rhythm to the command he retained the rhythm. Henry could readily recognize phrases such as "The stars and stripes forever" and he could respond to the phrase by pointing to a picture of the flag among several other pictures.

I developed a series of nursery rhymes, popular songs and familiar poems and sayings to build up Henry's vocabulary and to improve his responsiveness to speech.

After Henry got to the point that he responded well to me and began taking care of his own basic housekeeping and personal hygiene I began a daily routine designed to reinforce his awareness of the sounds of language. In effect, I gave him a course in analysis of the acoustical properties of speech. Using the phrases we had already established in his vocabulary I used Clark's meaningful associations for the alphabet and trained Henry to associate the sounds with the letters until he could pick out the picture representing the sound (eg., monkey, mmm).

Then I made Henry watch me closely as I made the sounds which he could repeatedly identify with one of Clark's association (eg., girl, guh). I held his hands to my lips and throat and trained him to explore with his fingers so that he could examine, on me, all the dynamic elements of making any particular sound. I used a cartoon of a midsection of the human head in the process of making that sound. I made Henry trace each of these drawings, both with pencil and finger. I had him trace or feel on me and on a model head all the parts involved in making any phoneme.

Next I showed him a slide of the associated image with several repetitions of the sound. He then drew the letter himself. Using a mirror I encouraged him to move his mouth into the shape of the sound. At first we did it silently and then making the sound. We used a TV tape and I immediately showed him his own self making the sound.

As this training went on Henry spent a lot of time with other teachers watching as they read from slide projections. He spent a lot of time looking at books and we encouraged him to "read". While we did think this was rather like play for a two year old Henry later recalled that he could read during this time, but with great difficulty.

I began to dictate words to Henry only after he could repeat sounds and to print letters dictated to him. At first, I would say the word, e.g., "kill". Then I would spell using the Clark associations, ie., "kicker, kuh; itchy, ih; leg, lll; leg, lll." Soon Henry was able to write words and simple sentences when I did not spell out the associations.

As Henry worked through the phonetic analysis he began to understand spoken commands.

After three months of training Henry began to speak individual words without prompting. Although Henry was obviously making a supreme effort to speak words I immediately began to train him to name objects. I focused on naming objects with similar names. When he made a mistake I immediately went back to the basic phonemic association. I continued to use myself as a model, the plaster head, the cartoons, the mirror and TV tapes of Henry himself.

My emphasis was not on drill. My effort was to make Henry vividly aware of the speech process. Henry had to be able to communicate the structure of the sound, the difference in words with similar sounds, and to analyze his failures and successes.

I also had Henry write at a chalkboard using very large strokes and speaking each sound out loud as he wrote it as well as the whole word when he completed it. Then the sentence. The first material was the group of rhymes, poems and songs we first used to establish Henry's communication.

I approached Henry's partial paralysis in a way similar to Tom, Dick and Harry and in about six months he was doing well.

IDA AND JACKIE: Making and Listening To Phonemes

IDA: Making Sounds

At age twenty Ida had been hit toward the front of the center of the left side of her head. She couldn't feel perfectly in her right hand but she had no other physical symptoms. Ida could repeat "Ah", "Oh, "ooo" and "eee" but no other sounds except a few words she had learned since the accident (mama, papa, Mary and Tom). She could not name objects or repeat other words. She could only write individual letters as they were said to her. When she tried to write a syllable or a word she usually just wrote the initial letter and stopped. She understood speech and writing without noticeable deterioration from her preaccident level of skill.

I started with the words Ida could already speak and trained her in the same manner as I had trained Henry. I showed her a vivid drawing of a letter, made the association which visually attaches with some meaning to the letter and thereafter called the letter only by its association and sound (eg., monkey, mmm). I also had her mimic many usual facial movements (blowing, chewing, growling) and used the movements she easily made to begin analysis of the acoustical properties of phonemes.

I was able to get Ida to associate all the basic English phonemes in two weeks. She became fluent at analyzing how the sounds were made. However, Ida had difficulty in getting the sounds into the right order . "Butter" became "ru-bu-bu-br-pa-tu". Ida also perseverated. However, as Ida learned more associations she perseverated less in her own practiced vocabulary.

I gave Ida a long period of training during which she wrote short words and said the new associations for the sounds (eg., jumper, juh). I taped all of this training and immediately showed Ida the tape in short segments. I made Ida repeat the sound while she watched herself on the tape or the monitor.

By the tenth week of training Ida could write complete words from dictation while she said them aloud (without having to say the individual sounds).

By the 14th week Ida could repeat polysyllabic words; she could speak spontaneously and carry on an elementary conversation. If she spoke carefully she had no serious mistakes but she could get flustered. She could write fluently from dictation.

