Michael P. Alexander

General Clinical Considerations

Language is a means by which people communicate with each other using verbal symbols. Dysphasia may be defined as a disorder of language due to brain damage. This monograph deals with disorders of language, not disorders of speech. Speech refers to the mechanical process of articulation, which can be disturbed by weakness, slowness, or incoordination of the muscles of the glossopharyngeal apparatus. Such disturbances would be termed dysarthria, dysphonia, or mutism. The term dysphasia is applied to a neurological disorder resulting from damage to those regions of the cerebral hemispheres which form the anatomical basis for the human capacity for language.

Clinical Guide to Classification of Dysphasic Syndromes

The preceding short examination for dysphasia can be used to provide a rough clinical guide to Classification of dysphasic syndromes. Formal language evaluation should be carried out to refine the initial impression. We emphasize that many patients with dysphasia do not have signs which can be easily or neatly categorized, regardless of the technical skill or years of experience of the examiner; in such cases a thoughtful description of the Observation is more helpful than an attempt to force the clinical findings to conform to a pre-conceived category.

Formal Language Evaluation

The formal, clinical assessment of dysphasia encompasses at least five aspects. Depending on the circumstances, all may be given equal weight, one may be dominant to the exclusion of all the others, or any distribution of emphasis between these extremes may obtain. These aspects are the following: 1. dysphasia testing as an inventory of language input and Output modalities, 2. linguistic aspects, 3. diagnostic aims, 4. the dysphasia examination as a case study, 5. quantitative aspects.

Special Clinical Forms of Dysphasia

Syndromes of dysphasia may vary from the forms described in the preceding sections, or certain aspects of dysphasic syndromes may appear more prominently than others, depending on associated clinical conditions, language background of the patient, history of left-handedness, lesion localization, or individual differences. In this section we consider clinical features of some of these special forms of dysphasia.

What Approaches to Dysphasia Rehabilitation Are Felt to Be Most Effective

Speech pathologists are called upon to rehabilitate adults with disorders which range from global dysphasia with severe impairment in all language modalities, to anomic dysphasia with impairment only in substantive word finding. There is little reason to expect that disorders which vary widely in nature should or can be treated in a similar manner. There are, of course, some general principles which can be applied to any rehabilitative process and dysphasia is no exception. Such clinicians as Backus (1937) and Schuell, Jenkins and Jimeniz-Pabon (1964) provide us with general principles of treatment, and these principles are no less appropriate today than when they were written. Few of us would dispute, for example, that speech processes operate with greater facility when the individual experiences a reasonable degree of social adequacy (Backus, 1937), or that the clinician should elicit and not force the response (Schuell, Jenkins and Jimenez-Pabon, 1964). But while such principles may guide us in the treatment process, we must have a specific method in mind when sitting across from the patient.

General Considerations for Dysphasia Rehabilitation

No matter which theoretical viewpoint of dysphasia the language clinician holds, or which resultant approach to treatment he chooses, there are some general considerations for improving the overall effectiveness of the rehabilitative process. In this section we will discuss some of these considerations.

Neuroanatomical and Neurophysiological Considerations

It is traditional that a review of the anatomy of language disorders commences with a summary of the history of the disputes between the proponents of the two main streams of thought about brain-language relationships. The ebb and flow of popularity of various localizationist and globalist theories is colorful and instructive, but it is well reviewed elsewhere (Hecaen and Albert, 1978). This issue is no longer relevant in the sense considered by previous generations. Clearly brain functions are not equally represented in all regions. Interhemispheric differences exist in 1) the perception and manipulation of higher level sensory information, 2) the Organization of axial, limb and buccofacial movements and 3) the ability to generate speech and language. These interhemispheric differences are based in part on anatomical asymmetries which are evident in fetal life (Wada et al., 1975). There is intrahemispheric specialization in brain function as well, and within the left hemisphere, much of this specialization in function constitutes the anatomy of language. Even many ostensible critics of the localizationist theories resorted to a system of language Classification that carried implicit functional localization which strongly resembled the classical formulations of Wernicke (1874) and Dejerine (1914). For example, Marie (1917), Head (1926), and Goldstein (1948), despite their reputations as antilocalizationists, utilized systems of Classification based on functional anatomy.

Brief, Clinical (Bedside) Examination for Dysphasia

In a short examination for dysphasia six language skills should be tested: spontaneous speech, repetition, naming, comprehension of spoken language, reading, and writing. The following examination can be completed in 10–15 minutes at the bedside.

Disturbances of Reading and Writing

A review of early accounts of dysphasia (Benton and Joynt, 1960) credits Valerus Maximus in 30 A.D. with the earliest description of acquired dyslexia: a case of head injury producing an isolated acquired dyslexia. After an interval of almost two millenia, sporadic reports of acquired dyslexia became more common in the 1800’s but definitive steps toward understanding the acquired disorders of written language were not made until Dejerine (1891, 1892). His descriptions of the clinical findings and anatomical correlations of acquired dyslexia, with and without dysgraphia, remain essentially unaltered as the foundation of the study of disorders of written language.