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Learning in dysphasia
Netbopsychologia,
1970, Vol.
8, pp. 465 to 474.
Pergamon
LEARNING
Press.
Printed
in England
IN DYSPHASIA
G. ETTLINGER and A. M. MOFFETT Institute of Psychiatry, London, S.E.5 and the National Hospital, London, W.C.l (Received 14 March 1970)
Abstract-The performance of a group of dysphasic patients and of a group of non-dysphasic patients (many of whom had verified unilateral cerebral lesions) was compared on tests of: sentence learning, sentence recall, rhythm learning, rhythm recall, word finding and of nonverbal intelligence. In Experiment II a small group of dysphasic subjects was taught to repeat a sequence of 5 names of objects (immediately after failing to name these 5 objects), and was thereafter tested for the ability to name the objects which previously could not be named. It was found that the dysphasic patients were significantly impaired at sentence learning, sentence recall and word finding, but showed only a trend towards impairment at rhythm learning and not even a trend at rhythm recall nor on the test of non-verbal intelligence. In Experiment II it was found that learning a sequence of object names facilitates, but generally does not ensure perfect performance at, object naming. The findings suggest that there might co-exist two disabilities in dysphasia: verbal learning and verbal recall. 1. INTRODUCTION RECENT work on the cerebral organisation of language has various origins. Neurologists have chiefly studied the effects of restricted lesions on different kinds of performance, verbal or “non-verbal”. Thus RUSSELL and ESPIR [I] and HBCAEN and ANGELERGUES [2] have systematically analysed the incidence of different forms of dysphasiain association with the locus of cerebral injury or disease. Or, to take another example, DE RENZI et al. [3] have considered the relationship between dysphasia and impairment on a “non-verbal” sorting task. Linguists, for instance and JAKOBSON [4] and their associates (e.g. GOODGLASS and HUNT [5]) have brought the methods of linguistic analysis to bear on the disordered speech of dysphasics. Psychologists of a statistical inclination have aimed at the classification of the disorders of language in dysphasia by using factor analysis to extract “factors” supposed to underly verbal performances [6, 71. Following the methods of experimental psychology our aim has been more limited: to study learning and recall of two kinds of material (verbal and “non-verbal”) in dysphasic patients and to determine whether rote memorisation of a sequence of words that could not be individually produced as the names of objects will facilitate subsequent naming of the same objects. With our case-material we wish to draw no conclusions regarding the localisation of the responsible lesions. Nor is it our intention to explore the nature of the dysphasic disturbances in our cases by reference to qualitative observations (although responses were recorded verbatim). Our point of departure was the report by ZANGWILL [8] that earlier findings and his own observations indicated a severe impairment of verbal learning in cases with evidence of (or a history of) dysphasia. Although much evidence has accumulated since 1946 that left-sided cerebral lesions (particularly of the temporal lobe) are associated with such a verbal learning defect in non-dysphasic subjects, we have been able to find only in the recent 46.5
466
G. ETTLINGERand A. M. MOFFETT
review by KREINDLER and FRADIS [9] an extension of ZANGWILL’S work for dysphasic patients. (Insufficient information is however provided by KREINDLER and FRADIS to allow a proper understanding defect in the dysphasic
of their findings.) Various questions arise: (i) is the verbal learning patient merely a component of a more general disorder of learning,
extending also to “non-verbal” material? (The evidence for non-dysphasic left-sided cases is strongly for a selective verbal defect not associated with impaired learning of “non-verbal” material.)
(ii) Can the verbal learning
defect be shown to exist reliably (i.e. other than by
chance) in an un-selected (i.e. consecutive) series of dysphasic patients? (iii) Is there a relationship between the defect of verbal learning in dysphasia and the level of performance on a “non-verbal” intelligence test? (iv) If the dysphasic patient has memorised verbal material in a standard manner to a criterion (so that any excessive number of trials required to learn can now be argued to be irrelevant), ficiently as the non-dysphasic subject ? dysphasic patients, can this impairment
is he able to recall what he has learnt as pro-
(v) If performance at verbal recall is impaired in be regarded as largely secondary to the defect of
verbal learning, or is there evidence for an independent defect in the process of verbal recall ? (vi) To what extent is it possible to demonstrate defects of verbal learning and/or recall in dysphasia
by the use of familiar
We have attempted
(i.e. previously
learnt) material
such as object-names?
to find answers to all of these questions.