In the beginning Ida seemed to have lost the idea of language. Her "conversations" were limited almost completely to nouns, especially when she answered questions. Rather than give her exercises in grammar I continued to give her a general program of psychokinetics, spatial orientation and social interaction.

We began to assign Ida "homework" of making up six statements on index cards. Her teacher would meet for short sessions in which she repeatedly asked Ida, "but, what did they do?" In addition, we gave Ida diagrams of simple actions. She was asked to analyze the cartoons only in terms of actions. "What is the boy doing to the dog, Ida?"

Ida still spoke in a disjointed and tense way after more than a year, and she was still ungrammatical in her speech at 18 months; however, by the end of two years Ida spoke appropriately, grammatically and fluently.

JACKIE: Listening

Jackie was a 14 year old girl who had a skull fracture in the left temple three months before we saw her. She was well oriented but she had great difficulty understanding even elementary words.

"What is a dog?" "A dog isn't a bog ... dog ... dog isn't pretty ... its wrong ... its the same as hog but dog is wrong."

"How do you like being here?" "The girl? ... she's ok ... well ... then there's ... I don't know?"

Jackie could write individual letters but often made mistakes. She had particular difficulty with similar sounds (eg., bpm, dtn). Words completely confused her. She could repeat the months of the year, days of the weeks, and numbers but could not use them appropriately. She could not successfully name objects.

I began Jackie's training by vividly drawing her attention to the importance of phonemes. Asking her "Do you want soap, or do you want soup? Soup? Or Soap? I would respond by handing her soap if she said soap, despite her hunger.

"Beam (a stick) or Bean?"

"Bread or Dead (a toy coffin)?"

All the staff working with Jackie were given lists of alternatives and were coached in how properly to present her with phonemically vivid alternatives.

Jackie was like Henry in that she could recognize words in common phrases, rhymes and songs. So we made up a similar set of phrases with Jackie. Pictures of objects with names differing only by one sound were given to her in a series. As Jackie began to develop more stable memory for sounds we then gave her lists of words which changed meaning by the intial sound:

tag, flag, hag, bag, fag;
dog, hog, tog, fog, frog.

We did not drill Jackie. The object of these exercises was to get Jackie to recognize that her defect was based on not being able to notice the differences. She needed to learn to say "of course, man is one thing and tan is another."

We trained Jackie in Clark's associations for letters (eg., kicker, kuh) and analysed lists of words while using these associations.

By the end of the first six weeks Jackie was beginning to analyze and to distinguish individual sound elements in polysyllabic words she had not seen since the accident. "Window" "Sharp teeth, wolf, wuh ... ah, yes, Window, window, that's right.

"Say, 'donkey'" "Nnnnu .. no, not that, the first is doggie-duh, yes, 'donkey'!" "Where is your stomach?" She begins to point vaguely with her finger, looking at the finger. "Ffff... no its hissie ssss, sto -stomach." (Putting her hand on her stomach.)

"Automobile!" "Armor...Arr ... oh no! I can't ... oh! It's for driving! Yes! Automobile. AUTOMOBILE!!"

As Jackie began to approach the problem of speaking in this systematic, planned and rational way we began to give her sentences describing vivid actions. Then we asked her to write down and say which word in a sentence was the action, which was the actor, and which was the person on whom something was done. As she grew more fluent we used more formal terms, ie., subject, object, verb). As she grew successful at this analytic task we asked her questions and had her write her replies.

By the end of the third six week session Jackie was speaking spontaneously and participating in conversations. She could read and write well although she continued to use reversals and substitutions when she wrote for a while. In conversations Jackie often had problems finding the right word. By the end of the year Jackie's writing and speech were fluent.

KATHY, LARRY, NICK, OLLIE, AND PAULA: Rapid Restoration Through Analysis

These five students recovered their ability with astonishing speed after the right tactic was used. The elegance of each solution underlines the essential correctness of the approach pioneered by A. Luria.

The injured person must consciously analyze the process of the disability. These individuals had not been helped by practical drill. Each of them quickly recovered fluent skill by learning a method to analyze the process by which their defects could be surmounted.

KATHY: Letter Analysis

We saw Kathy three years after she had fallen at age sixteen. Her skull had been fractured at the rear of the left temple. She was well oriented and she could speak well but slurringly. She was somewhat confused in understanding speech. She had difficulty in remembering words and in naming objects. She could sign her name, and print it, and she could draw individual letters. She could copy from texts but had great difficulty in writing from dictation. Kathy would miss single letters and substitute other letters.

Kathy had been in an intensive program of Doman-Delacato physical exercise, optometric training, and phonic drill and had not improved in the last two years.

