THE EFFECTS OF CRANIOTOMY ON ORAL COMMUNICATION ABILITY

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN THE GRADUATE SCHOOL OF THE TEXAS WOMAN'S UNIVERSITY

COLLEGE OF NURSING

BY GWEN BRIEGER, R.N., B.S.

DENTON, TEXAS MAY 1976 The Graduate School Texas Woman's University Denton, Texas

April 21 76 ------19______vVe hereby recommend that the Thesis prepared under Gwen Brieger our supervision by entitled ___ :�_The Effects of Craniotomy on Oral Communication Ability" ·------

------·------be ac.;cepted as fulfilling this part of the requirements for the Degree of

Ma ter of Science ------s---·------

------

Accepted:

(3�an�School ACKNOWLEDGEMENTS

Any r�search endeavor requires a coordinated effort of a number of individuals. The researcher wishes to express her gratitude and appreciation to the following people for their constant support, guidance, and encourage­ ment: To members of my thesis committee--Beth Vaughan­ Wrobel, Linda Brown, and Lois Hough--for their time, support, and guidance throughout the writing of this thesis. To Josephine Simonson--my deepest gratitude for all her help, encouragement, and valuable time spent in the evaluation of data. To Dr. Joan Reisch--for her encouragement and assistance in the computation of the statistical data. To my family and friends--for their support, patience, and constant encouragement throughout my graduate studies. To my employer and fellow employees--for·thefr understanding and encouragement throughout graduate school. And last, but not least, to the health agencies, physicians, and patients who allowed this data to be collected. iii TABLE OF CONTENTS

Chapter I. INTRODUCTION. 1 Statement of Problem. 2 Purposes...... • • . . 2 Background and Significance •. • 2 Hypotheses ...... •. • .••.• 8 Definition of Terms . . ... •.. ... 9 Limitations . . . . • . . • . . . .• 9 Delimitations ...... ••.. 10 Assumptions . • . • . • • . • . . 10 Summary . . . • . . . . • . • 10 II. REVIEW OF LITERATURE. 12 Anatomy and Pathophysiology of Cerebral Hemisphere and Speech Centers . . . . • 13 Parietal Lobe . . • • • . . • . . • . • 19 Occipital Lobe. . . • • . • . . • . . • . • 22 Temporal Lobe ...... • . • . . . 23 Cerebral Dominance. • ...... • 26 Craniotomy, Brain Tumors, and Aneurysm. . • . 30 Craniotomy. . . • . . . . • . . 30 Brain Tumors...... 31 Aneurysm. . . . . • . . . . . • . . 35 Aphasia ...... • 39 Nursing Implications...... • . 46 Summary . . . . • ...... • . • 5 2 III. PROCEDURE FOR COLLECTION AND TREATMENT OF DATA. 53 Type of Study ... •.• ...... •.• 53 Setting ... • •..... 54 Population. . . . • ...... 54 Development of Instrument ...... • • . 55 Validation of Tool .•...... •. • 57 Method of Data Collection .... 58 Analysis of Data...... ••.•.. 60 Summary . . • ...... 62

iv TABLE OF CONTENTS (Continued) Chapter IV. ANALYSIS AND INTERPRETATION OF DATA 63 Description of Sampie Population. • ••• 64 Presentation and Discussion of Findings • '68 Summary ... .. • ...... 75 V. SUMMARY, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS • • • . • . . . • . . . . . 76 Summary . • . . . . . • . . . . 76 Conclusions . . • . • •.• 79 Implications...... 81 Nursing Practice .... •...... 82 Nursing Research ....• 83 Nursing Education ... •.• 84 Recommendations .•. •...... 84 APPENDIXES ...... 87 REFERENCES CITED . 113-

V LIST OF TABLES

1. Clinical Analysis of Handedness. -28 2. Frequency of Craniotomy Sites .. 65 3. Frequency of Cerebral Hemisphere Involvement . 66 4. Relationship Between Cerebral Hemisphere and Oral Communication ... ..• 71 5. Relationship Between Sex and Oral Communication. • 72 6. Relationship Between Site and Oral Communication . 74 7. Relationship Between Age and Oral Communication. • 74

vi LIST OF FIGURES

1. Lateral View of the Left Cerebral Hemisphere 15 2. Location of Intracranial Aneurysms and Frequency of Sites .. •..••••... 37 3. Frequency of Communication Scores .• 67 4. Changes in Communication Scores •.. 70

vii CHAPTER I

INTRODUCTION

The ability to communicate is one of the most valuable functions a person possesses. It is desirable in all phases of life--physically or mentally. A lack of communication is detrimental to one's work and social and family life. The loss of any or all of one's ability to communicate necessitates considerable adjustments for the individual. A healthy brain is essential for communication. It is vital for thinking, feeling, understanding, writing, speaking, and reading. The relationship between the brain and speech is very important. A brain suffering from tu mor, injury, or aneurysm may cause a disruption of communication. This study investigates the effect of a craniotomy on one's communication processes. It reveals the areas of an unhealthy brain which are most likely to cause a loss in oral communication abilities. A patient's problem with communication can cause unique difficulties for both the nurse and the patient. The inability of patients to speak, write, read, or under­ stand is very frustrating and anxiety-producing to the

1 2 nurse as well as to the patient. Nurses caring for patients who have had surgery for brain tumors may be unaware of possible changes in the patient's ability to communicate. Unless a change in linguistic skills is very noticeable, it is often not recognized. To know that these changes may take place in craniotomy clients is very important in planning, caring, supporting, and evaulating nursing care the patient receives.

Statement of Problem The problem of this study was to determine the effects of craniotorny on oral communication ability.

Purposes The purposes of this study were: 1. To identify the extent of loss of oral communication ability in patients following craniotomy 2. To determine whether or not left-sided brain disorders cause more problems in the area of oral communication of patients following craniotomy than right-sided brain disorders

Background and Significance Communication is the conveyance of ideas from one person to another. These ideas or messages can be expressed 3 verbally or non-verbally. Communication is a very necessary part of life; without it, the world could not exist. Much has been written in reference to communication. A lack of it has been denoted as the main cause of many of the problems in the world today. It has been said that the generation gap,which is the conflict between the young and the old, is actually a problem of communication, that is, the inability of two groups to understand each other. Much of the communication today is brought to the people through the media. Most people have access to the news through radios, televisions, and newspapers. Cassirer has stated that the "media of communication, like government, becomes truly constructive and responsive to man's needs when they are not merely for the people but of the people and by the people" (1971, p. 308). Language formation is one aspect of communication. Since language is a human characteristic not found in animals, research has been more difficult. Much of the study of the brain, especially its association with language formation, has been done on patients having excision of cortical regions for epilepsy. Milner has done work in the representation of many of the studies on the higher functions of the brain in man (Geschwind 1970). However, the largest amount of research in language skills has been 4 done from long-term studies of patients who have suffered from communication disorders due to brain injuries from cerebral vascular accidents (Geschwind 1970). Aphasia is the interference in one's comprehension and use of language. The history of the study of aphasia dates back to the early 1900's. Paul Broca is noted as the first person to show the association of aphasia to the brain. In the late 1800's he was able to prove that "aphasia was linked to specific lesions within the brain and that these lesions were predominantly found in the left hemisphere of the brain" (Geschwind 1970, p. 941). However, the man who has been given the most credit for early works on aphasia is Carl Wernicke. In 1874, in his work The Symptoms Complex of Aphasia, he found linguistic differences between damage found in the left temporal lobe and damage found in the frontal lobe (Geschwind 1970). Wernicke's research findings prefaced many other works which identified the specialty areas in the brain. Because of these early works in the field of aphasia, experts are now able to determine the area of brain damaged from the communication disorder manifested by the patient. It has been stated by many authors that the speech function in most adults is found in the left hemisphere of the brain (Elliott 1971; Meyer 1974). This is felt to be 5 true regardless of the hand preference of the person studied. Witelson and Pallie in their study 1 hypothesized that the "area of the superior surface of the temporal lobe known to mediate language in the adult is larger in the left hemisphere than in the right hemisphere in the human neonate" (1973, p. 642). In this study, the researchers were trying to show that there were biological structures and not only environmental factors involved in the determination of the left hemisphere as the major area of the brain directing language skills. Post mortem adult and infant brains were studied. The infant brains were ch osen because they were of an age in which they had no learned hand functions or environmental experiences. Witelson and Pallie (1973), from their findings, were able to support the idea that biological structures do help determine the left hemisphere as the mediator of language. The transfer of language to the non-dominant hemisphere up to the age of fifteen has been described by Obrador in 1964 (Smith 1966). Coinciding with this train of thought was a general agreement that this transfer of language is less frequently found in the adult patient. A greater reluctance to remove the left hemisphere in adults reflect beliefs that the integrity of various dominant hemisphere structures is necessary for many functions including receptive and expressive language, higher mental functions, control of right-and left-sided purposeful 6 movements, arithmetical reasoning, and discrimination of colors (Smith 1966, p. 469). However, Aaron Smith in 1966 wrote of a case study which differed from some of the findings of Obrador. In Smith's study he told of a forty-seven-year-old man having had a left hemispherectomy. His results showed that "the minor hemisphere has considerable capacity, even in the adult, to organize language and non-language mechanisms" (Smith 1966, p. 470). Few articles were located concerning the effect of surgery for brain disorders on communication abilities. Several articles were found to be significant but were inaccessible since they were written in a foreign language. However, in 1973 Howard Landsnell did study a group of neurosurgical patients undergoing brain surgery. He studied these patients' ability to identify popular word asso­ ciations following surgery. Landsnell gave the patients a preoperative and a postoperative test to determine their ability to associate words. He compared two types of brain surgery as well as compared which hemisphere was involved. Sex of the patient being studied was also considered. His findings showed only a decrease in the ability to identify popular word association in the male patients who had subcortical surgery on the left side (Landsnell 1973). Landsnell explained these findings in the male 7 patients in terms of the findings from a previous study he did in 1964 in which he found that the male brain tends to be slightly larger than the female brain. Small sex differences in cerebral assymetry were also indicated in the 1964 study as was a tendency for the male brain to be without the small band of tissue which connects the two halves of the thalamus across the third ventricle (Landsnell 1973). Many studies in nursing research have been done about communication disorders (Fox 1971; Grey 1970; Reeves 1963). The main emphasis of this research is on understanding and giving support to the aphasic patient. A compilation of the supportive measures given in all of the articles include many similarities. Some of these are listed below: 1. Never act hurried with the aphasic patients; give them all the time they might need (Fox 1971) 2. Talk with the patient even if he cannot reply or understand what is being said; make him feel worthy of communication (Grey 1970) 3. Never criticize any kind of speech, even swearing or inappropriate wording (Fox 1971; Grey 1970) 4. If the nurse is not sure what to say to an aphasic patient, she should seek help from the doctor, speech 8 therapist, or another competent nurse; too little knowledge can be very dangerous (Reeves 1963). Most of the research on communication done by nurses provides suggestions or ideas which are helpfu1 to nurses caring for patients unable to communicate their needs. Some suggest the use of non-verbal expressions. Of course, this does not work on all patients, but if there is a chance for success the nurse should try it. Popelka and Berger found the use of appropriate gestures to be very helpful in speech reading (1971). This same theory may also be useful in patients having trouble with their ability to communicate,_. Much research has been done in the field of communication. The research has included studies done in nursing, medicine, speech therapy, psychology, and science. This study was undertaken to show more definitely the link between left-sided brain pathology and subsequent surgical intervention and the manifestation of speech disorders.

Hypotheses The hypotheses of this study were: 1. There is a decrease of oral communication ability in patients undergoing a craniotomy for brain tumor or aneurysm 9

2. There are more difficulties with oral communication in patients who have had a craniotomy for left-sided brain disorders than those for right-sided brain disorders

Definition of Terms The definition of terms used in this study were: Craniotomy--opening in the skull cavity for location and when feasible, excision of brain tumor. Oral communication ability (linguistic skills)-­ the ability to understand by ear and to communicate by speech. Aphasia--int erference with the comprehension and use of language, includes reading, writing, speaking, and auditory understanding. Articulation--the enunciation of words and sentences.

Limitations The limitations acknowledged in this study included: 1. The extent of pathology within the brain is covert and varies among patients and, therefore, cannot be controlled.