METHODS Subiects Group A comprises 27 patients, all dysphasic, drawn from the National Hospital, the Guys-Maudsley Neurosuraical Unit or from the Department of Neurosurgery - _ of the Whittington Hospital. These patients were seen-in the period June 1961-july 1964 and formed a pilot group for w&k to be done with Group B. A patient from Group A is included in this report only when examined for the ability to learn names (see Expt. II). Group B comprises 73 patients, all seen at the National Hospital between February 1966 and May 1969. Thirteen patients were excluded because either they were found to have evidence of bilateral cerebral lesions or of secondary carcinoma, or were found to be over 60 years of age, or were inadequately examined or failed to complete the examination; a further patient was excluded for lack of evidence of an intracerebral lesion. The remaining 59 patients were all: aged between 16-60 yr inclusive; able to pass two screening tests (naming the days of the week and months of the year); either dysphasic or judged to have an intracerebral lesion on surgical or radiological evidence; without evidence (surgical, radiological, EEG or clinical) of bilateral cerebral involvement or of secondary deposits. Clinical details of these patients are available from the authors on request. The great majority of patients were seen at 5-21 days after surgery (e.g. removals of glioma, angioma, meningioma or haematoma), but some after vascular accidents, and a few before surgery. On final review of the case notes, 5 patients (3 dysphasic, 2 non-dysphasic) were thought possibly to have bilateral involvement. Classification of dysphasia In most cases there was no doubt whether dysphasia was present or not, and if present of its kind. In some cases there was uncertainty: agreement was then sought between the opinion of the author examining the patient and the opinion stated in the hospital notes (neurological and/or psychological). If there remained a discrepancy of opinion (which might be expected for patients rapidly deteriorating or recovering) then the patient was carefully tested for interpretation of proverbs or for naming with the “microscope”, “telescope”, “periscope” series and on other tests. If there still remained genuine doubt concerning the presence of dysphasia, the patient was classified as not dysphasic: if concerning the kind of dysphasia, as mixed. The 59 patients were by this method subdivided into 31 cases of dysphasia and 28 patients without dysphasia. Examination for Experiment I Tasks. (1) Correct learning of a sentence, (2) correct reproduction of a rhythm, (3) naming of 12 individual objects, (4) performance of a non-verbal test of intelligence, (5) recall of the sentence previously learnt, and (6) recall of the rhythm previously learnt.
LEARNING
46-l
IN DYSPHASIA
Materials. For tasks (1) and (5) the sentence “Tom Brown’s dog ran quickly down the road with a huge bone in his mouth” (Terman-Merrill Scale, XIII, 3); for tasks (2) and (6) the rhythm l*l.l.l-1--1~1~1~1-1-1-1~1~1~1, where a vertical stroke represents a tap andthedotsand dashes of varying length indicate the durations between taps; for task (3) ring, watch, ball, dog, toy-car, shoe (all oc&r iO0 0; more times/million words), flag, apple (50_99/million)i sponge, thermometer (12/ million). bicycle (ll/million). kite (IO/million)-all freauencies from Thorndike and Lorae UOl-all were solid objects; seen bbt not t&ched,- except fo; bicycle aid kite which were line drawings _ fir task (4) the standard coloured blocks and designs of the Passalong Test (a non-verbal test of intelligence). Order of tasks: sentence learning was given to half the subjects before rhythm reproduction, and in the reverse order for the remainder, but a particular sequence was always retained for both initial learning and subsequent recall; tasks (3) and (4) were always presented in that order between tasks (2) and (5). Procedure. Sentences were repeated and rhythms reproduced (alternately by the examiner and the patient) until the patient was correct once, up to a maximum of 15 trials; for stages (5) and (6) the patient was asked : “Do you remember you learnt a sentence (rhythm) earlier on? I would like to see how much of it you can remember; please repeat any words (tap any parts) you can remember”; after this “zero” trial, the original learning procedure was resumed until performance was again correct. The time was recorded at the beginning and end of all tasks; and at least 30 min were allowed between the end of task (2) and the beginning of task (5), so that on the average there was an interval of about 35 min between learning of a task and recall of the same task. (Impairment at learning task (2) or at recall of task (5) would add, at most, a few minutes to the interval between tasks (1) and (5) or tasks (2) and (6) respectively.) Examination for Experiment II Only those patients in Groups A or B who failed to name 6 of the 10 or 12 objects correctly became subjects in this experiment. The 10 objects to be named by patients of Group A were: soap, chalk, paperclip, electric plug, sealing-wax, button, buckle, lock, cork, lip-stick; the 12 objects used with patients of Group B have already been described. Procedure. (1) The patient was asked to name again 6 objects he had failed to name in task (3) of Experiment I: (2) after the objects had been removed the names of 5 objects which were incorrectly named at this second attempt were repeated in the same order trial by trial alternately by the examiner and by the patient until 2 successive repetitions of the 5-name sequence by the patient were correct; (3) the 5 objects were individually presented for naming two times in new orders (different from the sequence used during learning of the names), or twice in the original order (the same sequence as during learning), or in some combination of new and original sequences.