Kathy's visual analysis seemed to be intact and I thought that a modest dose of the method used with Jackie would be adequate for Kathy. I did not teach her the Clark associations, nor did I use any of the vivid differentiation tactics we used with Jackie. I gave Kathy lists of words which differed only by the first phoneme. I encouraged her to analyze the differences among the words as she wrote each new word and as she pronounced it out loud. As she became fluent at analyzing these lists I then gave her other lists of words differing in the last phoneme, or by prefix or suffix and finally by an internal phoneme.

I used nothing more with Kathy than this analysis of written letters. In six weeks Kathy could write words from dictation. Her few errors were substitutions of "mbp" or "ndt" or reversals when she was tired or rushed.

Kathy's case underlines the fact that drill is futile. The student must be made consciously to understand, analyze and systematically attack the skill which has been scrambled.

LARRY: Rapid Analysis of the Acoustical Properties of Writing

Larry had been in coma for 76 days after an auto crash in which the left side of his skull was splintered. Larry's sensation was impaired, he was partially paralyzed on the right side, and his speech was grossly abnormal.

Larry could say a few simple words, "yes, no, mama". The few other words Larry tried to say were badly mispronounced, "water" became "bahda", "candy", "gameh". When Larry tried to speak in sentences he left out sounds, inserted similar sounds and transposed sounds. Larry often pronounced only the first syllable of a word and then made similar sounds. "Chimney" became "shi shi shi". For "banana, papa, or football" Larry could only say "vovo".

Larry understood speech well, but where substitution of similar sounds in a word created ambiguity or misunderstanding he became confused and could not understand well.

Larry could write individual words and simple syllables although he often substituted similar sounds. He could sign his name and print it and he could write a few common words. His most common errors were with g/k, m/b/p, l/t, and d/n. Larry could read letters freely, but he could not read words or sentences well at all.

To rehabilitate Larry I applied the methods I had used with Henry, Ida and Jackie. The first six weeks were spent training Larry to differentiate similar letters - r/l/s, m/p/b, t/d/n. Larry and I spent more work on breaking words down into syllables, and training him to recognize words which changed only by prefixes and suffixes. Larry's speech and reading improved quickly. By the sixth month it was unusual for Larry to make any errors in reading or speech at all.

NICK: Rapid Stabilization of the Acoustical Analyzer

Nick was an exciting case, all the more so as Luria had reported a similar process in an older engineer with a war wound. While all of my cases are similar to cases Luria saw in the 1940's his rapidly restored cases seemed almost magical and I did not expect to see even one. Thirty years later I know that these cases are not so rare at all. Nick's astonishingly rapid restoration makes it abundantly clear that drill and infantalized teaching are a waste of time and are actually harmful in the restoration of adults.

Nick had been an honor student in college when stricken with meningitis two years before I saw him. He was able to function at college because his family could afford a companion/secretary. Nick could not write.

Nick could understand lectures, he could remember and work from tapes to dictate notes and papers. He could make drawings and he had no disturbance of his spatial orientation at all. His speech was slightly impaired and he transposed sounds as he enunciated difficult words. His grammar was odd. He had no impairment in reading that we could discern.

Nick could write single letters and two letter syllables. He was utterly unable to write anything more complicated. He could not analyze word sounds by telling me what sounds were used in spelling a word. If I spelled out a word he couldn't say it. If I spelled out a sequence of sounds rather than naming the letters he couldn't name the word. "T-R-A-I-N" was unintelligible to Nick, as was "tuh, rrr, eh, ih, nnn".

Nick could look at a printed word and spell it. He usually missed when asked how many letters or sounds there were in a spoken word, even when I deliberately slowed my pronunciation of the word.

It was almost impossible for Nick to tell me which was the second or third letter or sound in a spoken word.

It was obvious that Nick's acoustical analyzer was broken. Since he could read, and remember speech it was clear that the connection between visual and acoustical analyzing and writing had been broken.

I taught Nick Clark's associations for letters in one session (eg. kicker, kuh). Then I had him read a word list, repeating each word several times before sounding out each separate letter as an association and writing it down.

In the second class Nick learned the proper names for phonemes. That is I taught him to differentiate between voiced and unvoiced phonemes; among plosives, fricatives, stops and vowels; and to notice the use of his oral apparatus and to describe each phoneme as labial, lingual, dental, alveolar, palatal, uvular, glottal, nasal or open. I had him draw cross sections of the head and label each part of the oral apparatus and then draw cartoons of a range of phonemes.

In one session he learned to analyze sounds formally as phonemes. He began spontaneously to use this method to attack the problem of writing.

