Volume 2

Aphasia and kindred disorders of speech / by Henry Head.

  • Head, Henry, 1861-1940.
Date:
1926
    Throughout the previous volume examples of disorders of speech have been cited, presenting various forms and due to diverse causes. This volume is devoted to a series of clinical reports of illustrative cases arranged in numerical order. Each number corresponds to that employed to designate the patient through¬ out all my papers on this subject1. But, in order not to multiply these reports unnecessarily, I have omitted the records of certain cases in the series, which either failed to illustrate any new point, or were in some way incomplete. Thus, although the numbers run from i to 26, no account is given of No. 3, No. 12 and No. 16. In most instances these reports represent drastically reduced versions of voluminous clinical records extending over considerable periods of time. Several of these patients have been under my care for some years and I have been compelled by exigencies of space to omit many observations of much interest, especially when they simply confirmed those made on some previous occasion. Each case illustrates some one or more aspects of the problems dealt with in the previous volume and, in order that the reader may have some guide to their contents, I have summarised them shortly under the following descriptive headings. §1. GRAVE DISORDERS OF SPEECH When the disturbance of symbolic formulation and expression is acute in onset or unusually profound, the loss of capacity to employ language may be extremely gross. Speech is reduced to “yes” and “no” together with a few emo¬ tional expressions. The patient fails to understand exactly what is said to him and cannot execute any but the simplest oral commands. lie is unable to read to himself with pleasure and fails to carry out orders given in print. Writing, whether spontaneous or to dictation, is affected, and printed matter cannot be copied in cursive script. The tests with the alphabet usually suffer severely and the patient finds it impossible even to arrange the block letters in due order. The free use of numbers may be gravely restricted and, in some instances, he cannot solve arith¬ metical problems, or indicate the relative value of two coins with uniform accuracy. Such cases conform more or less to the type usually spoken of as “Broca’s Aphasia.” But the loss of function varies profoundly in degree. Should it be still more gravely diminished, the patient may be reduced to a condition of organic dementia in which it is impossible to carry out any systematic examination; for he is then deprived of almost every means of reproducing his mental processes in propositional terms both for internal orexternal use. 1 [63], [64], [65].
    On the other hand, a severe case of acute aphasia, such as No. 20, may pass in the course of recovery through a stage in which the defects are confined to acts of verbalisation. On the other hand, exactly opposite changes may occur in patients who are suffering from progressive organic lesions of the brain. No. 26 (see p. 394) was a case of extremely severe aphasia of vascular origin in an un¬ usually intelligent man of sixty. Speech was reduced to meaningless sounds with “ Si, si ” used correctly for affirmation. He could repeat nothing. He understood what was said to him and chose familiar objects correctly, although he could not execute more complex oral commands. He read to himself with pleasure and selected common objects slowly but accurately when shown their names in print; but he failed to execute more difficult printed orders. He could write nothing spontaneously, except his name and the first nine numerals; yet he could copy correctly, provided he was not compelled to transcribe print into cursive script. The use of the alphabet was defective; even when given twenty-six block letters he failed to arrange them in order. Arithmetical exercises were impossible and he could neither name coins nor express the simplest relation between any two of them. Orientation was not affected. Games, except draughts, were difficult or impossible. He enjoyed music and could sing without words. Vision was unaffected and there were no abnormal physical signs in the nervous system. No. 21 (see p. 320) was a case of severe aphasia due to avascular lesion in an elderly man. When first examined by me four days after the onset of the stroke, he was speechless except for “yes” and “no” together with a few emotional expressions. He could not say or repeat his name. He understood much of what was said to him, provided it did not convey an order, and seemed to comprehend the meaning of simple words in print. Writing was profoundly affected. There was no disorder of motion or sensation and the reflexes were normal. Vision was unaffected. The arterial tension was grossly raised and the vessel wall thickened. He remained in fundamentally the same condition, and, eight and a half years after the seizure, I was able to make a complete examination with the following results. He was still speechless, except for “yes” and “no” and a few automatic expressions. He could not repeat anything said to him, even “yes” and “no.” He understood most of what he heard, choosing common objects and colours correctly to oral commands; yet he failed to execute more complex tasks, such as setting the clock and the hand, eye and ear tests. He could read nothing aloud and had difficulty in understanding what he read to himself; but he chose familiar objects to printed commands and on several occasions succeeded in selecting a printed card which bore words corresponding to the colour or to the simple pictures he had just seen. Thus, it is obvious that printed words conveyed some meaning to him, provided they did not imply a command. He could write nothing but his surname spontaneously, failed altogether to write to dictation and could not copy print in cursive script. He was unable to say, to repeat, to read or to write the alphabet. He succeeded in writing some of the letters to dictation and copied them with four errors only. He counted with extreme difficulty and failed to reach twenty. Simple problems in arithmetic puzzled him greatly, but he was able to indicate on his fingers with remark¬ able accuracy the relative value of two coins.
