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LE JOURNAL CANAD1EN DES SCIENCES NEUROLOG1QUES
Classification of Aphasic Phenomena
ANDREW KERTESZ
SUMMARY: A brief but comprehensive Most clinicians will agree that al- tions cover the same phenomenon.
survey of classifying aphasia reveals though aphasic disability is complex, In Table I the various terms are
that most investigators describe at least many patients are clinically similar shown to overlap and those describ-
four major groups, conveniently labelled and may be classified into identifi- ing the same disturbance appear un-
Broca's, Wernicke's, anomic and global. able groups. There are many classi- derneath each other. Four columns
Conduction and transcortical aphasias
fications indicating that none is al- appear to represent the entities that
are less generally described and mod-
ality specific syndromes rarely, if ever, together satisfactory. Nevertheless, almost everybody identifies:
exist purely. The controversy between this effort is useful and even neces- 1. What Broca (1861) described as
unifiers and splitters continues but ob- sary to diagnose and treat aphasics aphemia, Wernicke (1874) called
jective numerical taxonomy may solve and to understand the phenomena. motor aphasia. Marie (1906) did not
some of the problems of classification. The opponents of classification consider Broca's aphemia true
point out the numerous disagree- aphasia. Pick (1913) labelled it ex-
ments among observers, the many pressive aphasia with agrammatism
RESUME: Line etude breve, mais com- exceptions that cannot be fitted into and Weisenburg & McBride (1935)
prehensive, de la classification de
categories and the frequent evolu- popularized "expressive aphasia"
I'aphasic revile que la plupart des cher-
cheurs decrivent au moins 4 groupes tion of certain types into others. which still enjoys favor among
majeurs, clairement identifies: Broca, The controversy can be reduced many. The problem with the term
Wernicke, anomique et globule. Les to a few issues. Is aphasia a unitary " e x p r e s s i v e " is that all aphasics
aphasias de conduction et transcorti- disturbance or are there several have some "expressive" difficulties.
cals sont decrites de facon moins gene- kinds of aphasia? The answer, of Then came the "innovators" such
rale et les syndromes modaux speci- course, is yes to both. There is as Henry Head (1926) whose distaste
fique ne se retrouvent que rarement, something qualitatively different for his predecessors' diagrams re-
sinon jamais sous forme pure. La con- sulted in a unique psycholinguistic
about aphasic language disturbance
troverse de classification continue mais classification which is difficult to
la taxonomie numerique objective pent
which sets it apart from dysarthria,
mutism, confusion and psychotic apply to clinical c a s e s . B r o c a ' s
aider a resoudre quelques-uns des prob-
lemes courants. speech, just to mention the main aphasia thus became " v e r b a l
problems in differential diagnosis. aphasia". After Head, only Wepman
What makes it qualitatively different (1951) used the same terminology
is difficult to define to everyone's extensively in the literature. Luria's
satisfaction, but, the following defin- (1964) physiological concepts led to
ition might be acceptable to most: A "efferent motor" aphasia.
neurologically central disturbance of Jacobson's (1964) linguistic approach
language characterized by used " c o n t i g u i t y " or "combina-
paraphasias, word finding difficulty tion" disorders for this phenomenon
and variably impaired comprehen- and Osgood (1963) called it "encod-
sion, associated with a disturbance ing" disturbance. Bay (1964) like
of reading and writing with or with- Marie (1906) considered "aphemia"
out dysarthria, non-verbal construc- different from aphasia and gave it
tional and problem-solving difficulty the term "cortical dysarthria", a
and impairment of gesturing (con- theoretical deviation from the con-
structional and motor apraxia). sensus which considers these pa-
Ever since Broca (1861) described tients aphasic. Shuell's (1964) clas-
" a p h e m i a " and Wernicke (1874), sification is highly individualistic
sensory aphasia, many clinicians and difficult to correlate with others.
have tried to record their experience Her Group 3 "severe reduction of
From the Department of Clinical Neurological and improve the results of classifica- language" with "sensorimotor" dis-
Sciences, St. Joseph's Hospital, London, Canada.
tion. Although confusing at first turbance c o r r e s p o n d s best to
Reprint Requests to: Dr. Andrew Kertesz, De- glance, after gaining some clinical Broca's aphasia.
partment of Clinical Neurological Sciences, St.
