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The Quotient: The Taxonomic Approach to Measurement of Aphasic Disability

ANDREW KERTESZ AND ELIZABETH POOLE

SUMMARY 750 aphasiacs and 59 con­ Aphasia is one of the most fascinat­ mena. After some familiarity with the trols were examined with a scorable, ing and complex problems clinicians Schuell (1964) and Eisenson (1954) comprehensive battery, designed to be encounter. Some regard all aphasics tests, the L.M.T.A. Wepman & used by the clinician and the research alike, others make the usual distinc­ Jones (1961), P.I.C.A. Porch (1971), worker. The subtests of Fluency, Infor­ tion of expressive-receptive aphasia, F.C.P. Sarno, (1969) and the mation, Comprehension, Repetition and popularized by Weisenburg & N.C.C.E.A. Benton (1967), we de­ Naming were added and compared to a hypothetical normal of 100 obtaining the McBride (1935), which is too over­ cided to modify the Boston Aphasia "aphasia Quotient." This is a measure­ lapping and vague to be useful. Examination (at that time unpub­ ment of the severity of impair­ Henry Head's (1926) classification of lished) for our purpose Goodglass ment. On the basis of their performance verbal, semantic, syntactical and & Kaplan (1972). It is not intended on the subtests, the patients were clas­ nominal never gained to review the merits of various sified according to taxonomic principles popularity because it was difficult to tests, but the Boston Aphasia into Global, Motor (Broca's), Isolation, apply clinically. Many psychological Examination appears to cover Sensory (Wernicke's), Transcortical and linguistic studies of aphasia lack aphasic phenomena most compre­ Motor, Transcortical Sensory, Conduc­ neuroanatomical correlations and are hensively, while paying attention tion and Anomic groups (in order of not attractive to morphologically and to many linguistic and behavioral severity). This classification is consi­ dered a clinically valid baseline for physiologically oriented clinicians. aspects, consistent with clinical research, diagnosis and prognosis. There is a trend recently to unify observation and neurological con­ aphasic phenomena as if they were cepts. Modification of the test RESUME 150 aphasiques et 59 con- only variations of the same dysfunc­ became necessary to suit our basi­ troles furent evalues avec une batterie tion. This revival of the view of cally clinical and neurological d'etudes permettant gradation, celle-ci Pierre Marie was contributed to by approach to taxonomic grouping of comprehensive mais aussi pratique et the extensive work of Schuell (1964). aphasics. preparee pour etre utile autant.au clini- Our approach utilizes some of the cien qu'au chercheur. Resultats d'ex- concepts of Geschwind (1964), amens constituents individuels de Goodglass (1964), Quadfasel and Fluence, Information, Comprehension, METHODS Repetition et Identification, furent others, from the Boston Aphasia Our test Western Aphasia Battery additionnes et compares au normal Unit, which have gained acceptance (W.A.B.) is designed for research cumulatif, hypothetique de 100, because of their clinical applicability. and clinical use and can be adminis­ apportant le "Quotient d'aphasie." Ce Notwithstanding the complexity tered in an hour to most ambulant dernier est un indice de severite de defaut and confusion about the approaches, patients, although two such sessions de language. D'apres leur performance are often required. Severely affected a ces examens, les patients furent clas­ definitions and classifications, cer­ sifies selon des principes taxonomiques tain groups of patients are easily dis­ patients may take less time. The tests en groupe d'aphasie Globale, Motrice tinguished by the experienced. This selected should present no difficulty (Broca), d'Isolation, Sensorielle study is designed to measure these to a patient with intact language, as (Wernicke) Motrice trans-corticale, Sen­ clinical differences and to improve attested by the scores of 59 age sorielle trans-corticale, de Conduction et upon the arbitrary impressions of the matched controls from the same hos­ Anomique (en ordre de severite). Cette clinician, with a comprehensive, pital population. The controls con­ classification apporte une base valable scorable and practical test of lan­ sisted of a group of "normals," that pour recherche, diagnostic et pronostic. guage. Many tests to survey aphasics is, 21 non- damaged neurologi­ have been constructed and it seemed cal patients with spinal cord disease, rational to choose one for the pur­ peripheral neuropathy, blackouts, pose of surveying aphasic pheno- tics, vertigo, ataxia* etc., 17 non- dominant hemispheric lesions From the Department of Clinical Neurological ("comparable brain damage"), and Sciences, University of Western Ontario. St. 21 patients with diffuse or dominant Joseph's Hospital. London, Ontario, Canada. Reprint address: A. Kertesz, St. Joseph's Hos­ hemisphere or subcortical brain pital, London, Ontario N6A 4V2. damage, but clinically, no aphasia.