RESULTS Experiment
I
Performance scores for subjects of Group B are shown in Tables 1 and 2. The scores in columns (i)-(iv) represent trials to one correct reproduction. If performance was incorrect on the 15th trial the patient was given a score of 16. In columns (ii) and (iv) scores represent trials to one correct reproduction but exclude the “zero” trial, so that a score of 1 signifies that performance was incorrect on the “zero” trial but correct after the examiner had once read the sentence or tapped the rhythm. It should be noted that scores for recall [columns (ii) and (iv)] are available only for patients who learnt within 15 trials; and that the scores in columns (i)-(v) are neither normally nor continuously distributed. Statistical analyses. The mean age of the dysphasic patients was greater (at 45.5 yr) than that of the controls (39.5). Therefore learning and recall were treated by ana!yses of covariance with age as the controlled variable:
1. The dysphasic patients 56, 1, 1, p=
were significantly
impaired
at sentence
2. Considering only patients giving recall scores for both sentences phasic patients were significantly impaired at sentence recall p=
learning
(F=25.6,
cif
and rhythms, the dys(F= 10.3, df 27, I, 1,
G. ETTLINGER and A. M. MOFF~TT
46X
Table 1. Results of Experiment
(ii)
(i) Serial No. 2 3 10 12 13 16 17 20 21 22 25 26 27 29 31 32 35 37 38 41 43 45 48 49 50 53 55 56 59 60
(iii)
Sentence Learning 16 16 6 16 2 16 16 1 16 16 5 16 16 1 16 16 16 16 2 2 2 3 5 16 7 5 1
16 16 16
I for dysphasic subjects
(iv) Rhythm
Recall
Learning 16 16 10 16 3 16 8 2 16 16 2 16 16 16 16 6 16 16 2 16 3 3 14 9 4 4 16 16 16 16 16
(v) Words
(vi) Passalong
Recall
1
1 1 5 6
10 3 12 3 12 10 2 12 8 12 12 1 5 12 9 8 12 11 11 12 8 11 10 12 12 12 12 9 7 9 3
40 41 55 45 41 50 17 43 18 26 31 7 0
4.9 5 61 14 17 43 60 43 53 73 33 56 49 25 67 44 28 17
Figures in columns (i)-(iv) represent trials to one correct reproduction, in column (v) the number of objects correctly named, and in column (vi) the score on the Passalong Test.
3. The dysphasic patients tended towards worse performance at rhythm learning (F= 3.1, cff 56, 1, I,p=
LEARNING
Table 2. Results of Experiment (ii)
6) Serial No. 1 4 5 6 8 9 11 14 15 18 19 23 24 28 30 33 34 36 40 42 44 46 47 51 52 54 57 58
1 2 1 3 1 3 1 1 1 1 1 1 1 1 2 2 16 1 16 2 2 3 2 1 1 1 1 1
I for non-dysphasic
(iii)
Sentence Learning
469
IN DYSPHASIA
(iv) Rhythm
Recall 3 1 1 2 1 2 1 1 1 2 1 1 1 1 1 1 1 1 1 1 2 1 1 1
1 1
Learning
subjects
(v) Words
(vi) Passalong
12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 11 11 12 12 12 12 12 12 12 12 12 12 12
4 56 45 14 10 12 44 53 45 44 68 14 78 5 48 29 16 46 9 18 42 40 58 9 49 61 14 37
Recall 1 1 1
4 5 2 16 2 16 16 7 1 5 1 3 4 16 14 9 16 7 16 8 4 6 5 16 16 6 2 7
1 16 2 2 1 2 4 1 11+ 5 8 0 6+ 0 1 1 4
Figures have the same meaning as in Table 1. The symbol incorrect on the stated trial.