2. Postoperative complications which may cause further damage to the brain following the craniotomy cannot be controlled. 10 Delimitations The delimitations observed in this study included: 1. A minimum age limit of eighteen years 2. Only patients who had sufficient capability to understand the interview questions at the time of admission to the hospital 3. Only English-speaking patients

Assumptions The assumptions upon which this study were based were: 1. Communication is a basic human need 2. Communication skills are a function of the brain

Summary Chapter I has presented the purposes, hypotheses, and significance of the research to be studied. A review of the literature pertaining to the definition, type and indications for craniotomy, basic anatomy and physiology of the brain relating to its speech centers and cerebral dominance, meaning, history, types, causes, and prognosis of aphasia and nursing implications for patients with disruption of communication is found in Chapter II. Chapter III presents a discussion of the research 11 methodology including a description of the sample and instrument employed. Chapter IV identifies the findings of the study as well as the statistical analysis and interpretations. Finally, the summary, conclusions, implications, and recommendations are outlined in Chapter V. CHAPTER II

REVIEW OF LITERATURE

What separates man from beast? The significant dividing factor is communication. Animals communicate with each other by various ways and means. The birds sing, the dogs bark, the lions fight, and the skunks stink. All of these forms of communication reflect certain meanings to these animals--fear, hunger, anger, et cetera. However, the use of language and speech is a remarkable attribute of the human brain--one that is shared by no other animal (Gatz 1972). "The birth of language is the dawn of huma nity" (Pei 194 0 , p. 9) • This chapter reviews the literature pertaining to craniotomies performed for various brain disorders and their relationship to disruption of oral communication. It is done in four major parts: (1) a review of basic anatomy and physiology of the cerebral hemisphere and speech centers, (2) the definition of a craniotomy and an overview of various indications for performing, (3) a discussion of aphasia including its meaning. history, types, and causes, and (4) a description of nursing implications and considerations for patients suffering such speech disorders.

12 13 Anatomy and Pathophysiology of Cerebral Hemisphere and Speech Centers The brain is one of the most important organs within the human body. It is composed of a complex network of nerve cells which require a rich blood supply to assure an adequate oxygen and vitamin storage available for metabolism (Espir and Rose 1970}. The cerebrum is the major portion of the brain and is divided into two hemispheres. In looking at these hemispheres, they appear to be mirror images of each other. The outer layer of the cerebrum is the cerebral cortex. The development of these structures represents the only essential difference between the brains of humans and lower animals. As early as the second century A.D., Galen taught that the cerebrum is the organ of intelligence and conscious sensations. All modern work has confirmed his theory, and, in addition, has shown that in the cortex of gray matter lies the seat of consciousness (Spurling 1935, p. 56}. The direct evidence that is available about the functions of the cerebral cortex in humans stems from studies of localized lesions, studies from patient's responses to electrical stimulation to various points on the surface of the cortex, and from patterns of responses of epileptic seizures from lesions in different parts of the brain (Gatz 19 7 2 } •

Once established that the cerebrum contained the function of higher cortical activities, the localization 14 versus holism controversy began. Paul Broca and Carl Wernicke were known as early advocates for localization of speech centers within the brain (Geschwind 1970; Schuell 1975; Meyer 1974). Hughlings Jackson was the first person to .challenge this theory of localization (Meyer 1974). In 1878 he pointed out: .. • speech and words are physical terms; words have of course anatomical substrata or bases as well as other states have. We must as carefully distinguish betwixt words and their physical basis; a physical state is always accompanied by a physical state, but nevertheless the two things have distinct natures (Meyer 1974, p. 573). Followers of this Jacksonian view included Sigmund.Freud, Kurt Goldstein, Arnold Pick, and Henry Head (Meyer 1974). Several of these authors adopted a holistic functional view. This term meant they were holists in respect to language functions, but they compromised and accepted localization as far as clinical syndromes were concerned (Meyer 197 4 ) .• Modern views of cerebral localization began in the latter portion of the nineteenth century when the cerebrum, exposed in the living animal, was stimulated electricaily (Spurling 1935). This led to an extreme view on localization in which each center for various functions could be outlined '(Spurling 1935). More recent work now modifies this view. 15 Although but little definite localization in the old sense of centers is apparent, nevertheless, certain physiological changes have been demonstrated to occur more frequently with lesions at some sites than at others. By analysis of these physiological changes, the clinical neurologist is able to localize the site of lesions of the cerebral hemispheres with reasonable accuracy (Spurling 1935, p. 57). The cerebrum is divided anatomically into four lobes: frontal, temporal, parietal, and occipital. These are each discussed separately including their location and functions in the next few pages. Figure 1 shows the cerebral hemisphere with the four lobes indicated.

~rental \ I\ \ ) \ ~

� o pital Tempora �1 J _ �

Fig. 1. Lateral view of the left cerebral hemisphere_

Frontal Lobe The frontal lobe comprises the largest portion of each cerebral hemisphere in man. "It extends from the 16 frontal pole to the central sulcus of Rolando, and the Sylvian fissure defines its inferior border" (Schuell, Jenkins, and Jimenez-Pabon 1967, p. 68). The frontal lobe has several functions: motor, personality and intellect, and speech .• From the standpoint of functional activity, the frontal lobe may be divided into four well-defined areas: prefrontal, true motor, premotor, and motor speech (Spurling 1935). The functional activity of the prefrontal area in man has been studied from experimental lesions in lower animals and from the effect of disease upon this area in man (Spurling 1935). Disease or injury to the prefrontal lobe produces characteristic changes in the intellectual status of the patient such as decreased attention, difficulty in comprehension, distortions of emotions, marked irritability, and slowness in the execution of acts (Spurling 1935). Thus, one can see how this anterior portion of the frontal lobe deals with personality and intellect. At one time, psychiatric patients were treated with frontal lobotomies to slow down mental activity and decrease anxiety. The true motor area is situated immediately anterior to the central fissure (Spurling 1935). Brain damage in this area results in impair ment of motor functions. 17 When the true motor cortex on one side is removed in a monkey or chimpanzee, the contralateral extremities are at first paralyzed and flaccid.-­ This paralysis is temporary and the only permanent residual loss consists of clumsiness in finer movements (Spurling 1935, p. 64). The third functional area is the premotor.· This is located just in front of the true motor area. Skilled activities which require repeated practice for accuracy and perfection are developed in this portion of the frontal lobe. Damage to this area yields a transient loss of voluntary movement in the contralateral extremities with an increased resistance to passive manipulation (Spurling 1935). Musicians, typists, and other persons that are dependent on work requiring fine skilled movements would be affected most by damage in this area. However, just as with damage in the true motor area, damage in the premotor area is also temporary except for a residual awkwa1:dness ·-.in the performance of finely-skilled acts (Spurling 19 35) • The last functional area of the frontal lobe is the motor speech area. Since the frontal lobe deals with motor function of the entire body, it is easy to see that it also participates in the production of speech, which requires well-coordinated movements of the lips, tongue, soft palate, J.acypx., and the muscles of respiration (Schuell et al. 1967). The motor speech area, also known as Broca's 18 ares, is located in the posterior third of the frontal lobe; destruction of this area causes loss of ability to carry out the coordinated movements of the lips, tongue, pharynx, and larynx (Spruling 1935). In Broca's apna�ia, there ii a loss of the ability to express oneself appropriately; even so, the patient's mental capacities are not impaired. In left frontal lesions in right-handed persons, there is an inability to find the desired words for the expression of thought either verbally or in writing (Baker 1958). Lesions found on the right side may be associated with amusia (McFie 1969). If the motor speech area is disturbed, the patient is at first dumb, then recovers short words such as "yes," "no," "go," and "eat;" he then may learn to count or say the alphabet (Spruling 1935). Although the patient's tone may be monotonous and he must resort to gestures, he may eventually learn to express himself by skipping difficult words and omitting small words (Spruling 1935). This is an important point for nurses to remember. The frustration of persons who under­ stand events that are happening but who are unable to express their needs is great. The nurse must treat this person as an intelligent individual who is aware of his needs and desires but is unable to express them adequately (Simonson 1971). 19 Changes in the motor, behavior, or speech patterns of a p�rson are often signs of frontal lobe disease. Mullan (1961) describes the syndrome of the triple loss of T's: tension, tact, and tenacity. According to his theory, "there is lessening in tension or worry, loss of tact in judgment and social relations, and there is defective tenacity of endeavor" (Mullan 1961, p. 84).

Parietal Lobe The parietal lobe is the receiving station for sensory signals to the brain. "It is bound in front by the Rolandic fissures, below by an imagery line, connecting the preoccipital notch with the external portion of the parieto­ occipital fissure" (Spurling 1935, p. 73) . The parietal lobe produces more clinical phenomena following disease than any other area of the brain (McFie 1969). "Physiologically, the parietal lobe is a meeting place of the sensory systems, proprioceptive, visual, and auditory" (Mullan 1961, p. 89). Functions of the parietal lobe deal with tactile stimulation, fine discrimination and interpretation, spatial orientation, and awareness of body image. The parietal lobe also contains areas concerned with the memory of written words (reading center), perception 20 of form, and the use of things {praxic center) (Spurling 1935) The parietal lobe plays a role in discrimination of size, shape, and texture and helps maintain awareness of movements of parts of the body, and the position of body in space {Schull et al. 1964, p.69). With lesions of the parietal lobe, the patient has normal appreciation of contralateral tactile, olfactory, auditory, and visual stimuli; however, if presented with simultaneous stimuli to both sides, he ignores those coming from the side opposite the lesion {Elliott 1964). This unawareness of body parts or one-sided neglect is something normally taken for granted. To know where body parts are in relation to activities of objects is a highly automatic function of the human brain. Anosognosia or one-sided neglect has been studied in numerous patients suffering stroke or tumor. This term was first used by Babinski in 1918 to describe stroke patients who were unaware of the existing paralysis of half of their body (Ullman 1964). Lesions within the parietal lobe can also cause a homonyrnous h�mianopsia. This visual field cut attributes to the unilateral neglect seen in stroke patients. Fowler and Fordyce (1972} describe patients with severe forms of neglect who ignore input from 21 all the senses on one side. This can be so severe that the patient may cause injury to himself. In 1941 Brain reported three cases with right parietal lesions of the minor hemisphere causing neglect of the left half of the visual space (Oxbury, Campbell, and Oxbury 1974). The absence of the syndrome in dominant hemisphere cases was considered to be a result of masking from other effects such as severe dysphasia, disorientation,or different types of agnosia (Oxbury et al. 1974). In their study, thirty-nine stroke patients were observed for unilateral visuo-spatial neglect and for impairment of spatial analysis and visual perception. Significantly, forty-one percent of the seventeen patients with right hemisphere strokes showed evidence of left visuo-spatial neglect; whereas none of the fifteen patients with left hemisphere strokes or the seven with brain stem strokes, had unilateral visuo-spatial neglect (Oxbury et al. 1974). Henry Hecaen has done several studies on the effect of parietal lobe lesions in man. According to him, lesions from the right or left hemisphere may cause somatognosia, praxic disorders, disorders of spatial data, facial agnosia, spatial dysgraphia, or spatial dyscalculia (Hecaen 19 6 7) • 22

The most important area for language realization is the posterior temporo-parietal area composed of the posterior part of the temporal lobe and of the supramarginal and angular gyri (Hecaen 1967, p. 152). From his studies, Hecaen has found the parietal lobe to play some part in all aspects of language (1967). Parietal aphasia is especially characterized in verbal amnesia, alexic disorders, and agraphia predominate in the setting of moderate sensory aphasia; however, expressive difficulties can be seen such as with parietal stuttering (Hecaen 1967, p. 152). Specific types of aphasia dependent upon parietal damage include semantic aphasia, conduction aphasia, and agraphia (Hecaen 1967).

