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Language Disorder in a Case of Korsakoff's Syndrome by P J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.21.3.190 on 1 August 1958. Downloaded from J. Neurol. Neurosurg. Psychiat., 1958, 21, 190. LANGUAGE DISORDER IN A CASE OF KORSAKOFF'S SYNDROME BY P. R. F. CLARKE, MARUI WYKE, and 0. L. ZANGWILL From the Psychological Laboratory, the National Hospital, Queen Square, London In 1935, Curran and Schilder drew attention to with in aphasia. For instance, words are not garbled the incidence of a peculiar language disorder in cases and the rhythm of speech is normal. Further, mis- with acute cerebral disturbances of traumatic or naming was commonly referable to concomitant toxic origin. This disorder comprised misnaming, disorders of perception and orientation, and did not paraphasia, discursive and incoherent speech, and necessarily presuppose derangement within the in some cases bizarre forms of verbal expression sphere of language itself. Emphasis is also placed on reminiscent of schizophrenia. Although the phe- the role of motivational factors, more especially nomena were ascribed in part to focal dysphasia, those presumed to govern denial of illness. In con- the authors commented on their similarity to certain clusion, the authors argue that paraphasia in cases types of language derangement occurring in the of organic brain disease should not be classed as an guest. Protected by copyright. primary psychoses. Following Kleist (1914, 1934), aphasic disorder referable to a focal lesion of the they were led to place emphasis on the probable dominant hemisphere. It is to be regarded as the role of cerebral dysfunction in the genesis of lan- manifestation of a more general change in be- guage disorders in general. haviour, in which altered patterns of perception In studies of post-traumatic confusional states and motivation play an important part. undertaken during the war, Paterson (1942, 1944) In the analysis of confusional states it is obviously was likewise impressed by the frequency of para- important to ascertain whether, and if so to what phasic speech disorders. He pointed out that although extent, focal signs and symptoms contribute to the not all confused patients present a disturbance of overall picture. Although the attempt made by speech, in those who do the picture differs in no Paterson (1944) to explain confusion as a mere essential way from that shown in cases of focal aggregate of focal signs may well appear too lesion without confusion, e.g., in jargon aphasia. atomistic, the conception of a global organic Indeed in several of his cases clear-cut dysphasic reaction-type advanced by Weinstein and Kahn residua long outlasted the acute confusional state. (1952) undoubtedly goes too far in the opposite At the same time, it was suggested by Zangwill direction. As Paterson has pointed out, the con- (1945) that the speech disorder in certain of fusional state is always an individual affair and Paterson's cases appeared to transcend an ordinary shows very considerable variation from case to case. dysphasia and to involve an underlying derangement In particular, by no means all confused patients of the thought processes. exhibit paraphasic speech and the latter does not http://jnnp.bmj.com/ More recently, Weinstein and Kahn (1952) have appear obviously related to the depth or severity devoted a paper to paraphasia in organic brain of confusion. Further, defects of orientation disease. Their observations are based on a series (Paterson, 1944) and denial of disability (Critchley, of 30 cases in which misnaming and other peculi- 1953; Brock and Merwarth, 1957) are often par- arities of language were prominent. These dis- ticularly prominent in cases in which the lesion turbances, they point out, never occurred in isolation principally involves the parietal lobes. It might and were always associated with disorientation, therefore seem probable that both general and local denial of illness, and related symptoms of general changes in cerebral function contribute to the con- on September 30, 2021 by organic type. The intracranial lesions consisted fusional state and that these, in combination, deter- mainly of deeply situated or bilateral tumours, and mine the incidence of paraphasia. At all events, aneurysms with subarachnoid haemorrhage; in one may suggest that fuller analysis of language and nearly all cases the E.E.G. showed bilateral diffuse its disorders may throw light on the psychology of delta wave activity. The authors argue that the confusional states. language disorders observed in their patients differ We propose in the present paper to attempt a in important respects from those ordinarily met preliminary analysis of the disorders of thought and 190 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.21.3.190 on 1 August 1958. Downloaded from LANGUAGE DISORDER IN KORSAKOFF'S SYNDROME 191 language encountered in a case of Korsakoff's became less marked during the last few weeks in hospital, syndrome. It is hoped first, to determine whether when the patient also regained