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 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 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 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 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 , mutism, confusion and psychotic apply to clinical cases. Broca's aider a resoudre quelques-uns des prob- aphasia thus became "verbal lemes courants. , 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 , 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

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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 , 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 , 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 this picture. good comprehension. They read Alajouanine, 1956). These patients 4. Another common aphasic group is aloud poorly but reading com­ are often curiously unaware of their universally called global aphasia be­ prehension is often good. Writing is faulty communication and this is de­ cause of the severity of involvement affected similarly to speech. scribed as "anosognosia" for of both expressive and receptive 2. Sensory aphasia as described by speech. Their speech is often under functions. The patient does not Wernicke (1874) in his famous pressure, "logorrheic". The varia­ communicate and what is said is paper, "Der Aphasische Symp- bility of language production in often a stereotypic repetitive utter­ tomenkomplex" is recognized by Wernicke's aphasias induced some ance, at times, an expletive without everyone, even those wary of clas­ to split the symptom complex semantic value. At times these ut­ sifications such as Hughlings Jack­ further. Huber et al., (1975) for in­ terances are used quite fluently, with son (1879). His hierarchial view of stance, differentiates four varieties inflection and associated emotional language dissolution includes "jar­ such as 1. predominantly semantic expression. Comprehension seems gon" as a disturbance of expression , 2. semantic jargon, 3. almost entirely absent and even but these recurrent utterances were phonemic paraphasias, 4. phonemic when one has the impression that the more stereotypic than the profuse jargon, although a qualitative basis for patient "looks comprehending", the phonemic or semantic jargon of sen­ the discrimination is not provided. expressive outlets are so limited that

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it cannot be tested. Similarly, repeti­ see a few T.C.M. cases to recognize for mild impairment of comprehen­ tion and naming are very poor. Re­ the patient who says practically no­ sion associated with verbal cent studies of recovery indicate that thing spontaneously but com­ paraphasias. quite a few global patients regain prehends everything and repeats Modality specific aphasias are enough comprehension to be consi­ amazingly well. Rubens (1975) has rare and seldom if ever "pure". dered Broca's aphasics. There are a described this syndrome with infarc­ "Cortical dysarthria" (aphemia), few patients, often elderly, with se­ tion of the anterior cerebral artery. "verbal apraxia" (Johns and Darley, vere aphasia, who have fluent but We have seen this localization also 1970) is rarely if ever without some mumbling speech, which may be (supplemental speech area of Pen- associated disturbance of com­ mistaken for jargon, but the utter­ field). Isolation syndrome, also a re­ prehension provided the approp­ ances are stereotypic lacking the cently described entity is exemp­ riately difficult tests are used. phonemic variability of neologistic lified by the patient who remains Therefore, it should be considered jargon aphasia. non-fluent and does not seem to be aphasia rather than dysarthria. This There are aphasics who are more comprehending or attending to tasks has to be differentiated from the oc­ difficult to classify. A transitional but will repeat even longer phrases casional anarthric patient by testing group, having features of Broca's and complete sentences. One of writing which is usually impaired in (good comprehension) and these patients who had been ob­ the aphasie but intact in anarthria. Wernicke's (good fluency) but hav­ served to sing along with a radio and This entity is also called "subcorti­ ing poor repetition and a great deal even learn songs released since the cal motor aphasia", even though it is of phonemic paraphasias, was called onset of her illness caused by CO a nonaphasic disturbance related (Leitungs- poisoning (Geschwind, Quadfasel more to dysarthria. Transcortical aphasie) by Wernicke (1874) on the and Segarra, 1968), on autopsy had motor aphasics may also appear to basis of the theoretical consideration surrounding but not directly be mute but they will repeat well. that conduction of sensory impulses involving the parasylvian "speech "Pure word deafness" is occa­ to motor patterns is impaired. Many area". Transcortical (echolalic) sen­ sionally seen but most authors admit clinicians doubted the justification of sory aphasia is characterized by that their patients had some separating this group from other fluent but often irrelevant speech. paraphasias and word-finding diffi­ sensory and motor impairment. Good repetition and poor com­ culty even though the comprehen­ Weisenburg and McBride (1935) prehension is most often seen in sion deficit can be outstanding while claim that they have not seen a case post-traumatic cases and it is often everything else, including pure tone which would show clearly the pic­ transient. Investigators in rehabilita­ threshold is preserved. Interest­ ture of conduction aphasia in con­ tion units do not see these patients ingly, as Vignolo (1969) pointed out trast to Goldstein's description of as often as those in general hospi­ in his excellent review, these "central" aphasia (1948) and those tals. T.C.S. aphasia does not seem patients usually have "auditory ag­ of Kleist (1916), Isserlin (1936) and to occur frequently with . nosia" for nonverbal but meaningful many others who considered it an Many classifications will acknow­ sounds as well. independent form. Delineation is ledge the existence of only those possible on the basis of disturbed re­ aphasie defects which tend to persist Modality specific anomia is con­ petition which is out of proportion to in time. This way some theoretically troversial but an often recognized the relatively fluent spontaneous or very interesting language distur­ example is the difficulty naming fin­ responsive speech and good com­ bances remain unrecognized. gers and discriminating right from prehension. left in the Semantic aphasia was described (1927). Although Benton (1961) The opposite clinical picture is- originally by Head and meant im­ pointed out that this cluster of symp­ echolalic aphasia when repetition is paired word-meaning relationships toms including and acal­ preserved out of proportion com­ and difficulty in formulating the culia is rarely pure and the compo­ pared to the other language func­ goals of the speaker. The linguistic nents are often disturbed in tions. These patients were sub­ classification of Jacobson and Luria aphasics, this does not detract from divided by Goldstein (1948) into continued to use the term. Interest­ its usefulness in calling attention to transcortical motor (T.C.M.) show­ ingly, in our mathematical taxonomy the dominant . ing poor output but good com­ there is a group similar to but dis­ prehension and repetition; transcor­ tinct from by more Alexia without agraphia has been tical sensory (T.C.S.) characterized paraphasias and comprehension dif­ described with pathology by De- by poor comprehension but fluent ficulty which is not severely enough jerine (1892) and repeatedly con­ speech and good repetition and affected to group it with Wernicke's firmed since. Alexia with agraphia is mixed, featuring poor comprehen­ (or sensory) aphasia. It may be more common and it is often as­ sion, poor output but good repetition realistic to preserve the distinction sociated with mild anomic aphasia. similar to echolalia. The identity of between semantic and anomic The discussion of apraxias and these syndromes is defined by repet­ aphasia, reserving the term anomic various visual or tactile agnosias and ition and one has to test for it speci­ for the purer disturbance of word- constructional apraxia will be omit­ fically. However, one only has to finding and naming and the semantic ted here for sake of convenience, not