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One hundred and fifty (150) con­ answering conversational questions We grouped patients according to secutively examined aphasics from 2 and describing a picture. The same test scores, following the principles General and 1 Veterans hospital were questions and pictures were used for of numerical taxonomy, used in the included in the study. The majority all subjects. biological classification of species. of patients (86) came from one 2. Comprehension, tested with According to this principle, numeri­ General hospital, where all patients "yes" and "no" response, pointing cal criteria are established which known to the authors to be aphasic to ten categories of items and obeying allow a meaningful separation of sub­ were surveyed consecutively. This commands of increasingly complex groups with the greatest similarities material is thought to be more com­ sentences, similar to the "token on the basis of differential criteria. prehensive and representative of the test" DeRenzi & Vignolo (1969). In our instance, the major criteria were chosen — fluency, comprehen­ whole scope of aphasia than previ­ 3. Repetition of words, numbers ous studies on chronic patients in sion, repetition and naming. Accord­ and increasingly complex sentences ing to the scores obtained, all patients rehabilitation units. The great major­ of high and low probability. ity of the patients had cerebral infarc­ were unequivocally classified. Table tion and were neurologically and 4. Naming of visually presented II contains the summary of these cri­ pathologically stable. The next in fre­ objects, word fluency, sentence com­ teria. This table reflects the range of quency were tumors, followed by pletion and responsive . (See scores as well. They have been deter­ trauma, hemorrhage, aneurysm, and Discussion.) mined to include all test scores, after degenerative disease (Table 1). Men- 5. Information content of spon­ the basic criteria for the separation taneous speech scored on the same of subgroups were established. material as 1. Fluency below 5 separated the TABLE I aphasias with significant motor Distribution According To Diagnosis The scoring of the first and fifth subtests was on a 1-10 scale, accord­ involvement: Global, Motor, Isola­ tion and Transcortical Motor Controls ing to the criteria detailed in the (with Brain aphasia. Those with comprehension Diagnosis Aphasics Damage) appendix. The other tests were more structured and the items were easily better than 4 on our battery separated C.V.A. 114 20 Broca's or Cortical Motor aphasia Tumour 14 4 scorable for correct or partial response. By scaling the subscores from Global aphasia, and Transcorti­ Trauma 9 cal Motor from Isolation aphasia. Degenerative 4 5 to comparable levels (1-10), the per­ The latter two are distinguished from Aneurysm 4 centage of normal function can be Hemorrhage 2 1 quickly calculated by adding the sub- the former two by better than 5 A-V Malformation 1 2 scores and multiplying by 2, when repetition. Among the fluent Abscess 1 only the verbal language subtests are aphasias, the Anomic and Conduc­ Uncertain 1 used, as in this study. When expres­ tion aphasics have better than 7 com­ Parkinson's 3 prehension, in contrast to cortical 3 sed as a percentage of a hypothetical Korsakoff s normal score of 100, we call it (Wernicke) and Transcortical Sen­ sory aphasics, with poor comprehen­ Total 150 38 Aphasia Quotient (A.Q.). It indicates the functional severity of speech dis­ sion. Repetition below 7 clearly turbance and serves as a numerical separates Conduction aphasics from tally retarded and psychotic patients measure of improvement or effect of Anomics. Interestingly enough, or those with a language barrier were therapy. some of the Conduction aphasics not included. The controls had similar educational and language backgrounds. Intellectual levels may account for differences in some of TABLE II the subtests, such as word fluency. Criteria for Classification The sex ratio is heavily weighted — 99:51 — towards males, a differ­ Fluency Comprehension Repetition Naming ence explained mainly by the veteran Global 0-4* 0-3.9 0-4.9 0-6 population in the sample (37). Han­ Broca's 0-4 4-10 0-7.9 0-8 dedness was determined in all cases by a standard questionnaire: 146 Isolation 0-5 0-4 5-10 0-6 were right handed and 4 were left Transcortical Motor 0-5 5-10 8-10 0-8 handed. Wernicke's 5-10 0-6.9 0-7.9 0-7 The subtests which seemed to Transcortical Sensory 5-10 0-6.9 8-10 0-9 yield most information about the dif­ ferences between aphasics were the Conduction 5-10 7-10 0-6.9 0-9 following (See Appendix for details). Anomic 5-10 7-10 7-10 0-9 1. Fluency and prosodic value of "The numbers are raw scores. "spontaneous" speech, elicited by