We went over word lists in the same way as in the first class. Nick would repeat the word several times, then Nick would analyze the word in terms of its acoustical properties. " 'Train' ... let's see ... that's a lingual alveolar plosive, tuh; rrrr, hmmmm, that's a lingual ... lingual palatal fricative, or it could even be a vowel, couldn't it?" "Yes." " 'Ai' ... well, thats a dipthong, a complex vowel ... eh, ee ... right?" "Yes." "... And 'N' is a lingual alveolar nasal ... hey! that's neat! T-R-A-I-N, train!"

At first I used a Scrabble set to have Nick begin to make up words. I gave him simple words and had him repeat them aloud as sounds and as letters and then put down the Scrabble tiles, and later to write simultaneously as he sounded out. After these exercises Nick was able to fill in missing letters in complex words very easily.

By the fifth class Nick could recognize an error himself and could write words and phrases from memory after reading them aloud or deliberately to himself.

After the sixth class Nick was able to write fluently as long as he pronounced the words distinctly to himself. By the end of the second six weeks Nick could write adequately so long as he consciously enunciated clearly to himself or said the words out loud.

I frequently find that I cannot train a staff member who has never had an injury to remember and to use the formal phonetic system. In one case I became so frustrated with one 25 year old man that I foned his parents and had him enrolled as a student. Naturally I learned that he had a long history of dyslexia and other problems. Many supposedly intact individuals also cannot learn Clark's associations in several sessions. Nick's great intelligence enabled him rapidly to replace the broken link he had used unconsciously before his illness with a deliberate conscious vocalizing analysis which he later internalized. Practical drill has no place in restoring these abilities.

OLLIE: Restoration of the Rhythm of Speech

Ollie had lost his ability to move with smooth coordination, his sense of rhythm, and especially his ability to tell connected accounts. We saw him a year after he had been struck on the top of his head.

Ollie could not retell a story read or told to him, nor one that he had read to himself, and he could not write an essay or tell an account of an event.

I wrote on cards for Ollie cues such as "Once upon a time", "when", "then", "after that". I gave him the first card and asked him to tell me about a movie he had recently seen. He began and I gave him another card. Soon he was able to take the cards himself and tell a story by referring to the cards. By the end of the first six weeks Ollie didn't need to look at the cards. He remembered the cues, used them unconsciously and spontaneously developed new cues of his own. At this point his speech could not be told from normal speech.

Ollie had lost the connected rhythm of speech and the cues I taught to him served as links restoring the beat. His kinetic defect had carried over into speech; but the power of the verbal system is so great that this simple intervention allowed him swiftly to analyze the defect and to use the cues to restore the natural rhythm of speech. Ollie's defect was similar in nature to that of Frances.

Ollie's success in rapidly internalizing this scheme shows how powerfully an analytic method can work to restore function. Reorganization of the system of speech allows a dynamic recovery.

PAULA: The Melody of Speech

Paula was 14 years old when I saw her 6 months after a severe fever had caused convulsions and a temporary loss of motor and speech ability. Within two weeks of the crisis Paula seemed normal in every way except that she, too, could not give a connected account of events.

Paula could not retell "Bre'r Rabbit and the Tar Baby" or other simple tales well known to her before the illness even when they had just been read to her. She could not tell about an exciting trip to Europe she had taken just before her illness. She could answer questions and make unrelated statements.

I asked Paula to tell me about her trip. She made one statement and paused. I asked her to tell me something else about her trip. After a bit of prodding, but no prompting about the content of her statements, she had told me 17 separate statements. I typed these on 17 index cards and gave them to Paula. She read them over in great excitement and immediately arranged them in chronological and appropriate order. She immediately sat down and wrote a story about her trip.

I gave Paula five sentences about "Bre'r Rabbit" on index cards and she arranged the cards into sensible order and told me the tale fully.

We continued to use cards until Paula was able to carry on extended conversations and to write lucid essays. When she was given a Thematic Apperception Test card she could immediately begin to tell a story, using the ambiguous cues of the picture as a framework for the tale.

Paula, Ollie and Nick recovered so quickly as to seem impossible. When these children appeared in my clinic I blessed the memory of Alexandr Luria who first reported in English on similar cases.

These unfortunate youngsters might have suffered years of psychoanalysis, practical training and other abominations had I not read Luria's elegant work. I certainly was not wise enough to trust the reconstructive ability of the conscious mind before I read his work. All three of these youngsters had been "trained" with methods having no grounding in the dynamics of the signalling systems actually used by the brain. It required an accurate assessment of the interrupted process to find the surviving mechanisms which the brain could then use to restore itself.

George von Hilsheimer, 2:30 AM, 30 April 1986, Maitland, Florida