Occipital Lobe The occipital lobe is located at the posterior portion of the cerebral hemisphere. Lesions of the occipital lobe produce defects in the field of vision, especially hemianopsia (Mullan 1961). The occipital lobe is the only lobe with functions so closely related. The functions of this lobe are entirely related to vision. Left occipital lesions may result in right hemianopsia alexia, and color agnosia,whereas right-sided lesions may produce disturbances of visual aspects of spatial perception such as prosopagnosia or spatial dyslexia or dysgraphia (McFie 1969). 23 Temporal Lobe The last lobe of the cerebral hemisphere to be discussed in this section is the temporal lobe. The Sylvian fissure is the dividing line which separates the temporal from the frontal and parietal lobes. Functions of the temporal lobe include auditory functions, language, recent memory, and vision (Schuell et al. 1967). The left dominant temporal lobe is the location where one can find Wernicke's area for receptive speech. The temporal lobe of the dominant hemisphere is the center for reception and interpretation of sounds necessary for the understanding of speech (Espir and Rose 1970) . The temporal lobe of the minor hemisphere has no definite localization of function besides containing the cortical centers of hearing and smell (Spurling 1935). Lesions of the temporal lobe of the dominant hemisphere may result in receptive aphasia. Lhermitte and Gautier (1967) report disturbances of the motor realization of speech such as with paraphasia and jargon speech result from anterior lesions whereas disturbances of the semantic speech or formulation of sentences result from lesions of the posterior portion of the temporal lobe. Lesions near' the junction of the parietal, temporal, and occipital lobes may produce word blindness often associated with right 24 homonymous hemianopsia; the patient is unable to recognize the meaning of written words, and he is unable to read or write because he lacks visual comprehension (Spurling 1935). Right temporal lesions may result in.amusia and disorders of memory as well as some disturbances of spatial integration (McFie 1969). In 1974 Moore and Wiedner studied bilateral tachistoscopic word perception in aphasic and normal subjects. In doing this, they utilized thirty aphasic patients with various lengths of time since postcerebral injury. They also had a control group consisting of ten normal young adults. When the subject's eyes gazed upon a central fixation point, a slide was presented with one word on the right-half field and one word on the left-half field. All of the aphasic subjects showed a preference for the left visual field regardless of the amount of time since postcerebral insult; whereas the normal subjects preferred the right visual field (Moore and Wiedner 1974). Linguistic stimulation of the right hemisphere may reduce the amount of time in active therapy for this type of aphasic subject (Moore and Wiedner 1974). It has been previously stated that right-sided temporal lesions did not produce aphasia. However, Ettlinger, Jackson, and Zangwill reported a case of dysphasia following 25

� right temporal lobectomy in a right-handed man. This is significant in that Roberts in 1951 reported only two out of 258 right-handed patients resulting in dysphasia following· right hemisphere operations (Ettlinger, Jackson, and Zangwill 1955). The patient's expressive speech recovered rapidly; however, his receptive disability persisted suggesting that the major temporal lobe wa� on the right side (Ettlinger et al. 1955). The authors classified this man as a weakly, right-handed man and not as a shifted sinistral (Ettlinger et al. 1955). Numerous studies have been done on the effect of temporal lobectomies for control of epilepsy. Falconer and Serafetinides did a study of one hundred patients experiencing such surgery. They reported good results for the control of seizures. Postoperatively, twenty-nine of the fifty-six patients with left-sided resections showed some form of dysphasia (Falconer and Serafetinides 1963). Meyer and Yates were interested· in the intellectual changes following temporal lobectomies. Their study consisted of eighteen patients.· In their findings, they reported general intelligence relatively unimpaired; however, they sometimes found a significant learning disability caused by lesions in the dominant hemisphere (Meyers and Yates 1955). 26 Each lobe has some function related to communi­ cation. Brain injury or disease in any of these areas can cause some form of dysphasia anywhere on a continuum· from very mild to very severe. A chart which depicts various sites of lesions and the types of speech disorders involved is found in Appendix A. An outline of the basic speech centers within the dominant hemisphere and their related functions as well as the defects expected following injury is located in Appendix B.

Cerebral Dominance Thus far the dominant and non-dominant hemispheres have been mentioned. It is imperative that cerebral dominance be understood in any study of aphasia. Hemisphere dominance is used to define a function of the brain which is primarily located in one hemisphere. For years the relationship between the speech centers and cerebral dominance ·has. been studied. In 1836 Marco Dax verbally reported on forty cases of speech deficits resulting from lesions in the left hemisphere of the brain; this began the history of cerebral dominance (Meyer 1974). Broca, another leading researcher of aphasia, demonstrated that nineteen of his twenty "aphemia" cases had lesions located in the left posterior frontal lobe (Meyer 1974). Two years later in 27 1865, Bouillard suggested that speech and handedness were indeed related to cerebral dominance (Espir and Rose 1970}. However, it was Jackson in 1932 who introduced the dominant or major hemisphere. The two brains, he wrote, cannot be mere duplicates if damage to one alone can make a man speechless. For those processes (of speech), of which there are none higher, there must surely be one side which is leading. Both sides of the brain. are educated in speech, and yet the left is the leading side, and the right the involuntary or automatic (Brain 1961, p. 25). Speech is controlled in the dominant hemisphere. Usually, right-handedness implies that the left hemisphere is the dominant hemisphere (Elliott 1971}. However, this rule is not always correct. Shifted sinistrals are people who may innately be left-handed but are trained as children to become right-handed. In left-handed patients, the dominant hemisphere is usually the left (Elliott 1971). Subriana reported a new clinical analysis of handedness. Table 1 shows this report of the population in relation to handedness. Determination of the dominant hemisphere is often important prior to surgical intervention of brain disorders. Handedness is best determined by direct examination and by asking the patient and his relatives which was. the hand preferred for carrying out familiar as well as less common 28 skilled movements (Rossi 1967). However, handedness cannot always accurately pinpoint cerebral dominance. Therefore, other methods were devised.

TABLE 1 CLINICAL ANALYSIS OF HANDEDNESS Handedness Population Pure-absolute right handers.• 1/4 Strong right-handed preference . 2/5 Accentuated mixed preference . 1/4 Left-handed but performed some of test with right hand • • . . . • • . . . 1/10 Pure left-handed • Rare Source: Subriana 1969, p. 269.

If the operation could be done locally, inter­ ruption of counting or naming produced by electrical stimulation of the frontal or parietal regions gives positive evidence that speech is represented in the exposed cerebral hemisphere (Wada and Rasmussen 1958). However, if the operation cannot be done locally or if the current is not an adequate stimulus, this method is useless for determination of cerebral dominance (Wada and Rasmussen 1958). Therefore, Wade and Rasmussen developed a new test. After careful studies with monkeys, twenty humans were studied following injection of Amytol to give preoperative 29 proof of the lateralization of speech functions (Wada and Rasmussen 1958). In seventeen of the twenty cases who subsequently underwent craniotomy and cortical excision, all seventeen gave direct or indirect evidence of the correctness of lateralization of speech as determined by the Amytol test (Wada and Rasmussen 1958). Since speech functions are normally found within the dominant hemisphere, what can be expected following dominant hemispherectomy? Krynow in 1950 related that if brain injury occurs early in life, the minor hemisphere can take over language functions (Gott 1973}. Elliott has described the transfer of language to the non-dominant hemisphere up to the age of fifteen (�lliott 1971; Smith 1966}. However, Perlstein and Sugar report the critical age for speech transfer to the minor hemisphere to be about ten years (Gott 1973). Gott describes a twelve-year-old-girl who underwent dominant hemispherectomy at the age of ten. This child revealed a level of language surpassing that of the four adult left hemispherectomies described in the literature postoperatively. Following left hemispherectomy, the child remained functional in some areas of communication both receptively and expressively. 30

Craniotomy, Brain Tumors, and Aneurysms

Craniotomy A craniotomy is an incision through the cranium. It simply means a piece of the skull is temporarily removed to expose a portion of the brain for operation Trephining was one of the earliest treatments of brain disease. "Archeologists have uncovered trephined skulls in almost all areas of the world" (Cooley 1964, p. 731). In the nineteenth centur� exposing a large portion of the brain for surgical intervention in the treatment of intracranial disease was influenced by a knowledge of anesthesia, antisepsis, and cerebral localization. Frances Durante in 1884 followed closely by w. Wagner in 1889 established the use of an osteoplastic flap (Gurdjian and Webster 1952). Various types of saws, hammers, and chisels were devised to simplify the procedure of the bone removal. In 1907 Hartley and Kenyon introduced a small motor, enclosed in a sterilizable steel metal casing, with appro­ priate burrs and saws to replace the earlier flexible shaft type with remote motor (Gurdjian and Webster 1952). Improvements continue to be made in technique and equipment to insure the patient the best methods available; however, the procedure remains relatively the same. 31 Craniotomies are performed for various reasons. Anytime there is a chance for recovery with surgical removal of brain disease, a cra_niotomy is the procedure of choice. One such intracranial disorder often resulting in a craniotomy is a brain tumor. At one time, brain tumors were thought to be automatically fatal. However, with the development of chemotherapy, moderp surgical and radiological techniques, and newer diagnostic procedures, this view has been revised (Yahr 1973).

Brain Tumors · Paul Broca in 1860 was one of the first to contend that brain tumors could be localized clinically and removed surgically (Baker 1965). MacEwen and Godlee both performed craniotomies in the late 1800's, but their patients expired (Baker 1965). The first patient to.ever survive removal of brain tumor was operated on by Horseley in 1886 (Baker 1965) • · Tumors of the central nervous system are more common than tumors of·the stomach and less common than tumors of the breast (Mullan 1961)� From autopsy records, it has been estimated that between one and two per cent of all deaths are due to intracranial tumors; figures arrived at from national vital statistics are usually lower, possibly because of faulty clinical dianosis and lack of postmortem verification (Elliott 1971, p. 409). 32 Men are more prone to develop brain tumors than females, and some tumors such as medulloblastomas and cranio­ pharyngiomas are found primarily in the male population (Baker 1965). Brain tumors can occur in any age group. Cushing found his highest incidence in patients ranging from forty to fi£ty years of age (Baker 1965). Elliott states that intracranial tumors increase in frequency up to the seventh year, after which the incidence declines until a second rise starts at or about puberty and reaches a maximum in the fifth decade (1971, p. 409). Gilroy and Meyer also think the maximum incidence of brain tumors occurs around the age of forty (Gilroy and Meyer 1969). However, tumors of the central nervous system also show some difference in distribution with age; for instance, cerebral tumors are more common in adult life (Gilroy and Meyer 1969). The location of the brain tumor is very important diagnostically as well as prognostically. "The principle regions of the brain involved by brain tumors are the frontal, parietal, temporal, hypop�yseal, and cerebral areas" (Baker 1965, p. 462). Seventy percent of the brain tumors are supratentorial with frontal lobe location more frequent than the other lobes within the brain. 33

Determination of the location of a brain tumor can be done through careful neurologic examination and special techniques such as arteriogram, pneumoencephalogram, and ventriculogram. The pneumoecephalogram and ventri­ culogram were developed by Dandy, who was a student of Cushing {Baker 1965). If one is aware of the functions of the various parts of the brain, the signs and symptoms found during neurologic examination provide a start in identifying the location of the tumor. The signs and symptoms of an intracranial tumor are due to an increased intracranial pressure or local destruction from the tumor itself. The functions of the various lobes of the brain were outlined in the first portion of this chapter. By knowing these functions and how to recognize their disturbance, the neurosurgeon can begin locating the site of brain disease� There are many types of brain tumors both malignant and benign. There are two main classifications of brain tumors--extracerebral and intracerebral. Extracerebral tumors are outside the brain but press on it, whereas intracerebral tumors come from within the brain and infiltrate it {Mullan 1961). Gliomas, ependymomas, medulloblastomas, and pineolornas are examples of intra­ cerebral tumors, whereas meningiomas, neurinomas, 34 craniopharyngiomas, and pituitary adenomas are types of extracerebral tumors {Mullan 1961). There are many charts available representing the incidence of various types of tumors. Gliomas represent 45 percent of all brain tumors. Next come metatastic tumors followed closely by meningiomas and pituitary adenomas {Yahr 1973). Without surgical treatment most tumors grow in size resulting in increased intracranial pressure and destruction of brain tissue which will ultimately prove fatal (Brain 1956). However, radiation therapy and chemotherapeutic agents also play a role in their treatment (Yahr 1973). Malignant tumors such as medulloblastomas and metastatic lesions are often helped by radiotherapy (Forster 1973). Prognosis and result of treatment depend upon the type and location of the tumor as well as its surgical accessibility (Mullan 1961; Chusid 1973). Brain (1956) reports that mental deterioration and/or aphasia are likely to result from surgical removal of a large brain tumor. Recent development of neurosurgical techniques has greatly increased the range of cerebral surgery and in best hands, immediate mortality of operations for removal of tumor is less than ten per cent {Brain 1956, p. 281}. 35 Aneurysm Cerebral aneurysm is also a condition frequently requiring craniotomy. An aneurysm is a weakening of the wall of an artery; a ballooning out which alters the shape of the arterial wall {Baker 1965). Gull in 1859 wrote "Whenever young persons die with symptoms of ingraviescent apoplexy, and after death large effusion of blood is found, especially if the effusion be over the surface of the brain in the meshes of the pia mater, the presence of an aneurysm is probable" {Sahs et al. 1969, p. 1). Intracranial aneurysms are known to have been described in the late 1700's by Buimi and Morgagni; however, Pierre Diones in 1718 described in detail a Prince and a Duke, both of whom probably died from subarachnoid hemorrhage (Sahs 1969). Depending on the source, distribution relationships between aneurysms and sex can be found. Baker {1965) reports a slightly greater incidence of aneurysms in females. However, according to Elliott (1971) there is no real difference in incidences according to sex. And then again, Netter {1972) states intracranial aneurysms are more frequently found in men. Aneurysms may occur at all ages (Netter 1972). However, more than half cause symptoms during the fourth and fifth decades of life (Brain 1962). Aneurysms are the 36 most common type of avascular catastrophe in persons under the age of forty (Elliott 1971). After examination of the circle of Willis in 1437 brains, Riggs and Rupps found no instance of aneurysm before ten years of age (Baker 1965). Housepean also reported a low incidence in children. Out of 3,000 brain examinations of children under 12 years of age, not a single intracranial aneurysm was found (Baker 19 65) The most common cause of intracranial aneurysm is a congenital abnormality (Brain 1962). Other causes of aneurysm include hypertension, arteriosclerosis, emboli, or infection (Netter 1972). Most aneurysms are found on the main arteries of the circle of Willis, approximately thirty per cent arising from the anterior group (i.e. the anterior cerebral and anterior communicating arteries), thirty per cent directly from the internal carotid artery, usually at the level of the junction with the posterior communicating artery and thirty per cent from the middle cerebral arteries. The remaining ten per cent are situated on the various other intracranial arteries, i.e. vertebral and basilar of their branches, or on the peripheral branches of the cerebral artery (Espir and Rose 1970, p. 88). Figure 2 is a diagram of the circle of Willis, the intra­ cranial arteries,and the location of aneurysms compiled by McDonald and Korb (1939). Treatment of intracranial aneurysm has gone from conservative bedrest with supportive therapy to hypotension 37

------Posterior communicating

2------Posterior cerebral

143 ------Basilar

------Vertebral 34

RIGHT LEFT

Fig. 2. Location of intracranial aneurysms and frequency of sites.