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appear to have excellent naming. words) lexical items of emotional their performance on the verbal sub­ Naming score below 9.0 was arbi­ charge, often swear words. tests is similar. "Pure" word trarily chosen as a cut-off point, to 2. Cortical motor aphasia or deafness, meaning impaired com­ separate Anomic aphasics from non- Broca's aphasia is characterized by prehension but otherwise intact brain damaged controls; otherwise, impaired speech output with rela­ speech, repetition and naming, was the naming scores did not distinguish tively well preserved comprehen­ seen in 2 patients, but only tran­ between subgroups. sion. They speak little, with great siently, 28 cases belong to this Standard (Z) scores were obtained effort, often showing frustration but group, with a mean A.Q. of 39.1. to compare the subtests in each convey some information. Phonemic 5. Transcortical motor aphasia is aphasic group. However, the scoring and aggrammatisms are an interesting entity characterized by of subtests was designed to relate to common. Repetition and naming are good comprehension and excellent difficulty levels and the subtests were impaired but at times, better than repetition, but the patient speaks chosen to represent equally impor­ spontaneous speech output. 24 cases very little on his own. This is more tant language functions, in order to were seen, with a Mean A.Q. of 31.7. often seen transiently and by the time Arrive at a numerical value (A.Q.) 3. Isolation aphasia or speech iso­ the patients are tested, there is often which does not require statistical lation syndrome is a recently only slight anomia left or even that transformation by the clinician. (See described entity, with little or no has recovered. 4 cases were con­ Results and Fig. 2.) spontaneous speech, comprehension sidered to represent this group with or naming, but excellent repetition. a Mean A.Q. of 54.4. RESULTS Only 5 partial or incomplete exam­ 6. Transcortical sensory aphasia Table III summarizes the number ples were encountered — Mean A.Q. is fluent with good repetition but poor of patients in each subgroup, their = 34.3. comprehension and naming. This can mean age, scores by subtests and by 4. Cortical sensory aphasia or also be regarded as the sensory com­ aphasia quotient (A.Q.). The various Wernicke's aphasia is characterized ponent of the speech "isolation entities are ranked in the order of by fluent, paraphasic speech with syndrome." 8 cases were seen — severity, as determined by their A.Q. impaired comprehension, repetition Mean A.Q. = 59.5. 1. Global aphasia is the most and naming. Some of these patients 7. , also called severe form. It is commonly seen (26) have a great amount of neologistic "central aphasia" is distinguished by — Mean A.Q. = 10.5. These patients paraphasias, under pressure at times very poor repetition with a relatively are severely affected in all language and often, without too much aware­ fluent but paraphasic speech and functions. They are non-informative, ness of disability. (These patients are good comprehension. This group of non-fluent, have poor comprehen­ often misdiagnosed as psychiatric aphasics is most interesting and has sion, repetition and naming. They disturbances.) These we prefer to been paid little attention in the litera­ faiay produce variable amounts of separate as jargon aphasics but for ture until recently. One reason is that stereotypic utterances, and at times, the purpose of this study, they are they are infrequent and the other is well pronounced and even long (2-3 combined with this group because that repetition has to be tested speci-

TABLE III

The Number, Mean Ages, Mean Scores of Subtests and A.Q.'s and their Standard Deviations of the Subgroups and the Total of 150 Aphasics and 59 Controls

Age Fluency Compreh ension Repetition Na ming Information A.Q. No. Type of Aphasia X X S.D. X S.D. X S.D. X S.D. X S.D. X S.D. 26 Global 65.0 1.0 1.2 2.2 1.7 0.9 1.5 0.5 1.3 0.6 0.9 10.5 9.2 24 Motor (Broca's) 57.3 2.5 1.7 5.9 1.5 3.3 3.1 2.4 2.4 1.8 1.8 31.7 16.6 5 Isolation 65.6 3.0 1.7 2.5 1.0 7.8 1.7 2.1 1.7 1.8 1.1 34.3 11.9 28 Sensory (Wernicke's) 60.3 6.9 1.1 3.5 1.9 3.7 3.0 2.1 1.8 3.3 2.3 39.0 12.8 4 Transcortical Motor 67.0 3.5 1.0 6.2 1.3 9.2 0.9 4.3 2.4 3.5 1.0 54.4 8.4 8 Transcortical Sensory 51.3 6.9 1.4 4.9 1.3 9.3 0.5 4.0 2.5 4.6 1.3 59.6 5.5 15 Condition 62.2 6.1 1.2 8.3 0.9 5.0 1.9 5.2 2.6 5.7 2.2 60.5 12.7 40 Anomic 60.3 8.0 0.9 9.0 0.8 9.1 0.9 7.8 1.2 7.7 1.7 83.3 7.8 150 Total X 61.1 5.2 3.0 5.7 2.9 5.3 3.8 3.9 3.3 4.0 3.2 48.2 28.2

Controls 21 I Non-Brain Damaged 59.2 10.0 0.0 9.9 0.2 9.8 0.3 9.5 0.3 10.0 0.0 98.4 1.0 17 II Non-Dominant Hemisphere 59.4 10.0 0.0 9.7 0.4 9.8 0.2 9.1 0.4 9.9 0.3 97.1 1.9 21 III Mixed Group 58.6 9.7 0.7 9.5 0.6 9.6 0.5 8.9 0.5 9.2 1.3 93.8 4.7