Joseph's Hospital, London, Ontario, Canada N6A experience, one finds it striking that More recent clinically and linguis-
4V2 the new classifications and descrip- tically oriented classifications place
Vol. 3, No. 2 MAY 1976- 135
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https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0317167100025890THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES
an emphasis on the fluency- sory aphasia. Marie (1906) claimed Wernicke's aphasia as described
nonfluency dichotomy in aphasia. that sensory aphasia was the true by Goodglass and Kaplan (1972),
Goodglass and Kaplan (1972) and aphasia and this is still championed features impaired comprehension
many others recognized the clinical by Bay (1964). Shuell (1964) was also and fluently articulated, but
relevance of measuring fluency. impressed by the auditory distur- paraphasic speech. Repetition, nam-
They also advocate the retention of bance as the sine qua non of aphasia. ing or word-finding difficulty and
the classic eponym rather than using Curiously, her classification does impaired reading and writing are al-
"motor" or "expressive" aphasia in not have a single group which could ways present. Since various degrees
order to avoid suggesting that be identified unequivocally with of impairment are seen and the
speech output is normal in other sensory or W e r n i c k e ' s aphasia. fringes of the entity are often ill-
forms of aphasia. Head, like Wepman and Shuell after defined and controversial, retention
Much of the controversy about him, in order to avoid the input- of the eponym seems useful to de-
Broca's aphasia centers around the output dichotomy and the notion of scribe this clinically valid and com-
existence of comprehension deficit. pure language defects, created novel mon aphasic impairment.
These patients are characterized by classifications deviating from the 3. Probably the largest group of
relatively well-preserved com- clinically obvious, and confusing aphasics have relatively little ex-
prehension and their major disability generations of readers. Head's syn- pressive or receptive difficulty.
is in language output. However, if tactic aphasia is not the same as Their speech is fluent, at times very
comprehension is examined exten- W e p m a n ' s who called sensory circumlocutory, occasionally
sively, it is found to be impaired to a aphasia "pragmatic" and the motor paraphasic, and shows obvious
certain extent, almost without ex- " s y n t a c t i c " . J a c o b s o n ' s (1964) word-finding difficulty. Their verbal
ception. This prompted many inves- "similarity" or "selection" disorder paraphasias are semantic substitu-
tigators to emphasize that com- encompasses a range of clinical dis- tions, rather than phonemic (literal)
prehension is an all pervasive fea- turbances such as " s e n s o r y " , distortions. They have near normal
ture of aphasia and the variable "semantic" and "acoustic amnes- comprehension and repetition but
amount of motor difficulty at times t i c " aphasia as he used Luria's their naming is impaired. This is
labelled " c o r t i c a l d y s a r t h r i a " (1964) terminology. According to often called anomic or amnesic
superimposed on aphasia results in him sensory aphasia is characterized aphasia and this often appears de
the variation of the clinical picture linguistically by preserved syntactic novo or it may be the end result of
called Broca's aphasia. Mohr (1975) units, and phonemic combinations recovering from other syndromes,
claims that Broca's aphasia is rarely although certain phonemic distinc- such as Wernicke's, "conduction",
seen from the onset of a C.V.A. as a tions are lost. Osgood's (1963) de- or the "transcortical aphasias".