Source: Chusid 1973, p. 2�6. 38 an d hypothermia, to carotid ligations in the neck, and intracranial surgery or craniotomy {Sahs 1969). The choice of surgical treatment as opposed to medical treatment rests upon many circumstances, including the size and location of the aneurysm, the clinical status of the patient, the skill and experience of the surgeon, and the enthusiasm for a particular therapeutic regimen {Chusid 1973, p. 298). In general, intracranial surgery has·,_b�en favored by skillful and experienced neurosurgeons, by confident though inexperienced young surgeons, and by surgically minded neurologists who have been stung by the deaths of some of their patients from rebleeding during the course of ·an apparently smooth non-surgical recovery {Sahs 1969, p. 245). Various surgical procedures including trapping, clipping, packing, and plastic spraying have been successfully performed {Chusid 1973). Chusid {1973) designates intracranial aneurysm as a serious pathologic entity due to its high mortality rate. Aneurysms of the brain are often associated with spontaneous subarachnoid bleeds and a high probability of recurrence of subarachnoid hemorrhage {Chusid 1973). Statistics from various sources differ, but one may adopt the following as a convenient approximation to the average: of one hundred patients admitted, fifteen die within twenty-four hours. In the next week, another fifteen will die of the- initial hemorrhage or from a repeated hemorrhage. In the next two·weeks, another fifteen will die, usually from one of the subsequent hemorrhages. Of those who survive, probably ten will die later from a late occurrence of the hemorrhage. Of the surviving forty-five patients, fifteen will have severe,. residual neurologic disability, e.g., dysphasia, 39 hemiplegia, mental deterioration or severe seizures, which will prevent their earning a livelihood1 fifteen will have some after effect� such as diplopia, occasional headache, slight residual hemiparesis, or occasional seizure, and they can earn their own living. Fifteen will be entirely normal (Mullan 1961, p. 207). However, prognosis improves if aneurysms are not arterio­ graphically demonstrable, if patients are less than forty years of age with normal blood pressure, and if patients are not in coma (Mullan 1961).

Aphasia A disturbance of language resulting from damage to the brain is aphasia. It can be defined as the loss of ability to formulate, express, or understand the meaning of spoken words1 the inability to understand written words, gestures, sounds, or music (Espir and Rose 1970). Even though aphasia is literally defined as complete loss of speech and dysphasia as a partial loss, the terms are frequently used synonymously (Walton 1971; Espir and Rose 1970). Aphasia is a disturbance in language function which affects all four major language modalities: comprehension, speech, reading, and writing (Baker 1958). Probably the earliest case of aphasia ever recorded is in the first chapter of the Gospel according to St. Luke, where Zacharias was struck dumb but could still write, and the next in Roman times, when about A.D. 30 Valerius Maximum described a learned man of Athens who lost his memory for letters after being struck by a stone (Espir and Rose 1870, p. 30). 40 Ancient Egyptians reported cases of loss of speech between 3000 and 2500 B.C. and believed this loss of speech resulted from "something entering from outside," like "the breath of an outside god or death;" and that described the patient as· 11 silent in sadness" (Jenkins et al. 1975, p. 3}. Even though Paul Broca is often considered- as one of the first to localize speech in the brain, there were less noted predecessors to him.. Early in the nineteenth century, Franz Joseph Gall, a leading neuroanatomist in his time, explored the brain and localized language in the anterior lobes since he believed the development of the orbital areas produced the predominant appearance of the eyes he observed in students who excelled in oral recitation (Jenkins et al. 1975}. · In 1861 Paul Broca concluded that "the integration of the third frontal gyrus appears to be indispensable for the use of the faculty of articulated speech" (Lhermitte and Gautier 1969, p. 84). The term he designated for this loss of speech was "aphemie." In 1865 a paper written by Dr. Mark Dax was published; it implied that speech centers might be localized in the left hemisphere (Espir and Rose 1970). Carl Wernicke was one of the first to describe sensory aphasia (Meyer· 1974). In 1874 Wernicke located a 41 center for auditory images in the first temporal gyrus (Vinken-Bruyn 1969). Wernicke felt destruction of this area could abolish sound images and result in lack of understanding of spoken works through impaired function of the cerebral auditory center (Chusid 1973). He outlined three types of aphasia (1) sensory--his defined area, (2) motor--Broca's area, and (3) total aphasia--a loss of function of both of the above areas (Brain 1962). There have been numerous scientists throughout the years studying aphasia. These include Jackson, Head, Marie, Pick, Goldstein, and others. Each has played important roles in the development of the understanding of aphasia and has assisted in developing the disease as an entity of its own. In 1861 Trousseau applied the term aphasia for loss of speech due to a brain disorder and not to paralysis of the muscles concerned with speech or mental deficiency (Nielson 1936). This term replaced Broca's "aphernie" and is now universally accepted (Nielson 1936). Aphasia is rarely found in children and increases in frequency with age (Brown 1962). Pathologic conditions which commonly cause aphasia are cerebral vascular disorders, intracranial tumors, cerebral abcesses,and brain injuries (Espir and Rose 1970). "Cerebral hemorrhage causes aphasia less often than thrombrosis because it occurs in the deep white matter of hemisphere more than in the cortex of subcortical 42 regions" (Brain 1962, p. 90). Intracranial tumors are the most common cause of aphasia found during the first half of adult life (Brain 1962). In general, aphasia is divided into two types-­ motor and sensory. These are also interchangeable with expressive and receptive aphasia. Motor or expressive aphasia is generally the result of lesions in the neighbor­ hood outlined by Broca (Walton 1971). In its severest form the patient loses the power to speak completely or may say little more than yes or no. He nevertheless understands fully the spoken word, and will readily obey commands. When expressive aphasia is less severe, the patient uses far fewer words than his normal vocabulary would allow and these are utilized hesitantly and sometimes repetitively (perseveration) with slurring and long pauses, but nevertheless the words which are used are appropriate to the thoughts being expressed. So called nominal amnestic aphasia is regarded by some as the least severe form of expressive aphasia; in this condition the patient is unable to identify people or objects by their proper names though he is well aware of their nature and significance (Walton 1971, p. 87). Expressive aphasia may result in telegram mutism (speaking in telegram-style leaving out propositions and conjunctions) , grammatical errors with confusion of articles and conjunctions, cortical or apraxic dysarthria (disorders of word formation resulting in faulty pronunciation), perseveration,and paraphasias (disorders of sentence formation) (Espir and Rose 1970). One type of expressive 43 aphasia which is characterized by a loss of spontaneous speech and writing with the inability to read aloud even though the patient is able to repeat words or phrases and write by copying is called pure word dumbness (Espir and Rose 1970). Lesions in or around Wernicke's area produce sensory or receptive aphasia (Walton 1971). It is distinguished by difficulty in the understanding and expression of speech (Elliot 1971). Essentially, it is the inability to appreciate the significance of words, whether spoken or written, as symbols (Walton 1971). A complete failure to comprehend the meaning of words heard or seen may produce various types of receptive aphasia. These may include amusia (loss of appreciation of musical sounds), echolalia (repetition of a meaningless phrase), agraphia (inability to write), alexia (inability to understand the written word), and acalculia (inability to calculate) (Walton 1971). Since the patient has words at his command and his speech is fluent, he may speak inappropriately and unintelligibly. This is called jargon aphasia and in mild forms can be easily overlooked (Walton 1971). There are numerous classifications of aphasia. Wernicke's and Broca's classifications have already been discussed. They have been considered the method of 44 classification of aphasia in general. "Henry Head conceived aphasia as an impairment of the power to formulate and use symbols" (Chusid 1973, p. 207). His four types of aphasia are still used today. These include (1) verbal aphasia which is seen as a defect in the ability . to form words, (2) syntactic aphasia or a disturbance between the balance and rhythm of words or phrases spoken in sequence, (3) nominal aphasia characterized by impairment of the ability to name objects and understand the nominal meaning of words, and (4) semantic aphasia which is the inability to appreciate the metaphorical significance or coloration of words and phrases apart from their immediate meaning (Chusid 1973). Head felt that varying defects of all forms of speech exist in every case, though one form usually predominates (Gatz 1972}. Another type or classification is conduction aphasia. This type of aphasia is originally traced to Wernicke and is characterized by fluency and paraphrasia in spontaneous speech with normal or nearly normal comprehension of spoken language, but markedly impaired repetition of words and phrases, usually with difficulty in naming (Benson et al. 1973, p. 339). Boston Veteran's Administration Hospital reports 5 to 10 percent of all new aphasic admissions to be of this type and have a good prognosis (Benson 1973). Central aphasia 45 and repetition aphasia are terms sometimes used synonymously with this condition (Benson 1973). Fluency, normal comprehension, and repetition are the required criteria for diagnosis of conduction aphasia. Benson et al. examined three postmortem subjects who had been diagnosed as conduction aphasia. From their findings and a review of the literature they proposed: Conduction aphasia is a distinct clinical syndrome, readily separable from other varieties of aphasia. Conduction aphasia can result from a pure suprasylvian or a pure subrasylvian lesion as well as from a combination of the two. The presence of ideornotor apraxia in conduction aphasia implicates suprasylvian pathology (Benson et al. 1973, p. 339). Baker (1965) deems the treatment of aphasia has run a second to its clinical research. No one knows how long language recovery may take or if it will occur at all. Speech therapy is the patient's chance to recover optimum levels of communication. In helping patients recover their language abilities, start with the patient's skills he possesses and work out radially (Baker 1965). It is important for the speech therapist, nurse, and physician to know where the patient's communication level is and work toward the same goal at the same pace. The prognosis for the aphasic is largely dependent upon the cause (Brain 1962). Prognosis improves whenever the patient is young with a family who accepts the condition 46 or if there is left-handedness in the family, and if the aphasia simulates slips of speech. A poorer prognosis occurs with more extensive deficits, longer persisting aphasia, poor auditory decoding mechanisms, or when both aphasia and dysarthria are present as well as with passive paraphasic patients with unrealistic goals or aspirations (Simonson 1973).

