LE JOURNAL CANAD1EN DES SCIENCES NEUROLOG1QUES Classification of Aphasic Phenomena ANDREW KERTESZ SUMMARY: A brief but comprehensive Most clinicians will agree that al­ tions cover the same phenomenon. survey of classifying aphasia reveals though aphasic disability is complex, In Table I the various terms are that most investigators describe at least many patients are clinically similar shown to overlap and those describ­ four major groups, conveniently labelled and may be classified into identifi­ ing the same disturbance appear un­ Broca's, Wernicke's, anomic and global. able groups. There are many classi­ derneath each other. Four columns Conduction and transcortical aphasias fications indicating that none is al­ appear to represent the entities that are less generally described and mod­ ality specific syndromes rarely, if ever, together satisfactory. Nevertheless, almost everybody identifies: exist purely. The controversy between this effort is useful and even neces­ 1. What Broca (1861) described as unifiers and splitters continues but ob­ sary to diagnose and treat aphasics aphemia, Wernicke (1874) called jective numerical taxonomy may solve and to understand the phenomena. motor aphasia. Marie (1906) did not some of the problems of classification. The opponents of classification consider Broca's aphemia true point out the numerous disagree­ aphasia. Pick (1913) labelled it ex­ ments among observers, the many pressive aphasia with agrammatism RESUME: Line etude breve, mais com­ exceptions that cannot be fitted into and Weisenburg & McBride (1935) prehensive, de la classification de categories and the frequent evolu­ popularized "expressive aphasia" I'aphasic revile que la plupart des cher- cheurs decrivent au moins 4 groupes tion of certain types into others. which still enjoys favor among majeurs, clairement identifies: Broca, The controversy can be reduced many. The problem with the term Wernicke, anomique et globule. Les to a few issues. Is aphasia a unitary "expressive" is that all aphasics aphasias de conduction et transcorti­ disturbance or are there several have some "expressive" difficulties. cals sont decrites de facon moins gene- kinds of aphasia? The answer, of Then came the "innovators" such rale et les syndromes modaux speci- course, is yes to both. There is as Henry Head (1926) whose distaste fique ne se retrouvent que rarement, something qualitatively different for his predecessors' diagrams re­ sinon jamais sous forme pure. La con- about aphasic language disturbance sulted in a unique psycholinguistic troverse de classification continue mais classification which is difficult to la taxonomie numerique objective pent which sets it apart from dysarthria, mutism, confusion and psychotic apply to clinical cases. Broca's aider a resoudre quelques-uns des prob- aphasia thus became "verbal lemes courants. speech, just to mention the main problems in differential diagnosis. aphasia". After Head, only Wepman What makes it qualitatively different (1951) used the same terminology is difficult to define to everyone's extensively in the literature. Luria's satisfaction, but, the following defin­ (1964) physiological concepts led to ition might be acceptable to most: A "efferent motor" aphasia. neurologically central disturbance of Jacobson's (1964) linguistic approach language characterized by used "contiguity" or "combina­ paraphasias, word finding difficulty tion" disorders for this phenomenon and variably impaired comprehen­ and Osgood (1963) called it "encod­ sion, associated with a disturbance ing" disturbance. Bay (1964) like of reading and writing with or with­ Marie (1906) considered "aphemia" out dysarthria, non-verbal construc­ different from aphasia and gave it tional and problem-solving difficulty the term "cortical dysarthria", a and impairment of gesturing (con­ theoretical deviation from the con­ structional and motor apraxia). sensus which considers these pa­ Ever since Broca (1861) described tients aphasic. Shuell's (1964) clas­ "aphemia" and Wernicke (1874), sification is highly individualistic sensory aphasia, many clinicians and difficult to correlate with others. have tried to record their experience Her Group 3 "severe reduction of From the Department of Clinical Neurological and improve the results of classifica­ language" with "sensorimotor" dis­ Sciences, St. Joseph's Hospital, London, Canada. tion. Although confusing at first turbance corresponds best to Reprint Requests to: Dr. Andrew Kertesz, De­ glance, after gaining some clinical Broca's aphasia. partment of Clinical Neurological Sciences, St. Joseph's Hospital, London, Ontario, Canada N6A experience, one finds it striking that More recent clinically and linguis­ 4V2 the new classifications and