distinct entity but develops from coding disturbance is in this categ- Although Broca himself spoke
global aphasia, by virtue of improv- ory also. about "verbal amnesia", this entity
ing comprehension, or if it is present Jargon aphasia is at times iden- was not defined until Goldstein
early after a stroke, it often evolves tified as a separate entity although (1924) described amnesic aphasia as
into a milder syndrome. Most clini- most writers will classify it with an impairment of " a b s t r a c t at-
cians agree, however, that motor Wernicke's or sensory aphasia. The t i t u d e " . Henry Head (1926) de-
aphasia, primarily expressive fluent, profusely paraphasic speech scribed nominal aphasia as a diffi-
aphasia or Broca's aphasia, is an may be usefully subdivided into culty in naming but included im-
identifiable aphasic syndrome with semantic and neologistic jargon, de- paired understanding of names as
hesitant, scant and paraphasic spon- pending on the degree of phonemic part of the disturbance, which is
taneous speech, variably impaired distortions or neologisms (the contrary to what clinicians usually
repetition and naming, and relatively paraphasic and asemantic jargon of find in this picture.
good comprehension. They read Alajouanine, 1956). These patients 4. Another common aphasic group is
aloud poorly but reading com- are often curiously unaware of their universally called global aphasia be-
prehension is often good. Writing is faulty communication and this is de- cause of the severity of involvement
affected similarly to speech. scribed as " a n o s o g n o s i a " for of both expressive and receptive
2. Sensory aphasia as described by speech. Their speech is often under functions. The patient does not
Wernicke (1874) in his famous pressure, "logorrheic". The varia- communicate and what is said is
paper, " D e r Aphasische Symp- bility of language production in often a stereotypic repetitive utter-
tomenkomplex" is recognized by Wernicke's aphasias induced some ance, at times, an expletive without
everyone, even those wary of clas- to split the symptom complex semantic value. At times these ut-
sifications such as Hughlings Jack- further. Huber et al., (1975) for in- terances are used quite fluently, with
son (1879). His hierarchial view of stance, differentiates four varieties inflection and associated emotional
language dissolution includes "jar- such as 1. predominantly semantic expression. Comprehension seems
gon" as a disturbance of expression paraphasia, 2. semantic jargon, 3. almost entirely absent and even
but these recurrent utterances were phonemic paraphasias, 4. phonemic when one has the impression that the
more stereotypic than the profuse jargon, although a qualitative basis for patient "looks comprehending", the
phonemic or semantic jargon of sen- the discrimination is not provided. expressive outlets are so limited that
136 - MAY 1976 Classification of Aphasia
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it cannot be tested. Similarly, repeti- see a few T.C.M. cases to recognize for mild impairment of comprehen-
tion and naming are very poor. Re- the patient who says practically no- sion associated with verbal
cent studies of recovery indicate that thing spontaneously but com- paraphasias.
quite a few global patients regain prehends everything and repeats Modality specific aphasias are
enough comprehension to be consi- amazingly well. Rubens (1975) has rare and seldom if ever " p u r e " .
dered Broca's aphasics. There are a described this syndrome with infarc- "Cortical dysarthria" (aphemia),
few patients, often elderly, with se- tion of the anterior cerebral artery. "verbal apraxia" (Johns and Darley,
vere aphasia, who have fluent but We have seen this localization also 1970) is rarely if ever without some
mumbling speech, which may be (supplemental speech area of Pen- associated disturbance of com-
mistaken for jargon, but the utter- field). Isolation syndrome, also a re- prehension provided the approp-
ances are stereotypic lacking the cently described entity is exemp- riately difficult tests are used.
phonemic variability of neologistic lified by the patient who remains Therefore, it should be considered
jargon aphasia. non-fluent and does not seem to be aphasia rather than dysarthria. This
There are aphasics who are more comprehending or attending to tasks has to be differentiated from the oc-
difficult to classify. A transitional but will repeat even longer phrases casional anarthric patient by testing
group, having features of Broca's and complete sentences. One of writing which is usually impaired in
(good comprehension) and these patients who had been ob- the aphasie but intact in anarthria.