Nursing Implications Nursing plays an important role both physically and mentally in the management of the aphasic patient. A well-prepared nurse is one who knows the physiology behind the disease and knows how to manage the patient most effectively. With the information available such as that in the first portion of this chapter, the nurse has sufficient information pertaining to the entity on which to base her care. It is the nurse who has more contact with aphasic patients than any one other health worker. She is often the first person the patient sees when he realizes his disability. Because of all this, it is of utmost importance physiologically and psychologically, that the nurse understand the condition and know how to react to it appropriately. This close relationship between the nurse and the patient 47 can provide the necessary atmosphere to allow the type of meaningful interaction which may direct the patient toward language recovery (Twamley and Emerick 1973). The attitudes of nurses as well as physicians and families can be the difference between acceptance or rejection of the communi­ cation deficit incurred (Twamley and Emerick 1973). The communication between the nurse and patient can only be successful if the nurse is able to recognize the patient's disability and be willing to use his means of communication (Carter and Cornell. 1974). An initial nursing assessment of the patient's communication abilities both receptive and expressive is the basis for which she supports her plan of care. This assessment should determine if there is language impairment, if reading and writing are decreased, and if the patient has control over tongue and lip movement, breathing, and blowing (Twamley and Emerick 1973). Once the degree of communication ability is established, the nurse must devise ways to use the patient's abilities and initiate communication approaches as early as possible (Carter and Cornell 1974). Nurses can communicate with patients suffering from receptive difficulties in various ways. Stand close to the patient to see that you have his attention; speak at a slightly slower rate but in 48 a normal tone (Carter and Cornell 1974). Do not shout or raise your voice. "Shouting is likely to decrease attentiveness� or stir up negative feelings about himself and those around him" (Buck 1968, p. 123). Use short simple sentences; if the patient appears confused, simply rephrase and. slowly repeat the directions (Carter and ,_. Cornell 197 4) • · Non-verbal communication can also be an effective means of communicating with receptively aphasic patients; at times, it is the only means of communication available. Sometimes, words to the aphasic are like gray stones, empty shells of thought�and gestures often assist the aphasic to grasp the meanings better (Simonson 1971). Popelka and Berger (1971) found that gestures operate in two ways: (1) to delimit individual word choices within the message or (2) to lead to the expectation of a group of words in a specific order. Use appropriate gestures with a single word or short phrase so that the patient may be able to associate words with the desired action (Carter and Cornell 1974). Patients suffering from expressive aphasia often depend on gestures to communicate their needs. It is important that the nurse understand the message of the patient (Carter and Cornell 1974). Have frequently used objects available at the bedside for easy identification by 49 the patient. Commercial sets of pictures contain objects in them that most people have rarely verbalized; therefore, use real objects and common ones (Buck 1968). "Sensitivity, patience, and perserverance are the qualities needed by the nurse who attempts to understand the communication of a patient" (Carter and Cornell 1974, p. 87). No matter how frustrating, be a-calm but active listener. The patient who has difficulty with verbal expression will be waiting for the reaction of others to his attempts to communicate. A simple nod of the head combined with a facial expression of pleasure will let him know you heard. His thoughts will then be more coherent and less apt to be interrupted, and he may be more able to finish his sentences than if you show undue surprise or enthusiasm (Buck 1968, p. 122). A major point for the nurse caring for the aphasic patient to remember is to treat the patient as an adult. This adult has been enjoying years of conversing, now he must face an illness where he must accept a loss of some or all of his innate communication skills (Simonson 1971). The patient is seldom the voluntary object of illness; he must learn to deal with this change in his learned picture of himself (Hofling 1967). Because a patient has difficulty expressing himself, one must remember that his comprehension may be normal. Therefore, when conversations take place around him, assume he can understand what is being said (Carter and Cornell 1974). 50 Acceptance of the patient as he presents himself occurs only after we have some understanding of how he experiences his illness, his disability, and how he communicates these changes to others (Ullman 1964, p. 91). Communication with the aphasic can be very frustrating to the nurse as well as to the patient. However, it is imperative to give the aphasic patient the opportunity to communicate (Fox 1971). The nurse should be able to carry on conversation even if there is no response from the patient (Carter and Cornell 1974; Fox 1971). A conversation with nonspeaking patients providesthe patient with a feeling of worth and tells him she cares about him and his problem (Grey 1970). A quiet climate with scheduled rest periods enhances the patient's ability to communicate. Since aphasics have low frustration levels, an increase in visual or auditory stimuli tends to distract him (Wepman 1951). The aphasic patient must work very hard to regain his language functions. When the patient succeeds in a task do not hesitate to show pleasure at his success (Carter and Cornell 1974). The smallest amount of progress is vitally important to the patient (Belt 1974). Positive reinforcement of successful attempts can be very rewarding to him. The nurse must remember family involvement in her plan for the aphasic patient. Fear, anger, confusion, and depression are often emotions felt by family members of 51 aphasic patients (Grey 1970). · It is not uncommon to see families running from doctor to doctor hoping to find a quick cure (Boone 1965). It is up to the nurse to educate the family about the disease including its types, causes, and prognosis. Various pamphlets are available to assist in this endeavor. There are many factors important to remember in working with the aphasic patient. Be sure the subject discussed is familiar and personal to the patient. Do not provide stimulus which is too long or too loud. Any visual clues to accompany words will assist the patient in decoding the message. Allow the patient to see the speaker and be sure only one person is talking. In summary, conversations which are short with pauses for comprehension and not confusing will encourage understanding by the aphasic patient (Simonson 1973). The role of the nurse is very important in the recovery of language for the aphasic patient. Her close contact with the patient, accurate recording of language functions, and establishment of good, rapport with the speech therapist and understanding of his goals for the patient can be influential in the success or failure of the recovery of optimum communication for the aphasic patient (Carter and Cornell 1974; Twamley and Emerick 1973). 52 Through the nurse's awareness of a patient's frustrations and fears, through her ability to informally appraise a patient's communication problems, and through her proficiency in communicating on different levels and in different ways, the nurse will help to fulfill a funda­ mental need--the need to communicate with others (Carter and Cornell 1974, p. 89).

Summary This chapter has contained a review of literature pertaining to craniotomies performed for disorders such as brain tumors and aneurysms and their relationship to oral communication abilities. Basic anatomy and physiology of the brain and speech centers have been presented. Very little information was found on the direct relationship between craniotomies and communication. However, the material outlined should provide the reader an overview of the material available. CHAPTER III

PROCEDURE FOR COLLECTION AND TREATMENT OF DATA

"Aphasic disturbances constitute an important aspect of clinical neurology and can be expected to increase with the increasing age of the population" (Schuell 1957, p. 625). Thus far, this paper has shown significance for the study of aphasia resulting from craniotomy. It is an entity important for all nurses to recognize and understand. This chapter outlines the type of study, the population, the setting, the procedure and instrument utilized# and the method of treatment in the analysis of the data.

Type of Study This research was a descriptive, nonexperimental study. Abdellah and Levine describe a descriptive study as one which describes various phenomena and can be quantitatively interpreted with statistical tabulations (1965). Nonexperimental research is observation without controlled conditions--"nature left alone" (Abdellah and Levine 1965, p. 45).

53 54 Setting This study was conducted in Dallas, Texas,between March 1975 and February 1976. In the beginning, two private hospitals with bed capacities over 300 were selected. During the first five months of data collection, only five subjects were admitted to the study. Therefore, due to an inadequate number of clients available, three more hospitals were chosen for data collection in August 1975. They also had bed capacities over 300. Two were private-status hospitals while the third was a city-county-status hospital. Prior to any data collection, written permission (see Appendix C and D) was obtained from all five hospital administrations as well as from the physicians of those patients who were to be included in the sample. These permissions were obtained prior to the initial interview of each patient.

Population The subjects came from a convenience sampling of the craniotomy patients admitted to the five hospitals selected. Convenience sampling infers a sample constructed of persons available at the time needed (Abdellah and Levine 1965). This method of sampling is popular because it is cheaper and very convenient to employ (Abdellah and Levine 1965). The study sample consisted of the first twenty 55 patients who were scheduled to undergo a craniotomy and who were able to be interviewed before as well as after the surgical procedure. The patients selected were English­ speaking, eighteen years of age or older, had sufficient capabilities to understand the interview questions at the time of admission to the hospital, and were scheduled to have a craniotomy for brain tumor or aneurysm.

Development of Instrument Since there was no tool available to measure oral communication abilities alone, an interview with specific guide questions was developed. A more structured interview was developed since it provided greater ease to process the data and did not require the interviewer to be highly skilled in interviewing techniques (Abdellah and Levine 1965). Since this research was to determine the change in oral communication abilities following a craniotomy, a simple interview with the purpose to have the patient speak freely and normally was developed. The interview with specific guide questions (see Appendix E) was divided into two parts: assessment type questions and an oral reading. These interview questions were basically nursing assessment type questions dealing. with allergies, medications, diet, and sleep patterns. The questions were developed to check both receptive and 56 expressive language. Questions which produce automatic answers such as name, address, or birthday were specifically omitted. This type of automatic speech may often be seen in the presence of aphasia. The questions were devised to provide the patient with the proper stimulus to converse. Also included with the interview questions were demographic data such as handedness,·,·sex, age, and location of the brain disorder as well as the cerebral hemisphere involved. This information was recorded and was useful in determining associations between oral communi­ cation abilities and several variables other than the primary variables being studied. The oral reading was a short paragraph containing many of the consonants and consonant blends. This reading · was particularly useful in showing fluency and articulation abilities of the clients. The interview questions and the oral reading were identical for both the preoperative and the postoperative·sessions with the patients. A set of prepared criteria used. in the evaluation of the patient's communication abilities was also needed. The Boston Diagnostic Aphasia Examination has a standard aphasia sever�ty rating scale (see Appendix F). This was found acceptable and, therefore, used in the evaluation of the data collected. However, this method of rating provided 57 only a subjective measure for change in oral communication abilities. Since the researcher had no expertise in such a qualitative analysis of cornrn-nication, a competent speech therapist in the Dallas�Fort Worth area evaluated the data. She compared the preoperative and postoperative tapes for possible changes in the oral communication abilities of the participants. These possible changes included loss of grammar order, word searching, paraphasis, need for repetition, fluency, articulation, clarity, length of time between questions and answers (latency period), or full sentencing versus telegraphic speech.

Validation of Tool Validity is defined as criterion for evaluating the quality of data--data is valid if they actually measure what they are supposed to measure (Abdellah and Levine 1965}. Even though a speech therapist was consulted during the formation of the interview questions and oral reading, the tool had not bee� standardized. Therefore, validation was necessary. A panel 0£ judges with expertise in the field of speech pathology was chosen. The following persons served on the panel with qualification of: 1. A doctor in speech pathology working at Southern Methodist University Speech and Hearing Clinic, Dallas, Texas 58 2 •. A doctor in speech pathology also working at Southern Methods University Speech and Hearing Clinic, Dallas, Texas 3. A doctor in speech pathology working at Callier's Speech and Hearing Center, Dallas, Texas After obtaining their consent by telephone, a letter of explanation (see Appendix G) with __ a copy of the interview questions, oral reading, and criteria for evaluation of the data was mailed to each panel member. They were asked to make any comments or suggestions on the materials. All three had validated the questions, reading, and evaluation criteria by March 10, 1975. Only minor suggestions were offered by any one of them. Examples of the suggestions offered included incorporating less yes/no questions, rephrasing of some questions, and making minor word changes. All of these changes were made prior to the data collection.

- Method of Data Collection The method used for the collection of data was the interview. This approach allows the observer to gather data by verbal questioning of the study subjects to elicit data on the variables being studied (Abdellah and Levine 1965). The participants were all hospital patients with brain disorders such as tumors, aneurysms, and trauma. Each 59 client used in the research study was interviewed both preoperatively and postoperatively. Various ways were utilized to locate subjects. These included numerous phone calls to the neurosurgical units of the selected hospitals and neurosurgeons' offices as well as daily checking of the operating room schedules of each of the selected hospitals. Patient permission, awareness of the oncoming surgery, and ability to communicate were all considered as essential criteria for each patient prior to the initial interview. Anonymity was assured to each participant of the study when their permission was obtained. Since the information was an interview and was to be evaluated by someone else, the sessions were taped. The need for taping was explained to the patient prior to the initial interview. All interviews took place in the patient's room and when possible with no other persons present. Travis outlines general rules necessary to follow during the examination of aphasics. These included:

1. Examination of the patientI alone, in a room free of all abstracting sights and sounds 2. Recording not only what the patient says or does, but also every remark or question of the examiner 60

3. Avoiding all causes of fatigue or emotional strain 4. Recording the rate as well as the nature of response (Travis 1931) The initial interview took place one to two days before surgery. The postoperative interview was recorded between the seventh and tenth day after surgery. Due to variations in patient's postoperative abilities and progression, this provided a better chance to interview each patient at basically the same postoperative level. Performance of aphasic patients fluctuates with transient physiological states during the first few days and sometimes the first few weeks after brain damage is incurred (Jenkins et al.1975, p. 127). Several factors were considered necessary prior to the collection of the postoperative data of each patient. An appropriate level of consciousness was essential to provide the patient with the ability to converse normally to prevent masking of symptoms; the interview was postponed unless pain or sleep medication had not been given three to four hours prior to the interview.

Analysis of Data Once the responses of the sample were collected and evalu�ted, the data were treated in various ways. Language testing is very difficult to quantitate since no one person 61 answers the same question the same way twice. Because of this, the results of the interview questions and oral read1ngs were not quantitatively described. But instead, a grading scale from zero to six or from no deficit to severe deficit was used to grade the preoperative and postoperative tapes. From this, percentages were found on the number of patients who had a change in their communication abilities. Therefore, a qualitative analysis was performed from the interviews. The Wilcoxon matched-pairs signed-rank test was used to analyze the differences found between the preoper­ ative and postoperative interviews. It utilizes information concerning the relative magnitude as well as the direction of differences within pairs (Siegel 1956). It can be used in small samples such as this research. In general the Wilcoxon matched-pairs signed-rank test finds the differ­ ences between each pair of scores, ranks them according to sign and direction of change, and determines a level of significance for rejection or acceptance of the hypothesis (Siegel 19 56) • The Fisher exact probability test was used to show if there were relationships found between oral communication abilities and several other variables. Some of these variables observed for their association with communication 62 ability were cerebral hemisphere involvement, hand preference, location of craniotomy, sex, and age. The analysis of all the data was shown by various methods. Tables, histograms, and bar charts depicted. I the results of the research study.

Summary I This chapter contained the procedures utilized I in the collection and treatment of the data for this research study. An interview with specific guide questions 'Ji I and an oral reading were developed to measure oral communi­ i cation abilities following a craniotomy. The Boston I Diagnostic Aphasia Examination used by a competent speech I therapist was determined effective in evaluating the collected data. A panel of judges validated both the interview questions and criteria established. The data were collected by interviews both preoperatively and postoperatively of patients undergoing craniotomy. The analysis of data was .. made by comparisons, percentage tables, and the use of the Wilcoxon matched-pairs signed-rank test and the Fisher exact probability test.