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TABLE I TERMINOLOGY OF APHASIA https://www.cambridge.org/core The left column indicates the authors originating and popularizing the terms. The numbers on top refer to the four most common varieties described in detail in the text.

Authors 1 2 3 4 . https://doi.org/10.1017/S0317167100025890 Broca Aphemia Verbal Amnesia

Wernicke Motor Sensory Conduction . IPaddress:

Marie Aphemia Aphasia 170.106.35.76 Pick Expressive Impressive Aggramatism Paragrammatism

Head Verbal Syntactic Semantic Nominal , on

29 Sep2021 at20:53:57 Weisenburg & Expressive Receptive Mixed Amnesic Mixed McBride Transcortical Transcortical Mixed Goldstein Motor Sensory Central Amnesic Global Motor Sensory Echolalic Syntactic Pragmatic & We p man Semantic Global (Verbal) Jargon , subjectto theCambridgeCore termsofuse,available at Shuell III (Sensorimotor) I_|-II -fin IV? I (Simple) V (Severe)

Transcortical Transcortical Nielsen Cortical Motor Cortical Sensory Conduction Amnesic Motor Sensory

Bay Cortical Dysarthria Sensory Amnesic Echolalic

Mixed (or) Dynamic Expressive Syntactical Central Nominal Total Afferent Acoustic Luria Efferent Motor Sensory Semantic Global Motor Amnesic