Wernicke's (good fluency) but hav- served to sing along with a radio and This entity is also called "subcorti-
ing poor repetition and a great deal even learn songs released since the cal motor aphasia", even though it is
of phonemic paraphasias, was called onset of her illness caused by CO a nonaphasic disturbance related
conduction aphasia (Leitungs- poisoning (Geschwind, Quadfasel more to dysarthria. Transcortical
aphasie) by Wernicke (1874) on the and Segarra, 1968), on autopsy had motor aphasics may also appear to
basis of the theoretical consideration lesions surrounding but not directly be mute but they will repeat well.
that conduction of sensory impulses involving the parasylvian "speech
area". Transcortical (echolalic) sen- "Pure word deafness" is occa-
to motor patterns is impaired. Many
sory aphasia is characterized by sionally seen but most authors admit
clinicians doubted the justification of
fluent but often irrelevant speech. that their patients had some
separating this group from other
Good repetition and poor com- paraphasias and word-finding diffi-
sensory and motor impairment.
prehension is most often seen in culty even though the comprehen-
Weisenburg and McBride (1935)
post-traumatic cases and it is often sion deficit can be outstanding while
claim that they have not seen a case
transient. Investigators in rehabilita- everything else, including pure tone
which would show clearly the pic-
tion units do not see these patients threshold is preserved. Interest-
ture of conduction aphasia in con-
as often as those in general hospi- ingly, as Vignolo (1969) pointed out
trast to Goldstein's description of
tals. T.C.S. aphasia does not seem in his excellent review, these
"central" aphasia (1948) and those
to occur frequently with strokes. patients usually have "auditory ag-
of Kleist (1916), Isserlin (1936) and
Many classifications will acknow- nosia" for nonverbal but meaningful
many others who considered it an
ledge the existence of only those sounds as well.
independent form. Delineation is
possible on the basis of disturbed re- aphasie defects which tend to persist Modality specific anomia is con-
petition which is out of proportion to in time. This way some theoretically troversial but an often recognized
the relatively fluent spontaneous or very interesting language distur- example is the difficulty naming fin-
responsive speech and good com- bances remain unrecognized. gers and discriminating right from
prehension. left in the Gerstmann syndrome
Semantic aphasia was described (1927). Although Benton (1961)
The opposite clinical picture is- originally by Head and meant im- pointed out that this cluster of symp-
echolalic aphasia when repetition is paired word-meaning relationships toms including agraphia and acal-
preserved out of proportion com- and difficulty in formulating the culia is rarely pure and the compo-
pared to the other language func- goals of the speaker. The linguistic nents are often disturbed in
tions. These patients were sub- classification of Jacobson and Luria aphasics, this does not detract from
divided by Goldstein (1948) into continued to use the term. Interest- its usefulness in calling attention to
transcortical motor (T.C.M.) show- ingly, in our mathematical taxonomy the dominant parietal lobe.
ing poor output but good com- there is a group similar to but dis-
prehension and repetition; transcor- tinct from anomic aphasia by more Alexia without agraphia has been
tical sensory (T.C.S.) characterized paraphasias and comprehension dif- described with pathology by De-
by poor comprehension but fluent ficulty which is not severely enough jerine (1892) and repeatedly con-
speech and good repetition and affected to group it with Wernicke's firmed since. Alexia with agraphia is
mixed, featuring poor comprehen- (or sensory) aphasia. It may be more common and it is often as-
sion, poor output but good repetition realistic to preserve the distinction sociated with mild anomic aphasia.
similar to echolalia. The identity of between semantic and anomic The discussion of apraxias and
these syndromes is defined by repet- aphasia, reserving the term anomic various visual or tactile agnosias and
ition and one has to test for it speci- for the purer disturbance of word- constructional apraxia will be omit-
fically. However, one only has to finding and naming and the semantic ted here for sake of convenience, not
Andrew Kertesz MAY 1976 - 137
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https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0317167100025890TABLE I
TERMINOLOGY OF APHASIA
The left column indicates the authors originating and popularizing the terms. The numbers on top refer to the four most common
varieties described in detail in the text.