------CHAPTER IV

ANALYSIS AND INTERPRETATION OF DATA

This descriptive study investigated the effects of a craniotomy upon oral communication abilities. An attempt was made to determine whether or not a significant differ­ ence could be found between oral communication skills of craniotomy patients preoperatively and postoperatively. The data were also examined to determine if left-sided craniotomies- produced more deficiencies in oral communication than right-sided craniotomies. Certain demographic data such as sex, age, handedness, and craniotomy site were investigated to determine their relationships to oral communication abilities. Interviews with specific guide questions were done before and after a craniotomy was performed for tumor or aneurysm. The interviews were evaluated.by a speech therapist who assigned them a pre- and postcommunication score. The scoring came from the Boston Diagnostic Aphasia Examination, which has a standard aphasia severity rating scale. The interview questions and criteria for scoring were found to be valid by a panel of judges with an expertise in speech pathology. The Wilcoxon matched-pairs

63 64 signed-rank test and Fisher's exact probability test were utilized in the analysis and interpretation of the data.

Descripti6n of Sample Population The sample population was composed of twenty patients undergoing craniotomy for either a brain tumor or aneurysm. The sample consisted of both male and female patients ranging in age from nineteen to seventy-three years. All lived in the Dallas-Fort Worth metropolitan area. The sample size was small due to difficulty in obtaining subjects in the time allotted; however, the sample was fairly evenly distributed in the areas of sex, age, and cerebral hemisphere involvement. All of the clients were right-handed. The site of the brain disorder was less evenly distributed with the frontal lobe craniotomies outnumbering all other sites. A chart containing the pre- and postcommunication scores as well as the demographic data of each client can be found in Appendix H. As stated, there was a balanced distribution of subjects according to sex with half being male and half female. The distribution by age ranged from nineteen to seventy-three years with a mean age of 45.1 years. The majority ranged between twenty-one and seventy years of 65 age with only one younger than twenty-one years and one older than seventy years. Thirty-five percent of the patients were in their fifth decade of life. Another factor compared in the personal data of each client was their handedness. All twenty of the subjects were right-handed. This was not considered to be unusual since the majority of persons are dextrals and the sample size being small reflected this trend. A summary of the craniotomy sites found in the sample population is shown in Table 2.

TABLE 2 FREQUENCY OF CRANIOTOMY SITES

Site Number Percent

Parietal 3 15 Temporal. 2 10 Occipital 2 10 Frontal 10 50 Posterior Fossa 3 15 Total 20 100

One-half of the patients interviewed underwent frontal lobe craniotomies. The other 50 percent were distributed fairly even with three parietal and posterior fossa craniotomies and two temporal and occipital craniotomies each. 66 The frequency of cerebral hemisphere involvement is found in Table 3. Only seventeen of the twenty patients were categorized in this table since the three posterior fossa craniotomies were not located in either the right or left cerebral hemisphere.

TABLE 3 FREQUENCY OF CEREBRAL HEMISPHERE INVOLVEMENT

Cerebral Hemisphere Number Percent

Right 8 47 Left 8 47 Both 1 6

Total 17 100

Other than one patient being a bilateral craniotomy, an even distribution was found between right and left cerebral hemisphere involvement. This was particularly helpful since one of the hypotheses tested was to determine differences in communication skills following left- and right-sided craniotomies. A summary of the frequency of communication scores of the sample population preoperatively and post­ operatively is presented in Figure 3. 67

24

22

20 18

16 t:/) Preoperative Postoperative 14 ·n ent

.µ 12 Pa Pa � 0 10

8

z umber 6

4

2

0

0 1 2 3 4 5 6 0 1 2 3 4 5 6 Test Scores

Fig. 3. Frequency of Communication Scores Scale: 0--no usable speech 1--fragmentary expression 2--conversation about familiar subjects with help; frequent failure to convey ideas 3--reduction of some speech or comprehension 4--obvious loss of fluency in speech or facility in comprehension without significant limitation of expression 5--minimal discernible speech handicaps 6--normal speech--no handicap 68 Eighty-five percent or seventeen of the clients had normal scores preoperatively compared to only thirteen or 65 percent of the clients with normal scores post­ operatively. While none of the clients had scores lower than two preoperatively, 20 percent had scores lower than two postoperatively. Of a possible score of 6.0, the mean preoperative score was 5.65; whereas the mean postoperative score was 4.4

Presentation and Discussion of Findings This research study led to the consideration of two hypotheses. First, the effect of craniotomy for either brain tumor or aneurysm on oral communication ability was determined. Secondly, the researcher hypothesized that a left-sided craniotomy would produce more problems in oral communication abilities than a right-sided craniotomy. These two hypotheses were tested using the Wilcoxon matched-pairs signed-rank test and the Fisher exact probability test. If precomrnunication scores are compared to post­ communication scores, there are seven differences in scores found in the twenty patients interviewed. In other words, only 35 percent of the patients studied showed a change in their oral communication abilities after craniotomy. All seven of these score changes were in a negative or worsening 69 direction.. According to the Wilcoxon test, only the seven changes are considered in the analysis. Even so, the change was found to be significant at the .01 level of significance using a one-sided test of the hypothesis. Therefore, the hypothesis that oral communication abilities are decreased following craniotomy for removal of brain tumor or aneurysm was accepted. The percentage differences found between the pre­ communication and postcornmunication scores of the clients studied are found in Figure 4. This figure shows that in 65 percent of the cases no changes were present. However, in the 35 percent of the cases where changes did occur, a fairly balanced distribution of differences in scores between one and six was found. For the subjects who showed a decrease in communication abilities, the mean difference between precommunication and postcommunication scores was 3.5. To determine the relationship between certain demographic data and oral communication abilities as well as to test the second hypothesis that left-sided craniotomies cause more difficulties in oral communication skills than right-sided craniotomies, the Fisher exact probability test was utilized� This test is particularly useful in small samples in which scores from two independent samples all 70

1 Number 1 of Patients 1

8

6

4

2

0 5 6 0 1 2 3 4 Test Scores

Fig. 4. Changes in Communication Scores Scale: 0--no usable speech 1--fragrnentary expression 2--conversation about familiar subjects with help; frequent failure to convey ideas 3--reduction of some speech or comprehension 4--obvious loss of fluency in speech or facility in comprehension without significant limitation of expression 5--minimal discernible speech handicaps 6--normal speech--no handicap 71 fall into one or the other of two mutually exclusive classes (Siegel 1956). "The test determines whether the two groups differ in the proportion with which they fall into the two classifications" (Siegel 1956, p. 97). The level of significance utilized for these tests was .05. The relationships found between the cerebral hemisphere involved and changes in oral communication ability are summarized in Table 4.

TABLE 4 RELATIONSHIP BETWEEN CEREBRAL HEMISPHERE AND ORAL COMMUNICATION

Cerebral Hemisphere No Change Negative Change Total Right 7 1 8 Left 3 5 8 Total 10 6 16

p = .06

The three posterior fossa and the one bilateral craniotomies were eliminated in this analysis. Even so, there was a probability level of .06 found with the data analyzed. This showed a definite trend toward the hypothesis that left­ sided craniotomies produce more difficulties in the area of oral communication than right-sided craniotomies. Of the eight right-sided craniotomies, only one produced lower 72 speech scores postoperatively. This was only 12.5 percent of the right-sided craniotomies compared to 62.5 percent or five of the left-sided craniotomies who presented with lower scores postoperatively. The probability of .05 was considered to be of borderline significance, but could conceivably become significant with a larger sample size. However, since the level of significance was set at .05, the hypothesis that left-sided craniotomies produce more difficulties with oral communication abilities than right­ sided craniotomies could not be accepted. A summary of the relationship found between sex and oral communication ability following craniotomy is exhibited in Table 5.

TABLE 5 RELATIONSHIP BETWEEN SEX AND ORAL COMMUNICATION

Sex No Change Negative Change Total

Male 5 5 10 Female 8 2 10 Total 13 7 20

p = .175 73 The table shows a probability level of .175, which is not significant at the .OS level of significance. However, this variable would be worth investigating on a larger sample since there were 50 percent of the males studied who showed a decrease in oral communication skills compared to only 20 percent of the female population demonstrating such a decrease in postcommunication scores. The trend for more negative changes found in males was also reported in a 1964 study by Howard Landsnell. He found a decrease in the ability to identify popular word associations in the male patients who underwent subcortical surgery on the left side (Landsnell 1973, p. 256). The relationship found between the site of craniotomy and oral communication ability is revealed in Table 6. In order to fit the variables within the Fisher test, the frontal lobe was paired with the parietal lobe and temporal lobe was likewise paired with the occipital lobe craniotomies. The posterior fossa craniotomies were eliminated when treating this data. This table had an associated probability of .441, whi�h was not significant at the .05 level of significance. No relationships could be found between the site of craniotomy and decreas e in oral communication skills. 74 TABLE 6 RELATIONSHIP BETWEEN SITE AND ORAL COMMUNICATION

Craniotomy Site No Change Negative Change Total

Frontal-Parietal 7 6 13 Temporal-Occipital 3 1 4 Posterior Fossa 3 0 3

Total 13 7 20

p = .441

A summary of the relationship between age and oral communication skills postoperatively is shown in Table 7.

TABLE 7 RELATIONSHIP BETWEEN AGE AND ORAL COMMUNICATION

Age No Change Negative Change Total

Below 50 6 4 10 Above 50 7 3 10 Total 13 7 20

p = .50

Since there was a wide range in ages, the division over 50 and under 50 was arbitrarily chosen as the age groups to be compared. A probability of .50 was found. Again, this 75 was not significant at the .05 level of significance. Therefore, no relationship was found between age and oral communication skills following craniotomy.

Summary In summary, the Wilcoxon matched-pairs signed-rank test and the Fisher exact probability test were utilized to determine the effect of craniotomies on oral communi­ cation abilities. Pre- and postcommunication scores were compared to determine if communication abilities were decreased in patients undergoing craniotomy for removal of brain tumors or aneurysms. This hypothesis was accepted at the .01 level of significance. However, even though a strong trend was found for left-sided craniotomies to produce more difficulties in oral communication abilities than right-sided craniotomies after surgery, the hypothesis could not be accepted. With the Fisher exact probability test using a .05 level of significance, a probability of .06 was found. Age, craniotomy site, and handedness were not significantly related to oral communication abilities. However, even though sex was not statistically significant, a trend was found in males producing more changes in oral communication skills than females and could prove signifiant in a larger sample study. CHAPTER V

SUMMARY, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS

Summary The purposes of this study were two-fold: (1) to identify the extent of loss of oral communication abilities in patients following craniotomy for removal of tumor or aneurysm, and (2) to determine whether or not craniotomies of the left cerebral hemisphere cause more problems in oral communication skills than those of the right cerebral hemisphere. Also, an attempt was made to determine if a correlation existed between postoperative oral communication abilities and age, sex, handedness, and site of lesion. Five hospitals in the greater Dallas metropolitan area were utilized in the data collection. Twenty patients were chosen through a convenience sampling for the study. All of these patients were undergoing a craniotomy due to brain tumor or aneurysm. They ranged in age from nineteen to seventy-three years. A descriptive nonexperimental research design with a one-group before-after testing technique was employed. The data collection was performed through taped interviews of

76 77 each patient before and after craniotomy. Since no standard instrument was available, an interview with specific guide questions was developed by the researcher. This interview consisted of sixteen questions designed to allow the patient to converse normally. Questions which produced automatic answers were specifically omitted. A standardized. oral reading was included in the interview to show the fluency and articulation of the subjects. A set of criteria to evaluate the change in oral communication skills following craniotomy was also needed. The Boston Diagnostic Aphasia Examination aphasia severity rating scale was utilized to score the preoperative and postoperative tapes. The interview questions, oral reading, and scoring criteria were all validated by a panel of judges. These judges were all speech therapists in the Dallas-Fort Worth area and had expertise in the field of speech pathology. Once agency, physician, and patient permissions were obtained, data collection began. Each patient was inter­ viewed one or two days prior to their craniotomy. Seven to ten days postoperatively, the patients were again inter­ viewed with the same questions and oral reading. The preoperative and postoperative tapes were evaluated by a speech therapist who assigned the scores. The scores were 78 graded on a scale which ranged from zero to six or from no deficit to severe deficit. The Wilcoxon matched-pairs signed-rank test was utilized to determine if a correlation between oral communication abilities and craniotomy performed for brain tumor or aneurysm existed. A statistically significant alteration in postoperative communication scores was found. The results of the analysis of the data showed seven patients who reflected a change in their oral communication scores postoperatively. All seven of these patients showed a decrease in their oral communication abilities following craniotomy. Therefore, the hypothesis that there is a decrease of oral communication abilities in patients under­ going a craniotomy for tumor or aneurysm was accepted at the 0.01 level of significance. The Fisher exact probability test was used to determine whether left-sided craniotomies produced more changes in oral communication skills than right-sided craniotornies. A definite trend was defined for craniotomies of the left cerebral hemisphere to cause more decreases in oral communication abilities than craniotomies of the right cerebral hemisphere. The probability of .06 was considered to be a borderline significance. Even so, the hypothesis that left-sided craniotomies produce more difficulties than 79 than right-sided craniotomies could not be accepted at the .05 level of significance. The association between oral communication abilities and age, sex, handedness, or site of lesion was also determined by the Fisher exact probability test. There were no significant correlations found with any of these variables. However, there was a trend established between sex and oral communication skills following craniotomy. There were more changes in communication abilities in the male participants of the study than in the female participants. Even though the probability of .175 was not accepted at the .05 level of significance, the findings could change on a larger sample study.