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FLUENCY The ages of various aphasic and control groups were subjected to one-way analysis of variance and were found to be not significantly dif­ COMPREHENSION \ ferent from each other. (F = 1.35 at \ 10 and 198 df.) x/ DISCUSSION REPETITION These results indicate the propor­ I I tion of aphasics belonging to each I I I subgroup and the severity of their I T I communication deficit, as deter­ I V NAMING \ mined by the A.Q. The subtest which \\ V-T correlated best with A.Q. was infor­ mation, although it did not contribute \\ significantly to classification into INFORMATION \ various types. Reading and writing, I I although tested whenever possible, I I I were not used for the purpose of this I I study, because they tended to paral­ AQ I lel the oral language disturbance, e.g. a cortical motor aphasic had just as much trouble writing as speaking and -1 0 •! __. Wernicke cortical sensory aphasics produced Transcortical Sensory as much jargon in reading aloud as __.^__ Conduction in their speech and seemed to have Transcortical Motor _.^___ —^^^__- Anomic as much trouble understanding print Figure I—The profile of performances Non-fluent aphasics on the left, fluent as verbal stimuli. The occasional using standard (Z) scores (abscissa): ones on the right. jargon patient showed an interesting phenomenon; graphorrhea or writing of copious, unintelligible jargon, an fically to identify them. There were The difficulty levels of each sub­ example of which has been pub­ 15 patients with a Mean A.Q. of 60.6. test were quite comparable, as lished. (Kertesz & Benson, 1967). 8. Anomic or amnestic aphasia attested by the similarity of means Exceptions to this occur, however, was common. These patients have and standard deviations attained by such as cases of "pure word fluent, often circumlocutory speech, 150 aphasics (Fig. 2). associated with good comprehension and repetition but impaired naming. FLUENCY Some patients included in this study performed near normal on naming tasks, in spite of word finding dif­ ficulty. There are also a few patients COMPREHENSION whose spontaneous speech was very near normal but who had significant impairment of naming on visual stimuli. These may represent a pure stimulus-response defect. They were REPETITION rechecked on a control subtest involving naming by palpation, to see if there was significant difference between the two input modalities for naming, such as may occur in visual NAMING . 40 cases were seen, with a Mean A.Q. of 83.3. A profile of performance for each aphasic subgroup was drawn using INFORMATION standard (Z) scores (Fig. 1). This illustrates the outstanding features of 0 12 3 4 5 6 7 8 9 10 each aphasic group which is the basis Figure 2—The means and standard devi­ scores (abscissa) of 150 aphasics. of the presented classification. ations for each subtest, using raw