Authors 1 2 3 4
Broca Aphemia Verbal Amnesia
Wernicke Motor Sensory Conduction
Marie Aphemia Aphasia
Pick Expressive Impressive Aggramatism Paragrammatism
Head Verbal Syntactic Semantic Nominal
Weisenburg &
Expressive Receptive Mixed Amnesic Mixed
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0317167100025890
McBride
Transcortical Transcortical Mixed
Goldstein Motor Sensory Central Amnesic Global
Motor Sensory Echolalic
Syntactic Pragmatic &
We p man Semantic Global
(Verbal) Jargon
Shuell III (Sensorimotor) I_|-II - f i n IV? I (Simple) V (Severe)
Transcortical Transcortical
Nielsen Cortical Motor Cortical Sensory Conduction Amnesic
Motor Sensory
Bay Cortical Dysarthria Sensory Amnesic Echolalic
Mixed (or)
Brain Expressive Syntactical Central Nominal Dynamic
Total
Afferent Acoustic
Luria Efferent Motor Sensory Semantic Global
Motor Amnesic
Jacobson Contiguity (Combination) Similarity (Selection) Semantic
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Osgood Encoding Decoding
Geschwind, Transcortical Transcortical
Broca's Wernicke's Conduction Anomic Global Isolation
Goodglass etc. Motor Sensory
Motor Sensory Efferent Afferent Transcortical Transcortical
Taxonomic Semantic Anomic Global Isolation
(Broca's) (Wernicke's) Conduction Conduction Motor SensoryLE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES
because they are unrelated to ALAJOUANINE, T. (1956). Verbal realiza- KERTESZ, A. and POOLE. E. (1974). The
tion in aphasia. Brain 79, 1-28. aphasia quotient. Canad. J. Neurol. Sci. 1,
aphasia. 7-16.
Even though aphasic disorders BAY, E. (1964). Principles of classification
and their influence on our concepts of KERTESZ, A. and PHIPPS. J. (1976). Num-
often need to be classified, clinicians aphasia in Disorders of Language. London: erical taxonomy of aphasia. Brain and Lan-
are reluctant to define aphasic types Churchill, 122-142. guage (in press).
according to measurable paramet- B E N T O N , A. (1961). The fiction of the KLE1ST, K. (1916). Uber Leitungsaphasie
ers. Most investigators are satisfied " G e r s t m a n n S y n d r o m e " . J. N e u r o l . , und grammatishe Storungen Monatschsr. f.
with impressions of unmeasured per- Neurosurg. Psychiat. 24, 176-181. Psych, u. Neurol. 40, 118-121.
formance or established criteria on BROCA, P. (1861). Remarques sur le siege de LURIA, A. (1964). Factors and forms of
la faculte du langage articule, suivies d'une aphasia in Disorders of Language. London:
the basis of one, at the most two, observations d'aphemie (perte de la Churchill.
parameters such as the severity or parole). Bull. Soc. Anat. 36, 330-357. MARIE, P. (1906). Revision de la question de
fluency-nonfluency scale. Recently DEJERINE, J. (1892). Contribution a 1'etude I'aphasie: I'aphasie de 1861 a 1866: essai de
attempts were made to define clini- anatomo-pathologique et clinique des dif- critique historique sur la genere de la doc-
cally recognizable aphasic groups ferentes varietes de cecite verbale. C.R. trine de Broca. Sem. Mid. Paris: 26,
according to the performance on cer- Soc. Biol. (Paris) 4, 61-90. 565-571.
tain tests (Vignolo, 1964; Kertesz, GERSTMANN, J. (1927). Fingeragnosie und MOHR, J. P. (1975). Superficial and deep an-
isolierte agraphie ein neues syndrom Z. terosuperior sylvian syndromes. Abstract,
1974). Beyond these intuitive clas- Qes. Neurol. U. Psychiat. 108, 152-177. IV Pan American Congress of Neurology.