+ signifies that performance
was still
of the controls at 34.6 (t =0.52, p= ~0.25). There was a significant difference between the dysphasic and non-dysphasic patients at word naming (means of 9-l words against 11.9 words t = 4.49, p = < 0.001,when allowance is made in assessing the degrees of freedom for unequal variances). It should be noted that a different outcome is obtained when comparing the sentence and rhythm recall of the two groups if account is taken of learning performance in evaluating recall. Thus the mean savings for all the dysphasic subjects are 16-l and 25.9 per cent respectively for sentences and rhythms, compared with 6.6 and 30.5 per cent for sentences and rhythms for the non-dysphasic patients. (These values are computed by using the formula : learning
score -retention
score x 1o.
learning
score + retention
score
for each subject, and then finding savings of the dysphasic subjects at of original learning scores of I in when there is no real possibility of
the group mean.) It is possible to interpret the higher sentence learning as due to either (a) the higher incidence the control group, lowering the savings for this group re-learning in “zero” trials, or (b) contamination of the
G. ETTLINGERand A. M. MOFFETT
470
savings measure for the dysphasic subjects by their significantly worse performance at learning, giving a savings value which is too high. No statistical analyses have compared dysphasic patients with non-dysphasic patients, taking non-dysphasic cases of left-sided and right-sided cerebral lesions separately, because we lack confidence in the precise lateralisation of the lesions in all of our patients. However, we have sub-divided the dysphasic group into four types of disability; the analyses of covariance against age then show: 1. No difference
between
sub-groups
at sentence
learning
(F= 1.02, df26,
1, 3, p
2. Significant variation between sub-groups at sentence recall (F=20.6, df 5, 1, 3, I’=
between
sub-groups
at rhythm
learning
(F=0.56,
4. No difference
between
sub-groups
at rhythm
recalf (F=0.099,
df 26, 1, 3, p= ~0.65).
df5,1,3, p= <0.96).
Experiment II It was not possible to include all patients making 6 or more errors at word naming in Experiment II (for lack of time, tiredness, etc.). However, 5 patients of Group A and 4 of Group B became subjects in this experiment. (The higher proportion of Group A patients is accounted for by the greater difficulty of the objects used with Group A than Group B, so that more Group A patients made errors at naming objects.) Of the 9 subjects, 1 in Group A and 1 in Group B (case 3) failed to learn a sequence of 5 object names after 15 repetitions. Another patient of Group B (case 10) gave up after 7 repetitions of the 5-name sequence. (In general, patients found it more distressing to be unable to learn a 5-name sequence than to fail to learn the longer sentence of Experiment I.) These 3 patients were not tested for object naming after failing to learn the names. Details of the performance of the remaining 6 patients are shown in Table 3. The findings can only be considered as tentative owing to variations in procedure and differences in the severity and kind of dysphasia shown by the different patients. Given such reservations, it appears that: (1) learning a sequence of 5 names facilitates immediately subsequent naming of 5 objects (which, prior to the learning, could not be named on two occasions); (2) even when a sequence of names has twice been repeated without error, naming of real objects can still be impaired (only one case, No. A21, made no error with real objects); (3) the order of testing with real objects is not important (e.g. Case A6 made both of her 2 errors when the order of presentation was the same as the order of learning the names; and no other differences emerged in relation to the order of the presentation of the objects); (4) the facilitation of object naming consequent upon learning the sequence of names is not merely a non-specific result of increased frequency of hearing the names (because Case Al3 did no better after 11 repetitions than Cases A6, A8 or A21 after 2 or 3 repetitions; and Cases B16 and B60, who had failed to learn, did rather worse than the remaining cases when tested for naming of real objects). DISCUSSION Our findings are in agreement with those of ZANGWILL [S] that dysphasic patients are more severely impaired than at least certain other categories of neurological patient (e.g.