descrip­ tically oriented classifications place Vol. 3, No. 2 MAY 1976- 135 Downloaded from https://www.cambridge.org/core. IP address: 170.106.202.58, on 02 Oct 2021 at 10:35:25, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0317167100025890 THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES an emphasis on the fluency- sory aphasia. Marie (1906) claimed Wernicke's aphasia as described nonfluency dichotomy in aphasia. that sensory aphasia was the true by Goodglass and Kaplan (1972), Goodglass and Kaplan (1972) and aphasia and this is still championed features impaired comprehension many others recognized the clinical by Bay (1964). Shuell (1964) was also and fluently articulated, but relevance of measuring fluency. impressed by the auditory distur­ paraphasic speech. Repetition, nam­ They also advocate the retention of bance as the sine qua non of aphasia. ing or word-finding difficulty and the classic eponym rather than using Curiously, her classification does impaired reading and writing are al­ "motor" or "expressive" aphasia in not have a single group which could ways present. Since various degrees order to avoid suggesting that be identified unequivocally with of impairment are seen and the speech output is normal in other sensory or Wernicke's aphasia. fringes of the entity are often ill- forms of aphasia. Head, like Wepman and Shuell after defined and controversial, retention Much of the controversy about him, in order to avoid the input- of the eponym seems useful to de­ Broca's aphasia centers around the output dichotomy and the notion of scribe this clinically valid and com­ existence of comprehension deficit. pure language defects, created novel mon aphasic impairment. These patients are characterized by classifications deviating from the 3. Probably the largest group of relatively well-preserved com­ clinically obvious, and confusing aphasics have relatively little ex­ prehension and their major disability generations of readers. Head's syn­ pressive or receptive difficulty. is in language output. However, if tactic aphasia is not the same as Their speech is fluent, at times very comprehension is examined exten­ Wepman's who called sensory circumlocutory, occasionally sively, it is found to be impaired to a aphasia "pragmatic" and the motor paraphasic, and shows obvious certain extent, almost without ex­ "syntactic". Jacobson's (1964) word-finding difficulty. Their verbal ception. This prompted many inves­ "similarity" or "selection" disorder paraphasias are semantic substitu­ tigators to emphasize that com­ encompasses a range of clinical dis­ tions, rather than phonemic (literal) prehension is an all pervasive fea­ turbances such as "sensory", distortions. They have near normal ture of aphasia and the variable "semantic" and "acoustic amnes­ comprehension and repetition but amount of motor difficulty at times tic" aphasia as he used Luria's their naming is impaired. This is labelled "cortical dysarthria" (1964) terminology. According to often called anomic or amnesic superimposed on aphasia results in him sensory aphasia is characterized aphasia and this often appears de the variation of the clinical picture linguistically by preserved syntactic novo or it may be the end result of called Broca's aphasia. Mohr (1975) units, and phonemic combinations recovering from other syndromes, claims that Broca's aphasia is rarely although certain phonemic distinc­ such as Wernicke's, "conduction", seen from the onset of a C.V.A. as a tions are lost. Osgood's (1963) de­ or the "transcortical aphasias". distinct entity but develops from coding disturbance is in this categ­ Although Broca himself spoke global aphasia, by virtue of improv­ ory also. about "verbal amnesia", this entity ing comprehension, or if it is present Jargon aphasia is at times iden­ was not defined until Goldstein early after a stroke, it often evolves tified as a separate entity although (1924) described amnesic aphasia as into a milder syndrome. Most clini­ most writers will classify it with an impairment of "abstract at­ cians agree, however, that motor Wernicke's or sensory aphasia. The titude". Henry Head (1926) de­ aphasia, primarily expressive fluent, profusely paraphasic speech scribed nominal aphasia as a diffi­ aphasia or Broca's aphasia, is an may be usefully subdivided into culty in naming but included im­ identifiable aphasic syndrome with semantic and neologistic jargon, de­ paired understanding of names as hesitant, scant and paraphasic spon­ pending on the degree of phonemic part of the disturbance, which is taneous speech, variably impaired distortions or neologisms (the contrary to what clinicians usually repetition and naming, and relatively paraphasic and asemantic jargon of find in