Jacobson Contiguity (Combination) Similarity (Selection) Semantic

Osgood Encoding Decoding

Geschwind, Transcortical Transcortical Broca's Wernicke's Conduction Anomic Global Isolation Goodglass etc. Motor Sensory Motor Sensory Efferent Afferent Transcortical Transcortical Taxonomic Semantic Anomic Global Isolation (Broca's) (Wernicke's) Conduction Conduction Motor Sensory LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES

because they are unrelated to ALAJOUANINE, T. (1956). Verbal realiza­ KERTESZ, A. and POOLE. E. (1974). The aphasia. tion in aphasia. Brain 79, 1-28. aphasia quotient. Canad. J. Neurol. Sci. 1, Even though aphasic disorders BAY, E. (1964). Principles of classification 7-16. and their influence on our concepts of KERTESZ, A. and PHIPPS. J. (1976). Num­ often need to be classified, clinicians aphasia in Disorders of Language. London: erical taxonomy of aphasia. Brain and Lan­ are reluctant to define aphasic types Churchill, 122-142. guage (in press). according to measurable paramet­ BENTON, A. (1961). The fiction of the KLE1ST, K. (1916). Uber Leitungsaphasie ers. Most investigators are satisfied "Gerstmann Syndrome". J. Neurol., und grammatishe Storungen Monatschsr. f. with impressions of unmeasured per­ Neurosurg. Psychiat. 24, 176-181. Psych, u. Neurol. 40, 118-121. formance or established criteria on BROCA, P. (1861). Remarques sur le siege de LURIA, A. (1964). Factors and forms of la faculte du langage articule, suivies d'une aphasia in Disorders of Language. London: the basis of one, at the most two, Churchill. parameters such as the severity or observations d'aphemie (perte de la parole). Bull. Soc. Anat. 36, 330-357. MARIE, P. (1906). Revision de la question de fluency-nonfluency scale. Recently DEJERINE, J. (1892). Contribution a 1'etude I'aphasie: I'aphasie de 1861 a 1866: essai de attempts were made to define clini­ anatomo-pathologique et clinique des dif- critique historique sur la genere de la doc­ cally recognizable aphasic groups ferentes varietes de cecite verbale. C.R. trine de Broca. Sem. Mid. Paris: 26, according to the performance on cer­ Soc. Biol. (Paris) 4, 61-90. 565-571. tain tests (Vignolo, 1964; Kertesz, GERSTMANN, J. (1927). Fingeragnosie und MOHR, J. P. (1975). Superficial and deep an- isolierte agraphie ein neues syndrom Z. terosuperior sylvian syndromes. Abstract, 1974). Beyond these intuitive clas­ IV Pan American Congress of . sifications (taxonomies) a mathemat­ Qes. Neurol. U. Psychiat. 108, 152-177. GESCHWIND, N., QUADFASEL, F. A. Oct. 1975. Mexico City. pg. 7. ical approach to classification be­ and SEGARRA, J. (1968). Isolation of the OSGOOD, C. E. and MIRON. M. S. (eds.) came available to biologists and speech area Neuropsychologia 7, 327-340. (1963). Approaches to the study of aphasia, clinicians. Numerical taxonomy as it GOLDSTEIN, K. (1924). Das Wesen der am- Urbana Univ., Illinois Press. is called can provide objective clus­ nestischen Aphasie. Schweiz. Arch. J. PENFIELD, W. and ROBERTS, L. (1959). ters of aphasics on the basis of test Neur. & Psychiat. 15, 163-175. Speech and brain mechanisms. Princeton scores, free from the constraints of GOLDSTEIN, K. (1948). Language & lan­ Univ. Press. Princeton, New Jewsey. previous classifications. guage disturbances. New York: Grune & PICK, A. (1913). Die agrammatischen Stratton. sprachstorungen. Berlin: Springer. At the bottom of Table 1, the 10 GOODGLASS, H., KAPLAN, E. (1972). As­ RUBENS, A. B. (1975). Aphasia with infarc­ groups generated by numerical tax- sessment of aphasia and related disorders. tion in the territory of the anterior cerebral onomic methods (Kertesz and Philadelphia: Lea & Febiger. artery. Cortex XI, 239. Phipps, 1976) on 142 stroke patients HEAD, H. (1926). Aphasia and kindred dis­ SCHUELL, H. (1964). Aphasia in adults: orders of speech. New York: Macmillan. diagnosis, prognosis and treatment. Harper are labelled with due respect to cur­ and Row. rent terminology and previous clas­ HUBER, W., STACHOWIAK, F. J., POECK, K. and KERSCHENSTEINER, VIGNOLO, L. A. (1964). Evaluation of sifications. The major addition to the M. (1975). Die Wernicke's aphasie. J. aphasia and Language Rehabilitation: a re­ Goodglass, Kaplan, Geschwind Neurol. 210, 77-97. trospective exploratory study. Cortex I. classification is the splitting of con­ 344-367. ISSERLIN, M. (1936). 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