    No. i (see p. i) was a case of extremely severe aphasia, due to an extensive gun-shot injury of the left half of the head. The missile entered in the fronto-temporal and made its exit in the temporo-parietal region; at this point there was a small hernia cerebri (Fig- V)- There was profound right hemiplegia, in which face and tongue participated; the upper extremity was flaccid, the lower hypertonic. At first he was completely speechless except for “yes” and “no” and he could not repeat even these monosyllables. He understood much of what was said to him, but was unable to execute simple oral commands with certainty. He could not read and failed to carry out orders given in print; yet he was able to point to the word on a list which expressed the object he desired. At first he wrote nothing but his surname and a scrawl, which somewhat resembled one of his Christian names. Copying from print was im¬ possible. He recovered power rapidly and it then became obvious that his defects of speech were mainly of the Verbal type. He talked slowly and with obvious difficulty. When repeating anything said to him, his articulation, though defective, was better than with spontaneous speech. He understood all that was said and executed even complex oral commands correctly. Although he succeeded in carrying out printed orders, he still failed to comprehend exactly what he read to himself owing to defects of internal verbalisation. He wrote badly, employing the left hand because the right was powerless; not only was the act of writing difficult, but the words were badly spelt. To dictation the faults were of the same character though less gross. He could, however, copy print perfectly in cursive script, evidence that the defect was intellectual rather than mechanical. He was unable to say the alphabet spontaneously and had great difficulty in writing the letters in due sequence. In spite of his University education, he was puzzled by simple arithmetical problems. Orientation was in no way affected and he drew from memory a perfect ground- plan of his ward at the hospital. He could play simple card games, but not bridge; puzzles he enjoyed and solved with ease. No. 20 (see p. 295) was a case of acute and severe aphasia in an elderly woman due to the removal of an extra-cerebral tumour, growing from the dura mater, which indented the brain around the meeting point of the inferior frontal and inferior precentral fissures. The operation was followed by flaccid right hemiplegia, loss of movement in the same half of the face and tongue, together with the usual changes in the reflexes on the paralysed side. At the expiration of sixteen days all abnormal signs had passed away and there was no difference between the two halves of the body. The loss of speech was at first profound and she could say “yes” and “no” only. The acts of speaking, reading and writing were all affected at first; even the power of under¬ standing what was said to her was somewhat disturbed. As she regained her capacity to use language, those aptitudes returned first which were least dependent on accurate word-formation. Clinically, within four months of the opera¬ tion, she had been transformed from a severe example of loss of speech into one of Verbal Aphasia, so slight that it might have been mistaken for an articulatory disturbance only.