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deafness," who understand written auditory sequencing test, similar to verely affected, especially those in material better. our "commands with auditory the isolation group (A.Q. of 34.3) but The basis of our classification was sequencing." The recently popular their repetition was disproportion­ to choose outstanding clinical token test is a long, complicated ver­ ately better over other features. The characteristics which would be found sion of the same task, and even some mean repetition scores of isolation in each member of the group. Such normal controls find it difficult to do. aphasics were 7.8, compared with characteristic constants are well Our test also utilizes the important their fluency 3.0, comprehension 2.5 known in biology as "natural observations of Goodglass et al and naming 2.1. Transcortical motor taxons" and form the basis of clas­ (1970) on the importance of relational aphasics had mean repetition of 9.2 sification of species of animals and words. and low fluency—4.00 but better plants. The principles of numerical The use of "yes" and "no" comprehension—6.2 and transcorti­ taxonomy establish the existence of responses avoids the pointing diffi­ cal sensory aphasics had mean repe­ constant characteristics, while vary­ culty or apraxia the patient may have tition scores of 9.3 with fluent, spon­ ing in an uncorrelated manner in in carrying out the auditory sequenc­ taneous speech scores of 6.9, com­ other subgroups Sokal & Sneath ing task. Unfortunately, for some pared with relatively poor com­ (1963). Some of these characteristics aphasics a considerable amount of prehension scores of 4.9. One does are agreed upon by almost everyone "yes" and "no" confusion may not have to see too many transcorti­ dealing with aphasia. exist. That this may be a phenome­ cal motor aphasics, who are practi­ non beyond and separate from com­ cally mute, except when it comes to Fluency appears to be one of the prehension difficulty, more aligned repetition, or transcortical sensory most important factors differentiat­ with apraxia, is evidenced by the aphasics, who do not understand ing various aphasics Benson (1966), frustrated, corrective behaviour of anything but repeat well, to believe Kerschensteiner, Poeck, Bruner many global aphasics, most often in the existence of a substantial dif­ (1972), Howes & Geschwind (1964). exhibiting "yes" and "no" con­ ference between these and the more We rated fluency according to set fusion. They often indicate by ges­ common varieties of aphasia. The criteria (See Appendix b) applied to tures that they meant "yes" when terms "cortical" and "transcortical" the "spontaneous speech," elicited they said "no." This response is are used here for the sake of tradition by recording the responses to stan­ often spontaneous and not in rather than to denote established dardized questions and by asking the response to the examiner's inadvert­ anatomical differences. patient to describe a picture (a simple ent disapproval. It is also frequently The naming tasks, used for all sub­ drawing of a house, a pond, people wrong, that is, the patient may be and animals, used by Schuell). jects, included confrontation with frustrated with the correct answer! visual stimulus—60% of the naming Comprehension of language is not Repetition is essential to distin­ score; word fluency—20% sentence a simple, unitary function and there guish conduction and transcortical completion—10% and responsive are many ways to test, it. The most aphasics clinically from other sen­ speech—10%. These correspond to traditional is to ask the subject to sory and motor aphasics. The repeti­ various items at N.C.C.E.A. Benton point to items. We used objects, pic­ tion task utilized single words, sen­ (1967). The last 2 items, comprising tures of objects, body parts, letters, tences, numbers, and number-word 20% of the naming score, probably numbers and colors. The instructions combinations. The words and sen­ require auditory sequencing as well were standardized. Multiple choice tences were chosen to represent a dif­ as word finding. The first item con­ of 6 was usually offered, although in ficulty gradient for length, probabil­ sists of naming objects, pictures of a few items, such as pointing to furni­ ity and articulatory facility. Scoring objects, geometric figures, letters, ture and body parts, the patient had considers errors in order, as well as numbers, body parts, colors, greater choice. The auditory phonemic substitutions. Most clini­ national symbols, punctuation stimulus was only one word (auditory cians will concur that there are marks, etc. This requires relatively recognition). patients who have great difficulty little comprehension, provided the It has become evident that comprehending or producing spon­ patient understands the initial although some aphasics (motor or taneous speech but nevertheless, instruction and stays with the "set." Broca's) do very well, on the audi­ repeat exceedingly well. To separate Many of these items were the same tory recognition tasks, almost all these cases from the larger group of as used on the pointing task for com­ aphasics except some Anomic, sensory and motor aphasics has a prehension. The large number of Transcortical Motor and Conduc­ valid foundation in clinical experi­ items were designed to detect cases tion aphasics will have difficulty with ence, as attested by our data, regard­ of specific naming problems for sequentially presented items. This less of the theoretical implication colors, numbers, body parts, etc. or task is variously called auditory of disconnection of speech region cases of "asymbolia." Such specific retention span or auditory sequenc­ from other association areas. Repeti­ naming defects are the subject of ing and its significance has been rec­ tion is regarded as a function of another study. For the purposes of ognized by Pierre Marie, who the intact speech area alone Gesch­ this study and clinical use, we measured comprehension with the wind, Quadfasel & Segarra (1968). decided to use the shortened version "three paper test," essentially an These aphasics were relatively se­ only; that is, the naming of 20 com-