LEARNING
471
IN DYSPHASIA
Table 3. Effect of learning object names on naming objects
Gp.
Serial No.
Type of Dysphasia
Clinical Diagnosis
Errors in Naming before Learning
Trials to learn 5 Names
Errors in Naming after Learning
Order (see legend)
A
6
Nominal
?L. Hem. glioma
5 in 10
2
2 in 10
5 original 5 new
A
8
Mixed
L. parietotemporal atrophy
6 in 10
3
1 in 10
10 original
A
13
Nominal
L. temporal lobectomy
6 in 10
11
2 in 10
10 new
21
Mixed
?L. Hem. V.A.
6in 10
2
Oin 10
5 original 5 new
16
Mixed
L. temporal angioma
10 in 12
15+ (failed)
2 in 5
5 new
60
Receptive
L. temporoparietal haematoma
9 in 12
5+ (gave up)
3 in 5
5 original
Patients of Gp. A and Gp. B were tested on different objects (see text). Errors made in naming objects before learning are for a series of 10 objects (Gp. A) or 12 objects (Gp. B). Trials to learn a sequence of 5 object names are given to the first of 2 successively correct repetitions. The symbol + indicates that the patient failed to give 2 correct repetitions within the stated number of trials. After learning, the 5 objects were presented for naming either once or twice, and either in the same order as used for learning of the 5 names (=“original” order) or in a different order (=“new” order).
non-dysphasics) at verbal learning. (Our findings do not, however, extend to amnesic patients.) In addition, we have new evidence that dysphasic subjects are significantly impaired at recalling a sentence after an interval of about 3.5 min. Our procedure was designed to ensure that the sentence had, apparently, been learnt as proficiently (i.e. to one correct repetition) by the dysphasic as by the non-dysphasic patients (even though more trials might be required by one group to achieve this level of performance). Moreover, to the extent that our dysphasic subjects were not significantly slower than the control patients in learning to reproduce rhythms, their verbal learning defect can be argued not to reflect a non-specific disorder of learning extending to all classes of material. (This argument is weakened, however, because (a) with larger groups of subjects the dysphasic patients might have been shown to be significantly impaired at rhythm learning; and because (b) the significant correlations between sentence learning and both Passalong score and rhythm learning may indicate that some of the variance at sentence learning may be related to non-verbal abilities.) Since our dysphasic patients recalled rhythms as proficiently as the non-dysphasic patients (considering only subjects giving recall scores for both sentences and rhythms), their impaired recall of sentences does not reflect a non-selective disorder of recall or retention, extending to all classes of material.
472.
G. ETTLINGER and A. M. MOFFETT
If we have, then, evidence for impaired verbal learning and recall in our dysphasic group, we can ask to what extent the disorder of recall is dependent upon the defect of learning. There is no clear-cut answer. However, the savings measures suggest that if account is taken of retarded verbal learning then the retardation of verbal recall is commensurate in degree (so that the mean savings for sentences is, if anything, greater for the dysphasic than non-dysphasic patients). In contrast, inspection of performance on the “zero” trial of sentence recall (where the patient was asked to say what he remembered of the sentence before hearing it again from the examiner) suggests a different outcome: spontaneous (i.e. unprompted) recall seems much more disorganised in many of the dysphasic than the nondysphasic records. If, then, we might entertain the possibility that separable disorders of verbal learning and of verbal recall co-exist in dysphasia, can the findings of Experiment II be held to be contributory? The subjects of this experiment were few, and their experimental treatment diverse. Subject to the qualification that our findings in this experiment can, at best, be considered merely suggestive, it seems that rote memorisation of object names can overcome, but only in part, the defect of dysphasic patients in naming the appropriate object. No attempt was made to teach the dysphasic subjects to associate objects with their names. Instead, 5 object names were repeated by the examiner (always in the same order) until the patient was able to repeat these names on 2 consecutive attempts. Successful learning of such a sequence of object