    §2. SPECIFIC FORMS OF APHASIA No two examples of aphasia exactly resemble one another; each represents the response of a particular individual to the abnormal conditions. But, in many cases, the morbid manifestations can be roughly classed under such descriptive cate¬ gories as Verbal, Syntactical, Nominal or Semantic defects of symbolic formulation and expression. (a) Verbal Aphasia. The characteristic manifestations, which I have called Verbal defects, consist mainly of inability to discover the exact form of words and phrases necessary for perfect external or internal speech, together with want of power to transform them into written characters. Although verbalisation is profoundly affected, it is obvious that the patient can recognise names. For he chooses an object or colour in response to a printed order and, when shown some particular object, can select its name in print. Capacity to execute oral and printed commands is on the whole preserved unless the disturbance is severe. The patient can usually understand what is said to him in conversation or what he reads to himself, provided the sentences are not unduly long and complicated. But he cannot write spontaneously with ease and his spelling shows the same errors of verbal formation that are so evident in articu¬ lated speech. There is often extreme difficulty in transcribing print into cursive script. Numbers are grossly defective; yet he can recognise and express in some roundabout way the relation between coins of different value and has no difficulty with money. Orientation is not affected; he can usually construct a ground-plan of some familiar room. The power of playing games is not disturbed, although the defects of articulated speech may make it difficult to express the score. The slighter the loss of function, the more closely does the disorder appear to be one of articulation. But spontaneous writing always shows defects of the same order as those of external speech. Moreover, the power of employing block letters in various ways to compose an alphabet or to form words is usually affected, showing that the fault lies in verbalisation and is not in origin simply “motor,” “mechanical ” or even purely “anarthric.” No. 6 (see p. 76) was a case of Verbal Aphasia, due to a gun-shot injury over the anterior portion of the left precentral gyrus, extending downwards on to the inferior frontal convolution (Fig. 7, Vol. 1, p. 445). There were no abnormal signs in the nervous system, except a transitory weakness of the right half of the lower portion of the face and some deviation of the tongue to the same side. Four days after he was wounded he was speechless, but he soon began to utter a few badly articulated words. His power of speaking rapidly improved and throughout it was verbal structure and not nomenclature that formed his main difficulty. He could under¬ stand what was said to him and commands exacting a single choice were carried out accurately; but, as soon as two of these orders were combined, his response became slow
    and hesitating. Comprehension of printed phrases was obviously defective. Although he rapidly recovered the power of writing his name and address correctly, he could not write that of his mother with whom he lived. He was unable to count, but wrote the numbers up to twenty-one. Orientation was not affected. He drew well spontaneously and to command. Seven years and eight months later, he had regained his power of carrying out all the serial tests, but still remained a typical example of Verbal Aphasia. He hesitated in finding words to express his thoughts, the pauses were unduly frequent and prolonged, and enunciation was defective. He could read aloud intelligibly, but stumbled at the longer words and complained that, when reading to himself, he was obliged to go over the same passage twice before he could grasp its meaning. As he said the words to himself silently, he was liable to mispronounce them and this confused him. In the same way, although he could write an excellent letter unaided, he did so slowly. He still failed to say or write the alphabet perfectly and even hesitated in putting together the twenty-six block letters; but he could repeat the alphabet after me, read it aloud and write it correctly to dictation. He counted slowly without mistakes, though articulation was somewhat slurred. He solved all the problems in arithmetic, except the most difficult of the subtraction sums, and he had no trouble with money. He drew excellently and produced a perfect ground-plan of the room in which we worked. He could play all games correctly. Thus, the difficulty throughout lay with verbal construction, whether for external or internal speech, rather than with verbal meaning. No. 9 (see p. 124) was a case of grave Verbal Aphasia due to an extensive gun-shot injury in the left parieto-occipital region. This produced profound right hemiplegia, both motor and sensory, with gross hemianopsia. His speech was reduced to little more than the use of “yes” and “no” and he could not even pronounce his own name correctly. He had extreme difficulty in finding the names of common objects and colours, but the sounds he uttered bore a distinct relation to the words he was seeking. When he attempted to repeat what was said to him, articula¬ tion was extremely defective. His comprehension of single spoken words was good and he executed oral commands, provided they did not necessitate elaborate choice. He could select a familiar object in response to its name in print, but was slower and less certain with colours and failed grossly with the more complex tests. He wrote his own name, but could not add his rank, regiment or address, and was unable to write down the names of common objects. He could copy printed matter in capitals only. These defects of writing were not due to mechanical inability to form the letters, but rather to a difficulty in using them as appropriate symbols; for, if he were shown an object and asked to compose its name from a set of block letters, he was unable to do so. He counted up to ten, but could go no further and failed to solve simple problems in arithmetic. He succeeded in naming coins, although the words were badly pronounced, and in every case recognised their relative value. He showed a vivid appreciation of pictures and could draw on the whole correctly, even to command. He produced a ground-plan of his corner of the ward, but tended to draw some of the objects in elevation. Orientation was in no way affected. He played an excellent game of draughts. Three years and nine months later, the defects of speech, though less severe, retained the same character, consisting mainly of loss of power to evoke words in a correct form and still greater difficulty in translating them into written symbols.