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mon objects. These were selected for that either their fluency score was theoretical interest to the mechanism their availability and handy size but below 10 or their naming fell below of anomia. The whole group had a variations of the shape and the cate­ 9.0. (There was one mildly anomic higher Mean A.Q. (93.8-S.D.= 7.8) gory of the objects and difficulty patient whose fluency was scored as than (83.3 —S.D. level ("expectation or frequency or 10 but his naming on confrontation = 4.3), the least severe of aphasic occurrence") were introduced was only 7.9.) The lowest naming groups. The difference is very signifi­ deliberately. (See Appendix g). The score for the non-brain damaged con­ cant at P^- 0,0005 level, using Stu­ word fluency item was very sensitive trols was 9.1. The controls were com­ dent's "t" test (t = 5.7 at59df). Since to aphasic disturbances of word find­ parable in age and since they were the control group has a smaller sam­ ing but also seemed to depend on taken consecutively from the same ple size but also smaller variance, the intelligence, degree of relaxation and hospital population, probably for calculated t ratio is likely to be concentration and probably, on other socio-economic factors as well. smaller than the tabled probability educational levels as well. Many The control of educational levels levels. "controls" with otherwise normal would be more important in the read­ Determination of A.Q. seems use­ language did poorly on this task, ing and writing tasks, which were not ful to distinguish between aphasic indicating the role of non-language surveyed here. The majority of and non-aphasic, brain damaged factors. patients was tested on Raven's patients. An operational definition of Colored Progressive Matrices, also aphasic score may be provided by The rating of paraphasias proved a non-verbal test of intelligence. The to be extremely difficult. Linguistic the above control scores. The patient performance of aphasics was com­ may be considered normal if the A.Q. studies of phonemic and verbal sub­ parable to the controls, suggesting stitutions are rarely quantitative is 95 or above. The most useful, that the population was matched for single subtest seems to be the fluency Lecours & Lhermitte (1969). How­ intelligence as well Kertesz (1973). ever, the amount of neologistic rating, where all the controls output clearly separates jargon achieved 10. Overlapping scores were observed aphasics from the rest of cortical sen­ This study did not account for the sory aphasics Kertesz & Benson with the third group of controls examined on the battery. The border change in aphasic performance with (1970), although for the purpose of time. It has been recognized that the this study, they are kept together. appeared indistinct between this group and recovering mild anomic rate of recovery among various sub­ Conduction aphasia will have a groups is different; for example, higher rate of phonemic paraphasias aphasics. A comparison with aphasics seemed to be worthwhile, global aphasics usually remain than sensory aphasia (with the excep­ severely disabled while transcortical tion of jargon aphasics), transcortical because of the problem of drawing the line between diffuse brain dam­ motor aphasics, although often mute sensory, and anomic aphasias and on admission, recover within weeks. this deserves further quantitative age affecting language and aphasia. The group consisted of 3 cases of Par­ Sensory aphasics often go through a study. Another area where rating of predictable course of evolution. This paraphasias may be useful is to dis­ kinsons's Disease with dementia, 3 cases of Korsakoff s Psychosis, 5 is a subject for further quantitative tinguish mild or recovered cases of study using the above method. sensory aphasias from normals cases of Subcortical or Infarcts, 3 cases of Presenile Demen­ Recently, evidence for distinct because their scores on the battery localization of the lesions in each of would be within normal range. tia—2 presumed to be Alzheimer's clinically—1 proven Jakob-Creut- the sub-groups has been There is a group of recovered or zfeldt on autopsy, 2 Left Hemisphere accumulated, suggesting that the mild aphasics, whose word finding Tumours —1 Parietal Glioma classification presented above, difficulty or the occasionally uttered ( without although far from final, could be a paraphasias would justify regarding aphasia)—1 Parasagittal Men­ diagnostic tool for the neurologist. them with the aphasic group clini­ ingioma, 1 Postconcussion Syn­ cally but their performance on the drome, 1 Postencecephalitic and 3 ACKNOWLEDGMENTS battery is in the normal range. For patients with the diagnosis of The authors would like to thank the the purpose of this study, we did not "organic dementia." Common to physicians who referred the cases for include them in the aphasic group, them was diffuse, dominant hemis­ study, J. McGlone for some of the test­ although for some individuals, this phere or subcortical brain damage ing and computations and P. McCabe so called "normal" performance was and no obvious difficulty with lan­ and C. Spencer for their assistance. probably below their usual language guage. Some of the presenile demen­ Lea and Febiger gave permission to ability. Since they were referred to tias, of course, involve the speech reproduce parts of the Boston Aphasia us as either questionable aphasics or Examination — Appendix a, parts of Ap­ areas sooner or later in the course pendix d, e, f, i, j, k. known but recovered aphasics, we of the disease, although they are could not include them in the normal not as likely to present with aphasia. REFERENCES group either. The implication of verbal memory BENSON, D. F. (1967) Fluency in All our aphasics differed from the loss in Korsakoff s Disease as a fac­ aphasia: correlation with radioactive "non-brain damaged controls" in tor in the mild anomia seen is of scan localization. Cortex, 3,373-394.