Conclusions The findings of this study have ·resulted in various conclusions concerned with the effect of craniotomy on oral communication abilities. From the analysis of the data, the conclusion is drawn that there is a decrease in communication skills following craniotomy performed for brain tumor or aneurysm. This was attributed to the fact that the speech centers are located in the cerebral hemispheres of man. Each lobe of the brain has some function involved with communication. Brain disease and surgical removal of brain tissue can cause a loss of some function involved with speech. 80 Even though a statistically significant association could not be established between loss of oral communication abilities and left cerebral hemisphere involvement, a trend in that direction was identified. In the majority of persons, the speech centers are located in the left cerebral hemisphere. This is not only true in dextrals, but also in the left-handed population as well. Therefore, one would expect that loss of brain tissue of the left cerebral hemisphere through disease or surgery would produce a loss in some communicative functions. From the analysis of the data, one can conclude that the site of the lesion was not related to a change in oral communication abilities postcraniotomy. Even though there was no correlation established between these two variables, questions arise. Since certain lobes of the brain in man are more concerned with communication than others, why is this not seen statistically? Brain surgery in Broca's or Wernicke's area of the dominant hemisphere should yield some loss in comi�unication. Perhaps this is not reflected in this study since there was such a small sample size with an unequal distribution of craniotomy sites. From the findings, age and handedness were found insignificant to loss of oral communication skills. However, 1. '

81 even though sex was not significantly associated to a decrease in oral communication, an interesting trend was recognized. The male subjects were found more likely to· produce a loss of oral communication abilities than the female subjects. This was particularly interesting since Howard Landsnell found the same association in his 1964 study of the effect of brain surgery on the ability to identify popular word associations. Thus, it can be concluded that males do have a tendency to yield lower communication scores following brain surgery than females. In summary, from the study conducted, the conclusion can be made that oral communication abilities are effected by craniotomy. The cerebral hemisphere involved in the surgery is related to the effect produced on oral communi­ cation. Age, sex, handedness, and site of lesion were not significantly associated with oral cornmuncation skills following craniotomy; however, the male patients did establish a trend to produce more decreases in oral commu­ nication abilities than the female patients.

Implications Based on the findings of the study, various implications can be drawn from the effect of craniotomies on oral communication abilities. These can be divided 82 into implications for nursing practice, nursing education, and nursing research.

Nursing Practice Changes in one's ability to communicate orally sometimes occur following craniotomy. Personnel working with such patients must be aware of these possible changes. Not only must they be aware of them, but they also must know how to define the changes as well as know how to incorporate the change into their care of the patient. Optimum quality of care should be provided for all patients suffering disorders of communication. Staff nurses should leamassessment techniques in order to identify communication disorders. Once they are able to determine whether the problem exists, they must be able to plan appropriate care for the problem. In-service education programs can be very helpful in teaching nurses assessment and nursing care plan techniques. An assessment tool should be made available for nurses to utilize in the determination of communication deficits. Once the problem has been recognized, it is imperative that appropriate nursing actions be initiated. Working closely with the speech therapist and the physician, the professional nurse can better direct the care. It is of utmost importance for all the medical team to be working 83 with mutual goals which move the patient along his road to recovery at virtually the same pace. Patient and family education should be included in the care of patients with speech disorders. It is within the domain of the professional nurse to plan and teach classes on communication disorders to patients, families, and/or nursing personnel. Various books and pamphlets are easily accessible to the nurse who, in turn, can share them with whomever has such a need. Not all aphasic patients recover all of their language facilities; however, most do recover some aspects of their communication skills. For these patients and their families, it is .the nurse's responsibility to stay abreast of knowledge and understanding of the problem and bf·ho� she can best care for her patients suffering from it.

Nursing Research Communication disorders cause widespread problems within the hospital, family, and community setting. To provide optimum quality of nursing care, it is important that the nursing profession investigate the effect of a loss of communication in all of these areas. These investi­ gations can reveal attitudes of nurses, patients, and families when various aspects of communication are diminished or lost. By determining these attitudes, 84 recommendations can be made and appropriate changes implemented, which will strengthen the quality of care given to the aphasic patient.

Nursing Education The responsibility of increasing the knowledge and understanding of aphasia lies within the realm of the nursing education. Nursing education is the center from which the role of nursing as a profession grows. Nursing students are tomorrow's nursing leaders. It is up to the nursing educators to help mold them into responsible, continually-learning nurses of the future. A basic understanding of the physical and psychosocial needs of the aphasic patient must be included in the education of the nursing student. A curriculum which provides the student with the ability to assess the problem as well as these physical and psychological needs will in turn prepare her to assess, implement, and evaluate appropriate nursing care for the patient suffering from communication deficits.

Recommendations Based on the findings of this study, the following recommendations are made: 85 1. A similar study with a larger population be conducted in various geographical areas to determine if the findings are consistent 2. A similar study be conducted with an even distribution of handedness among the population 3. A longitudinal study be done to determine the long-term effect of craniotomy on oral communication abilities 4. A similar study be done to determine the effects of postoperative sedatives and narcotics on the oral communication skills of patients following craniotomy 5. Further studies be done with a less structured interview to provide more open-ended questions to produce more spontaneous speech from the patients 6. A similar study be conducted with a more balanced distribution of craniotomy sites 7. A larger study be conducted testing all phases of communication abilities following craniotomy 8. A similar study be done to determine the effect of family visits on oral communication abilities post­ operatively 9. A similar study be conducted to determine the effect of sound stimulation such as television, radio, or 86 conversation on oral communication abilities post­ operatively 10. Studies be conducted with staff nurses and intensive care nurses to determine if they possess accurate knowledge of aphasia and its nursing implications 11. Studies be conducted to determine nurses' assessment skills for determining communication deficits 12. Further studies be conducted to determine attitudes of nurses toward aphasia 13. Time studies be conducted to determine the amount of time spent in aphasic patient's rooms compared to the amount of time spent with patients without communi­ cation deficits APPENDIX A TYPES OF SPEECH DISORDERS AND VARIOUS SITES OF LESIONS TYPES OF SPEECH DISORDERS AND VARIOUS SITES OF LESIONS

1:-i Cl) Cl) :::1 Cl) ::ro� ci" � ::ro� Cl) �� � z (D 'I-'• t-0 CD t-0 CD O C I-'· CD CD O CD t-0 t-' CD t1 Ill t-0�8 � C/l rt Ci> 0 0 :::1 s p, Ot-0 � S Ill CD 0 Ill I-'· s ::rt-0 I-'· CD CD � � C/l t-0 I-'· � CD Cf) t-0 p, t-' CCL rt I-'· 0 n en rt I-'· ti rt rt I-'· ti I-'· t-' p, I-'· I-'· � p,C/l CD :::1f 0 ::r Ill 0 CD 0 I-'· I-'· � � 1-l·O I � I ti I �0 CD I ..0 � � l.Q l.Q "° Ill 1-h � "°

Posterior 3rd I N L N N (L) L I I Broca's frontal. ,':L Efferent Broca Motor Syntactic Posterior Para- I I I I I Para- I Wernicke superior phasia graphia Sensory. temporal (Semantic) Syntactic gyrus-- Wernicke CX) CX) Conduction Para- N I N I I Para- I Conduction system phasia graphia L Central (Arcuate fas- (Phonemic) to I Afferent culus) on Motor longitudinal Sensory fasiculus Frontal lobe No volun- N N N N N I but I Isolated watershed ary speech usually L speech sparing but better area perisylvian repetition than speech areas N spontan� eous

Note: N = normal, L = limited, I=impaired TYPES OF SPEECH DISORDERS AND VARIOUS SITES OF LESIONS (Continued)

t-'CJl CJ) ::s CJ) ::z::, CJ) !Z �1-3 ::r () r'rt· CD!:ti (D::r (D() !:ti .....,� (D!:ti � (D I-'· '"d (D '"d CD O C O '"d t; DJ ::s Pi O'"d !:$ s DJ (D I-'· fJlr'· rt CD O 0 s 0 OJ ��DJ (D CD ro C ::S en '"O .-,. ::s (D en '"d Pi ....., C Pi rt � 0 () fJl rt I-'· t; rt rt r'· Ii I-'· ....., Pi I-'· I-'· b. t/l ::, 0 !:l' OJ 0 CO 0 I-'· 0 CO t:s I-'· ::, ::, l.Q f-J·O t-ti I ::, Iy I; I ::, I l.Q LQ l.Q Ill Hi l.Q::,

Parietotempo- Para- I I I I I Para- I Isolated ral watershed phasic graphia L speech sparing area perisylvian Acoustic- speech areas Amnestic Inferior N N N I I I I I parietal-- Letters L angular Words co gyrus \0 Left N N I N ill N I occipital Words Letters

Note: N = normal, L = limited, I=impaired. Source: Harrison 1974. APPENDIX B AN OUTLINE OF BASIC SPEECH CENTERS AND THEIR RELATED FUNCTIONS 91 DIAGRAM SHOWING AREAS ACCORDING TO BRODMAN WITH RELATED LANGUAGE FUNCTIONS

Motor Fron� (

Language Defects Caused Area Function by Destructive Lesion

41 and 42 Recognition of Auditory Verbal Agnosia Wernicke's spoken language 22 and 21 Recall and inter- Loss of verbal recall pretation of spoken language 44 Memory of motor Motor Aphasia (speech) Broca's Area patterns of speech 37 Recall of names Anemia and words; language formulation Amnesic Aphasia 39 Symbols for read- Alexia Angular Gyrus ing, writing, and Agraphia (spelling) arithmetic Acalculia (letters and numbers) 92

Language Defects Caused Area Function by Destructive Lesion 8 and 9 Knowledge of how Agraphia (motor) Exner's Writing to make movements Center of hands and fingers in writing 17 and 18 Visual perception Visual-Verbal and recognition Agnosia without Agraphia

Source: Agranowitz and McKeown 1968, p. 17. APPENDIX C PERMISSION SLIPS 94 PARTICIPANT PERMISSION

I give my permission for Gwen Brieger, a graduate nursing student at Texas Woman's University to interview me before and after my surgery for a paper she is writing at school. I understand that the interviews will be taped and that my name will not be identified on the tapes or in the paper.

Name ------Date ------O T� \JMAN'S UNIVEFSITl COUEGE OF NlJFSTI,iG DENTON, IBXAS DALLAS CENTER HOUSTON CEN'l'ER 1810 Irrt1ood Road · 7 1130 M.D. Anderson Blvd, Dallas, 'l:x. 5235 95 Houston, Tx. 77025 AGENCY PERMISSION FOR CONDUCTING STUDY�'

THE ____ P_a __r__ k ...... d--.;.;;..M_;;e.;.;.m;..;o la_____n__ __ r i __ a;..,;1,__..H ..... __ o�s;:;..i;p:;...f .... a;;;...:.1t ______

GRANTS TO Gwen Brieger a student enrolled in a program of nursing leading to a r.'Iaster's Degree at Texas \'lanan' s University, the privilege of its facilities in order to study the follow'.u,g p�ob lem:

The Effects of Cranfotomtes on Oral Communfcatfon Abi littes

The conditions mutually agreed upon are as follows:

1. The agency (may) ��} be identified in the final report.

2. The narnes of consultative or administrative personnel in the agency (may) �}:ZiQll) be identified in the final report.

3. The agency -.,in) (does not want) a conference with the student when the report is canpleted.

4. 'l'he agency is ( ·willing) (litlfil.\��w��) to allow the ccmpleted report to be circulated through interlibrai')' loan. )fl/4eu4?: a- :?Y;/£-=

Signature of Faculty Advisor

{iFill out and sign three copies to be distributed as follows: Original­ Student; first copy - agency; second copy - 'I\HJ College of Nursing.

BV/4/10/74/sic TEXAS WOMAN'S UNIVERSITY COLl..EGE OF NURSING DENTON, TEXAS DALLAS CENTER HOUS'IDN CEN'IBR 1810 Inwood Road 96 1130 M.D. Anderson Blvd. Dallas, Texas 75235 Houston, Texas 77025

AGENCY PERMISSION FOR CONDUCTING STUDY*

a student enrolled in a program of nursing leading to a Master's Degree at Texas Worran's University, the privilege of its facilities in order to study the following problem:

/4- 6-r=r=--e"� ,::1/{?/f.3,p.,,v/t:],?""Zf,,??/6:S ?J� 0/2,9� ��?/..4/ /�/0 ,,(.,,I �&/,< / ?.7'6� .