some measure of orienta- the disorders in question are or are not referable to tion. He was facile and totally without insight, denying focal dysphasia; and secondly, to ascertain their that he was ill or that his memory was in any way affected. In all these respects his mental state approxi- relationship to concomitant changes in other spheres mated to that of the classical Korsakoff psychosis. of psychological function. Although the patient's speech appeared essentially normal in ordinary conversation, a curious paraphasic Case Report disorder was in evidence during the earlier stages of the N. H. (Case No. 66352), a British Railways clerk, illness. This was brought out most strikingly when the aged 62, and right-handed, was admitted under the care of patient was asked to name objects, define words, explain Dr. Purdon Martin with complaints of episodic double proverbs or to undertake kindred tasks implying some vision, weakness in the legs, and numbness and coldness measure of directed thinking (see below). There were in the fingers of both hands of six months' duration. also signs of a minimal defect in comprehension of One week previously, he had begun to " wander" in speech at this time. Although the patient's hearing was his mind, talking of the past and claiming to have in no way defective, he commonly asked for questions recently seen his parents and other relatives long dead. to be repeated and it was sometimes apparent that he He had become sleepy and difficult to rouse. There was had not fully grasped their import. Occasionally, he also a history of recent loss of appetite, and of long- appeared completely at a loss for the meaning of a standing alcoholism. common word. He was, however, able to write with On examination, the patient was facile, euphoric, and reasonable adequacy and showed no obvious defect of much given to confabulation. His speech was remarked letter formation or spelling. Apart from want of sus- to be nonsensical on occasion. He was disorientated tained attention, reading did not appear to be affected. in all spheres, believing himself to be in a flat in the These language disabilities receded very considerably guest. Protected by copyright. vicinity of a hospital and the other patients to be railway during the last weeks of the patient's stay in hospital. workers. He gave the day (Monday) as Friday and the Formal psychometric testing gave an uneven picture. month (June) as May. His general knowledge and recent The vocabulary score was just below the mean, but this memory were very poor and insight was completely may have been in part due to the language disability. lacking. Performance on other Wechsler-Bellevue subtests sug- On neurological examination, the main findings were gested an I.Q. in the region of 110. Despite his amnesia, unequal pupils, the right being slightly larger than the the patient could repeat seven digits forwards and five left, and some nystagmus, with impaired conjugate backwards. He was unable to solve Weigl's test, sorting deviation in all directions. Convergence, on the other being inept and concrete. Performance on a Rorschach hand, was relatively well preserved. There was some test was grossly perseverative and typical of an organic loss of muscle power in the distal parts of the limbs but confusional state (Zangwill, 1945). the most striking finding elsewhere was extreme tender- Air encephalography indicated a marked degree of ness of the muscles, with peripheral impairment of all cerebral atrophy: good filling of the ventricular system forms of sensation. The tendon reflexes were uniformly was obtained and the system was observed to be central. diminished. The lateral ventricles showed a marked degree of A diagnosis of alcoholic peripheral neuropathy with generalized symmetrical enlargement. There was a con- Wernicke's encephalopathy was made and some of the siderable increase in the size of the cortical subarachnoid symptoms gradually settled down with large doses of channels and the basal cisterns were a little enlarged. B group vitamins. The eye signs were the first to clear; The patient was discharged to another institution several weeks later four the patient was again ambulatory months after admission. Although the brain-stem http://jnnp.bmj.com/ and made few complaints of paraesthesiae. The results disturbances and peripheral neuritis had improved of liver function tests were relatively normal, but a appreciably, the underlying Korsakoff state remained histamine test meal revealed the absence of free acid in unaltered. the stomach. The patient was first seen in the Psychological Depart- Follow-up Studies.-The subsequent history of the ment two weeks after admission and thereafter re- patient is briefly as follows. He remained for four and examined at regular intervals until discharge. a half months in hospital, during which time he made He was at first completely disorientated for place and some progress, becoming gradually more lucid and less person, commonly believing himself to be in his usual given to confabulation.
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