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BENTON, A. L. (1967) Problems of test in Adults. New York: Harper and (8) Same as above with much circum­ construction in the field of aphasia. Row. locution and word finding difficulty. Cortex, 3, 32-58. SOKAL, R. R. and SNEATH, P. H. A. (7) Correct response to 5 of the first DeRENZI,E.andVIGNOLO,L.A.(1962) (1963) Principles of Numerical Taxono­ 6 items, incomplete description of the The token test: a sensitive test to detect my. San Francisco: W. H. Freeman picture. receptive disturbances in aphasics. &Son. (6) Correct response to 4 of the first Brain, 85, 665-678. WEISENBURG, T. and McBRIDE, 6 items on page 2, and mention at least EISENSON, J. (1954) Examining for K. E. (1935) Aphasia. New York: The 6 of the key nouns or verbs in the picture Aphasia. New York: The Psychological Commonwealth Fund. (No. 7) with some meaningful grouping Corporation. WEPMAN, J. M. and JONES, L. V. of words into phrases. GESCHWIND, N. (1965) Disconnexion (1961) The language modalities test syndromes in animals and man. Brain, for aphasia. Chicago: Education- (5) Any 4 of all items. 88, 237-294 and 585-644. Industry Service. (4) Any 2 of the first 6 items plus some GESCHWIND,N.,QUADFASEL,F.and response to 7. SEGARRA, J. (1968) Isolation of the APPENDIX a (3) Response to 3 items. speech area. Neuropsychologia, 6, 327-340. / — Spontaneous Speech: (2) Only response to any 2 items. GOODGLASS, H., QUADFASEL, F. Record patient's speech verbatim, (1) Only response to any one question. and TIMBERLAKE, W. (1964) Phrase on paper, preferably, on tape. Substi­ length and the type and severity of tute similar questions if necessary. (0) No information. aphasia. Cortex 1, 131-153. 1. How are you today? GOODGLASS, H., GLEASON, J. and 2. Have you been here before? or Have B. Rating of Fluency Hyde, M. (1970) Some dimensions I tested you before? of auditory language comprehension (10) Sentences of normal length and 3. What is your full name? in aphasia. J. Speech and Hearing complexity, without perceptible delibera­ Res., 13, 595-606. 4. What is your full address? (Accept tion about grammatical usage. No per­ ceptible halting or distortion of rhythm GOODGLASS, H., KAPLAN, E. (1972) any response which includes correct street in phrasing. The assessment of aphasia and re­ and number or street and city.) lated disorders. Philadelphia: Lea and 5. What kind of work did you do before (9) Tendency to simplify sentences, or Febiger. you became ill? leave longer sentences incomplete; hesi­ HEAD, H. (1926) Aphasia and kindred 6. Tell me a little about why you are tation over particles of speech, auxiliary disorders of speech. New York: here? or What seems to be the trouble? verbs or word-endings. Some paraphasias. Some word finding dif­ MacMillan. 7. Presentation of picture. Show the ficulty. HOWES, D. and GESCHWIND, N. test picture and tell patient to "Tell (1964) Quantitative studies of aphasic everything you see going on in this (8) Circumlocutory, fluent speech. language. Ass. Res. Nerv. Ment. Dis., picture." Point to neglected features of Obvious word finding difficulty. Seman­ 42, 229-244. the picture and ask for elaboration if tic jargon. KERSCHENSTEINER, M., POECK, patient's response is skimpier than his K. and BRUNNER, E. (1972) The apparent potential. A minute should (7) Phonemic jargon with semblance to fluency-nonfluency dimension in the be allowed. English syntax and rhythm with varied phonemes and neologisms. classification of aphasic speech. (The simple drawing from Schuell's Cortex 8, 233-247. test — a house, a pond with people and (6) Predominantly telegraphic speech, KERTESZ, A. and BENSON, D. F. animals — is shown.) but some grammatical organization. Nor­ (1970) Neologistic jargon: a clinico- mal rhythmic patterning may be present pathological study. Cortex 6, 362-387. within phrases, but does not connect KERTESZ, A. (1973) Intelligence and APPENDIX b phrase to phrase. aphasia. Trans. Am. Neurol. Ass. In Scoring of Spontaneous Speech (5) Many paraphasias and halting press. speech but some sentences well construc­ LECOUR, A. R. and HERMITTE, F. A. Rating of Information ted and pronounced. (Similar but worse than 6.) (1969) Phonemic paraphasias: linguis­ (10) Correct responses to all 6 items tic structures and tentative hypo­ on page 2, on number 7, sentences of (4) Predominantly single words, but thesis. Cortex, 5, 193-229. normal length and complexity, integrat­ with occasional verbs or prepositional PORCH, B. (1971) Porch Index of Com­ ing people and action in the picture, and phrases. municative Ability. Palo Alto: Con­ referring to at least 3 of the principle (3) Fluent recurrent utterances or sulting Psychologists Press. activities. No perceptible circumlocution mumbling, very low volume jargon. SARNO, M. T. (1969) The functional or word finding difficulty. communication profile. Manual of (2) Single words, often inappropriately (9) Correct responses to all 6 items on directions. Rehabilitation Monograph used or recurrent utterances used in a page 2. Some sentences or longer phrases 42. New York: Institute of Rehabili­ meaningful way. used in integrating people and actions of tation Medicine. the picture (No. 7), at least 10 important (1) Recurrent utterances with meaning. SHUELL, H., JENKINS, J. J. and people, objects or actions should be (0) No words or short, meaningless JIMENEZ-PABON, E. (1964) Aphasia named. utterances.

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APPENDIX c //. Auditory Verbal Comprehension a. Yes and No Task — ask patient to answer these questions with yes or no only. Make certain he understands the task and if he does not comply, remind him. Note if patient seems to understand but appears to have "Yes and No Confusion." In this case, eye closure for "yes" may be substituted with improvement of the score. If the patient corrects himself, accept it, but if both responses are given, score 0. Score W2 for each correct answer.