The conditions mutually agreed upon are as follows:

1. The agency (rray) (may not) be ident i.fied in the final report.

2. The names of consultative or administrative personnel in the agency -{m.a-y,) (may not) be identified in the final report. 3. The agency (wants) (e.ee&-,-oot-want) a conference with the student when the report is completed.

4. The agency is (willing) ·(unw::�-) to allow the completed report to be circulated through interlibrary loan. 5. Other ------

I 1 _-_-•_-- -/· _//-,_:,.,__ -__·_ _.•-.-- Date .. /;,: -- __ /· <·:., ~t ,_. ~ .)r_ 1 - .-, .•,-. ;(/, - ·,: _ : ,. (,-. . :. .. _ Signature of Agency Personnel ,;-/ , I / ) . :.,;. ------( ;_. r/'\...._, Sl 1':nature or Facult� Advisor

*l•'ill out un..i �,1yn three copies to be di stributt::.,d as follows: Origi nal ��tudent; first copy -- agency; second copy -- T.W.U. College of Nursing. 'IEXAS WOMAN'S UNIVERSITY COLLEGE OF NURSING DENTON, TEXAS DALLAS CENTER HOUS'IDN·CENTER 1810 Inwood Road 97 1130 M.D. Anderson Blvd. Dallas, Texas 75235 Houston, Texas 77025

AGENCY PER'VITSSION FOR CONDUCTING STUDY* ����;:;���r �::.::.:�-.:;;;;t;;;...• -______GRANTS 'ID /ef&X-1 x::.>d,?/EC3�� a student enrolled in a program of nursing leading to a Master's Degree at Texas Worran's University, the privilege of its facilities in order to study the following problem:

.� cr �e;r c;/c-::' / � o � ,.,63 LJ A..J l?�/4. �.,-?77c//l/��,, ►d?.A:/ .A6/..-

The conditions rrutually agreed upon are as follows: 1. The agency (may) (may not) be ident Lfied in the final report. 2. The names of consultative or administrative personnel in the agency (may) (mav not) be identifi� in the final report. 3. The agency (wants) (does not want) a conference with the student when the report is completed. 4. The agency is (willing) (unwilling) to allow the completed report to be circulated through interlibrary loan. 5. Other ------

Date

/ I ..·' I .I / .-·· I . .. ! ,; ~ Sknatur€ of Facul�y Advisor *Pill ()Ut un.i slti:n three copies to be d.istributt-xi as follows: Original ��t:udent; first cory -- agency; second copy -- T.W. U. College of Nursing. TEXAS t•10MAN' S UNIVERSITY COLLEGE OF NURSING DDITO�l, TEXAS DALLAS CENTER HOUSTON CENTER 1810 In�ood Road 98 1130 M.D. Anderson Blvd. Dallas, Texas 75235 Houston, Texas 77025

AGENCY PERMISSION FOR cmmUCTING STUDY*

THE ___ __M .e;...;;dc:;,_a ...f..... __ l.;_,...-=:::t--f ...::;t ...v ___ H..,.;o;..;;s:;..cp;...;f;._,t;::;.;;a;;.__I ______�1S TO__ ,__.;:::...;...;;:;..;.,;_,::;..;..,_;;...:..;::..;;:..:�------Gwen Br f eoer a stu=ent enrolle� in a program of nursing leading to a �.aster's Degree at Texas �:o�an's University, the privilege of its facilities in order to study the following problem: The Effects of Cranfotomfes on Oral Communication Abilities

The conditions mutually cgreed upon are as •follows: /.\ (may 1. The ag�ncy (may),....__....,, not) be identified in the final report • 2. The names of consultative or administrative personnel in the (may agency (:nay)'J ...not) be identified in t the final report. 3. The agency (wants) (does not �ant) a conference with the stu­ dent when the report is cocpleted. ,.- ----...... _ f 4. The agency is ((willing) (un�·illing) to allow the completed report to be circulated thrcugh interlibrary loan.

S. Other: ______

Signiitilr of Agency Per o- 1 � _ ; 7 i{1/-:, ,' {Ii' t',1_,1/'{C S�. Signature of student � �-at�rg cf. ��ltR, Adv�s.7r. _, , *Fill out �nd sign three'copies to be d��t�-��!': �� Student; first r.".:i)Y - agency: second copy -- T .W .t:. College of Nursing. TEXAS WOMAN'S UNIVERSITY COLLEGE OF NURSING DENTON, TEXAS DALLAS CENTER HOUS'IDN CENTER 1810 Inwood Road 99 1130 M.D. Anderson Blvd. Dallas, Texas 75235 Houston, Texas 77025

AGENCY PERMISSION FOR CONDUCTING STUDY*

THE Baylor Medical Hosoftal - Truett Hosoftal GRANTS TO Gwen Br f eoer a student enrolled in a program of nursing leading to a Master's Degree at Texas Worran's University, the privilege of its facilities in order to study the following problem: The Effects of Cranfotomies on Oral Communication Abi I itfes

The conditions mutually agreed upon are as follows: 1. The agency (may) (may not) be ident Lfied in the final report. 2. The narnes of consultative or administrative personnel in the agency (may) (�y not) be identified in the final report. 3. The agency (wants) (does not want) a conference with the student when the report is completed. 4. The agency is (willing) (unwilling) to allow the completed report to be circulated through interlibrary loan. 5. Other ------

Date 2-.J?-7:f'

1 *l• Ul t'llt a111 s1gn three copies to be dLstributc""tl as follows: Original ��-t udent; first cory -- agency; second copy -- T.W. U. College of Nursing. 100 BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS 75246

AUTHORIZATION FOR RCLEASE OF INFORMATION

Date: ------

I the undersigned, hereby grant permission to Ms. Gwen Brieger, R.N., B.S.N., (T.W. U.) graduate student to interview me/my family in order that she might meet the requirements for completion of her masters thesis.

Patient

1-\ddress APPENDIX D PHYSICIAN PERMISSION 101 PHYSICIAN PERMISSION

I give Gwen Brieger, a graduate student at Texas Woman's University permission to use my patients in her study concerning the effects of craniotomies on oral communication abilitie.s.. APPENDIX E INTERVIEW QUESTIONS AND ORAL READING 103 THE EFFECTS OF CRANIOTOMIES ON ORAL COMMUNICATION ABILITIES

1. What is today's date? 2. Are you allergic to any foods or drugs? If so, what are they and how does the allergy present itself? 3. Are you currently taking any medications? If so, what are the names of the drugs and how often do you take them? 4. Have you ever had a blood transfusLon? If so, when was the last transfusion and have you ever had a reaction from a transfusion? 5. Why are you in the hospital? 6. What symptoms of illness have you experienced? 7. Have you ever been hospitalized before? If so, what was the cause for your hospitalization? 8. Do you have any physical complaints other than the symptoms of your present illness? If so, what are they? 9. Do you smoke? If so, how many packs do you smoke per day? 10. What are your dietary habits? a) special diets b) foods you dislike c) normal meal patterns 11. What are your normal sleeping habits? a) number of hours of sleep per night b) use of sleeping pills 12. What hobbies or special interests do you have? 13. Describe one of your average days to me. 104 14. Are you being treated by any physician other than the doctor who admitted you? If so, what is his name and what is he treating you for? 15. Who can we notify in case of an emergency? At what number can this person be reached? 16. Are you right- or left-handed? 17. Describe your work or school habits. 18. Describe your family.

THANK YOU VERY MUCH FOR YOUR COOPERATION! t I•#'� • ...•; I < I > ) • I I ,o ' • I : • • 1 '► I t ' • • • !

105 MY GRANDFATHER

You wished to know all about my grandfather. Well, he is nearly 93 years old; he dresses himself in an ancient black frock coat, usually several buttons missing; yet he still thinks as swiftly as ever. A long flowing beard clings to his chin, giving those who observe him a pronounced feeling of the utmost respect. When he speaks, his voice is just a bit cracked and quivers a trifle. Twice each day, he plays skillfully and with zest upon a small organ. Except in the winter when the ooze or snow or ice prevents, he slowly takes a short walk in the open air each day. We have often urged him to walk more and smoke less, but he always answers, "Banana oil." Grandfather likes to be modern in his language. APPENDIX F CRITERIA FOR SCORING 107 APHASIA SEVERITY RATING SCALE

0. No usable speech or auditory comprehension. 1. All communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. The range of information which can be exchanged is limited, and the listener carries the burden of communication. 2. Conversation about familiar subjects is possible with help from the listener. There are frequent failures to convey the idea, but patient shares the burden of communication with the examiner. 3. The patient can discuss almost all everyday problems with little or no assistance. However, reduction of speech and/or comprehension make conversation about certain material difficult or impossible. 4. Some obvious loss of fluency in speech or facility of comprehension, without significant limitation on ideas expressed or form of expression. 5. Minimal discernible speech handicaps; patient may have subjective difficulties which are not apparent to listener. 6. Normal speech; no handicap. APPENDIX G LETTER OF INSTRUCTION TO COMMITTEE FOR VALIDATION OF TOOL 109 LETTER OF INSTRUCTION TO COMMITTEE FOR VALIDATION OF TOOL

These questions will be used to determine if craniotomies performed for possible brain tumors will cause a change in oral communication abilities. The interview will be guided by these questions in hopes of getting spontaneous speech and not only automatic answers. The interview as well as an oral reading will be conducted both pre­ operatively and postoperatively. There will be no attempt to classify any types of aphasias or speech disorders, but instead an attempt will be made to evaluate the tapes for the degree of change in one's ability to communicate orally following a craniotomy. These tapes will be evaluated by J. Simonson, who will use the same set of criteria for evaluating all the tapes. She will be looking for articulation, word clarity, distinction of sounds, word searching, the need for repetition, relevant answers, latency periods, full sentences, and the use of key words. From this, she will grade the response from a rating scale of zero to five. The Aphasia Severity Rating Scale will be used for this with: O. No usable speech or auditory comprehension. 1. All communication is through fragmentary expression; great need for inference, questioning and guessing by the listener. The range of 110 information which can be exchanged is limited, and the listener carries the burden of communication. 2. Conversation about familiar subjects is possible with help from the listener. There are frequent failures to convey the idea, but patient shares the burden of communication with the examiner. 3. The patient can discuss almost all everyday problems with little or no assistance. However, reduction of speech and/or comprehension make conversation about certain material difficult or impossible. 4. Some obvious loss of fluency in speech or facility of comprehension, without significant limitation on ideas expressed or form of expression. 5. Minimal discernible speech handicaps; patient may have subjective difficulties which are not apparent to listener (Boston Diagnostic Aphasia Examination, p. 6). The preoperative tapes will be compared to the postoperative tapes to determine if there is a change in the ability to communicate orally. Thus, a qualitative analysis wil l be performed with the interviews. However, a quantitative analysis can and will be performed on the results of the oral readings. Please review these interview questions and evaluate their ability to determine oral communication abilities. Thank you very much for your help in this area. If you have any questions, please notify me at 691-4241. Please add any comments--I will pick this up Thursday, March 13. Gwen Brieger APPENDIX H DEMOGRAPHIC DATA AND COMMUNICATION SCORES DEMOGRAPHIC DATA AND COMMUNICATION SCORES

Patient Site of Cerebral Communication Scores Number Sex Age Handedness Craniotomy Hemisphere Pretest Posttest

1 F 54 Right Parietal Right 6 6 2 M 66 Right Occipital Left 4 2 3 F 55 Right Frontal Right 6 1 5 M 30 Right Frontal Left 6 6 7 M 73 Right· Parietal Right 6 6 8 F 53 Right Occipital Left 6 6 11 F 44 Right Temporal Right 6 6 12 M 63 Right Frontal Left 6 0 13 M 31 Right Post Fossa 6 6 14 F 23 Right Post Fossa 6 6 6 16 F 60 Right Frontal Right 6 I-' M I-' 17 55 Right Frontal Left 6 6 N 18 F 57 Right Post Fossa 6 6 19 M 33 Righ� Frontal Left 6 3-4 20 F .19 Right Frontal Left 6 0 22 F 22 Right Frontal Right 6 6 23 M 60 Right Parietal Right 6 6 24 M 42 Right Frontal Bilateral 2 0 Left & Right 25 F 32 Right Temporal Right 6 6 26 M 30 Right Frontal Left 5 4-5

Total 10 M 19- Parietal-3 Right-8 6-17 6-13 20 10 F 73 All Right Frontal-10 Left-8 5-1 4-5-1 Occipital-2 Bilateral-! 4-1 3-4-1 Post Fossa-3 2-1 2-1 Temporal-2 1-1 0-3· I

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