sifications (taxonomies) a mathemat- GESCHWIND, N., QUADFASEL, F. A. Oct. 1975. Mexico City. pg. 7.
ical approach to classification be- and SEGARRA, J. (1968). Isolation of the OSGOOD, C. E. and MIRON. M. S. (eds.)
came available to biologists and speech area Neuropsychologia 7, 327-340. (1963). Approaches to the study of aphasia,
clinicians. Numerical taxonomy as it GOLDSTEIN, K. (1924). Das Wesen der am- Urbana Univ., Illinois Press.
is called can provide objective clus- nestischen Aphasie. Schweiz. Arch. J. PENFIELD, W. and ROBERTS, L. (1959).
ters of aphasics on the basis of test Neur. & Psychiat. 15, 163-175. Speech and brain mechanisms. Princeton
GOLDSTEIN, K. (1948). Language & lan- Univ. Press. Princeton, New Jewsey.
scores, free from the constraints of
guage disturbances. New York: Grune & PICK, A. (1913). Die agrammatischen
previous classifications. Stratton. sprachstorungen. Berlin: Springer.
At the bottom of Table 1, the 10 GOODGLASS, H., KAPLAN, E. (1972). As- RUBENS, A. B. (1975). Aphasia with infarc-
groups generated by numerical tax- sessment of aphasia and related disorders. tion in the territory of the anterior cerebral
onomic methods (Kertesz and Philadelphia: Lea & Febiger. artery. Cortex XI, 239.
Phipps, 1976) on 142 stroke patients HEAD, H. (1926). Aphasia and kindred dis- SCHUELL, H. (1964). Aphasia in adults:
orders of speech. New York: Macmillan. diagnosis, prognosis and treatment. Harper
are labelled with due respect to cur- and Row.
H U B E R , W., S T A C H O W I A K , F. J.,
rent terminology and previous clas- POECK, K. and KERSCHENSTEINER, V I G N O L O , L. A. (1964). Evaluation of
sifications. The major addition to the M. (1975). Die Wernicke's aphasie. J. aphasia and Language Rehabilitation: a re-
Goodglass, Kaplan, Geschwind Neurol. 210, 77-97. trospective exploratory study. Cortex I.
344-367.
classification is the splitting of con- ISSERLIN, M. (1936). Aphasie. in Handb. du VIGNOLO, L. A. (1969). Auditory agnosia: a
duction and anomic groups (labelling Neurol. O. Bumke & O. Foerster (eds.) review and report of recent evidence in
them efferent conduction, afferent Berlin, Springer 6, 627-806. contributions to clinical neuropsychology.
conduction, and semantic and JACKSON, J. H. (1879). On affectations of Chicago: Aldine Publ. Co.
speech from diseases of the brain. In W E I S E N B U R G , T. and M c B R l D E , K.
anomic aphasias respectively). Selected Writings, New York: Basic, (1935). Aphasia. New York: Common-
129-145, 1958. wealth Fund
JACOBSON, R. (1964). Towards a linguistic WEPMAN, J. M. (1951). Recovery from
typology of aphasic impairments in Disor- aphasia, New York: Ronald.
ders of Language, London: Churchill, W E R N I C K E , C. (1874). Der aphasische
REFERENCES 21-42. symptomenkomplex. Cohn & Weigart.
ALAJOUANINE, T. et al. (1939). Le syn- JOHNS, D. F. and DARLEY, F. L. (1970). Breslau, in Boston Studies on the
drome de desintegration phonetique dans Phonemic variability in apraxia of speech. Philosophy of Science IV: 196, Dordrecht:
I'aphasie. Paris: Masson. J. Speech and Hearing Res. 13, 556-583. Reidel.
Andrew Kertesz MAY 1976 - 139
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