Answer Correctness Verbal Gestural Eye Blink 1. Is your name Smith? 2. Is your name Brown? 3. IS your name (real name) ? 4. Do you live in Toronto? 5. Do you live in (real residence) ? 6. Do you live in Windsor? 7. Are you married? 8. Do you have children? 9. Are the lights on in this room? 10. Is the window closed? 11. Is this a hotel? 12. Is this St. Joseph's Hospital? 13. Are you wearing red pyjamas? 14. Will a stone sink in water? 15. Do you eat lunch before supper? 16. Do you eat a banana before you peel it? 17. Does it snow in July? 18. Is a lion larger than a dog? 19. Is a hammer good for cutting wood? 20. Are you a doctor? Maximum Score — 30 Patient's Score

APPENDIX d b. Word Discrimination Task Present real objects, color cards. Ask patient to point to each object or his own body part by saying, "Show me the . . ." or Point to the . . ." Only one repetition of the command is permitted, if no response or patient asks. If the patient points to more than one item, score 0, unless it is clear that the patient recognizes his mistake and firmly chooses one after correcting himself. Score V2 for each correct.

Real Objects Pictured Objects Forms Letters Numbers Key Helicopter Circle L 7 Feather Key Spiral H 42 ' Pencil Comb Square R 700 Cactus Feather Triangle T 1936 Comb Pencil Cone S 15 Helicopter Cactus Star G 7000

Colors Body Parts Furniture Blue Ear Window Brown Nose Chair Red Eye Desk (Table) Green Chest Light Yellow Neck Door Black Chin Ceiling

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c. Fingers and Right and Left Discrimination APPENDIX g (May present your own fingers if necessary) V. Naming Score 3 if correctly named, V2 if required Thumb Left Shoulder a cue or named the object on a second Ring Finger Left Knee attempt. Give credit for recognizable Index Finger Right Ankle paraphasias. May try tactile naming for the objects missed. Little Finger Right Wrist 1st 2nd Middle Finger Left Elbow Objects Score Attempt Attempt Right Ear Right Cheek 1. Gun Maximum Score — 30 2. Ball Patient's Score 3. Knife 4. Cup APPENDIX e 5. Pin Commands with Auditory Sequencing 6. Hammer Have the patient carry out the following commands, giving credit for each underlined 7. Toothbrush element which he carries out. One repetition is permitted on request, but command must always be repeated as a whole — not broken up. 8. Eraser Score 9. Padlock Make a. fist. 1 10. Pencil Shut your eyes. 1 Point to the chair. 1 11. Screwdriver Point to the ceiling, then to the floor. 2 12. Key (After lining up a pencil, watch and card, in that order, on the table before the patient.) 13. PaperClip 1 Point to the pencil and the card. 2 14. Pipe 2 2 15. Comb 4 Point with the pencil to the card. 16. Elastic 2 2 4 Point to the pencil with the card. 17. Spoon 2 2 4 18. Tape Point to the watch with the pencil. 19. Fork 4 With the card point to the watch. 20. Matches 2 2 Put the pencil on top of the card, then put it back. 7 Maximum Score: 60 Patient's Score: 2 4 2 2 10 Put the watch on the other side of the pencil and turn over the card. Maximum Score 40 APPENDIX h Patient's Score 1. WORD FLUENCY Ask patient to name as many animals as he can in 1 minute. (Normals may score 18 APPENDIX f or more.) He may be helped if hesitant: IV Repetition "Think of domestic animals, like the dog Ask patient to repeat: record answer verbatim. May repeat items once, if patient or animals in the jungle, like a tiger." At asks for it or does not seem to hear. If incompletely repeated, score 2 for each this point, he should be timed. recognizable word. Take 1 off for errors in order or literal . Maximum Score — 20 Patient's Score aximum 10. Sixty-two and a half 10 Score 11. The telephone is ringing 8 j. SENTENCE COMPLETION 1. Chair 2 12. He is not coming back 10 2. Nose 2 13. The spy fled to Greece 10 1. The grass is. (green). 3. Pipe 2 14. First British Field Artillery 8 2. Sugar is (sweet). 4. Window 2 15. No ifs ands or buts 10 3. Roses are red, violets are (blue). 5. Banana 2 16. The quick brown fox jumps 4. They fought like cats and (dogs). 6. Snowball 4 over the lazy dog 18 5. Christmas is in the month of. 7. Two 2 (December). 8. Forty-five 4 Maximum Score 100 Maximum Score — 10 9. Ninety-five percent 6 Patient's Score Patient's Score

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k. RESPONSIVE SPEECH 1. What do you tell time with? (Watch, 4. What do you do with soap? (Wash) Clock) 5. Where do you go to buy medicine? 2. What color is coal? (Black) (Drug Store, Pharmacy) 3. How many things in a dozen? Maximum Score — 10 (Twelve) Patient's Score

APPENDIX i Score Sheet Patient's Maximum Subscores Total

Spontaneous Speech: Information 10 Fluency 10 Total 20 Comprehension : Yes - No 30 Word Discrimination 30 Commands (Objects) 40

(Divide by 10) Total 10 Repetition: (Divide by 10) Total 10 Naming: Object Naming 60 Word Fluency 20 Sentence Completing 10 Responsive Speech 10

(Divide by 10) Total 10 Add and Multiply by 2 A.Q. A.Q.

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