names generally failed to ensure correct naming of the actual objects (presented one at a time) immediately after the learning procedure. This finding supports the notion that dysphasic patients have defective verbal recall (the requirements of learning names and of naming objects were sufficiently different to preclude successful perfomrance on the naming task through rote recall of the learnt sequence). Moreover, the difficulty of many dysphasic subjects in learning a sequence of 5 names supports the evidence from Experiment I for an impairment of verbal learning. With the reservations already stated it appears, then, that certain of our dysphasic patients may have shown defects of both verbal learning and verbal recall. Brief mention should be made of the trend for dysphasic patients to be impaired at rhythm learning. BOLLER and DE RENZI [l l] have discussed their own and earlier findings tasks (e.g. finding hidden figures, of impairment by dysphasic patients on “non-verbal” recognising meaningless figures, etc.). Impaired learning of rhythms might be attributed to a “verbal” component in a “non-verbal” task. However, there was no trend towards Instead, there was a tendency towards a worse rhythm recall by the dysphasic patients. correlation between poor rhythm learning and increasing age (for all subjects). The significance of these findings is not clear. However, this test has proved both simple and meaningful as a measure of recall (the savings scores of both groups are superior for rhythms than for sentences, although sentences were learnt more rapidly by both groups). In analysing the results we sub-divided the dysphasic patients by the type of their dysphasia. Such classification was done less confidently than assignment to the dysphasic/ non-dysphasic groups. Only one analysis reaches significance: sentence recall. This finding relies, however, on groups of only 3, 3, 2 and 2 patients (because in the analyses of recall only patients giving recall scores on both sentences and rhythms were included). We are therefore reluctant to place too much weight on this finding (ahhough it could have occurred by chance only 3 times in 1000 cases); and more particularly because the subgroup with the more severe impairment of sentence recall, the “mixed” dysphasics, also included the most severe cases of dysphasia in our sample.
LEARNINGIN DYSPHASIA
473
In conclusion, we have confirmed the findings of ZANGWILL [8] and extended them to a series of patients unselected by defect, comparing their performance on a verbal and nonverbal task; and we have, perhaps, provided suggestive if not compelling evidence for an impairment of verbal recall in addition to that of verbal learning in dysphasia. Ackno~~[edgementse are grateful to the Physicians and Surgeons of the National Hospital, to Mr. M. A. FALCONERof the Guys-Maudsley Neurosurgical Unit and to Mr. I. MCCAUL of the Whittington Hospital for permission to examine patients under their care. To Dr. R. T. C. PRATTwe are especially grateful for making all our facilities at the National Hospital available to us, and for help with the preparation of this paper. We thank Mr. B. EVERIT~and Mr. 0. WHITE for help with the statistical computations and Mr. kindly commented A. D. MILNERand Mr. R. E. PASSINGHAM for stimulating discussion. Dr. H. H~~CAEN on an early draft of the paper. Miss A. M. MOFFETTwas supported by a grant from the M.R.C.
REFERENCES 1. RUSSELL,W. R. and ESPIR, M. L. E. Traumatic Aphasia. Oxford University Press, Oxford, 1961. R. Pathologie du Language. Larousse, Paris, 1965. 2. HBCAEN,1-I. and ANGELERGUES, 3. DE RENZI, E., FAGLIONI,P., SAVOIARDO,M. and VIGNOLO,L. A. The influence of the hemispheric side of the cerebral lesion on abstract thinking. Cortex 2, 399420, 1966. 4. JAKOBSON,R. Towards a linguistic typology of aphasic impairments. In Disorders of Language,A.V.S. DE REUCK and M. O’CONNOR(Eds.). Churchill, London, 1969. 5. GOODGLASS,H. and HUNT, J. (19%) Grammatical complexity and aphasic speech. Word 14, 197-207, 1958. 6. SCHUELL,H., JENKINS,J. L. and CARROLL,J. B. A factor analysis of Minnesota Test for Differential Diagnosis of Aphasia. J. Speech Hear. Dis. 27, 349-369, 1962. 7. JONES,L. V. and WEPMAN,J. M. Dimensions of language performance in aphasia. J. Speech Hear. Dis. 26, 220-232,
1961.
8. ZANGWILL,0. L. Some qualitative observations on verbal memory in cases of cerebral lesion. Br. J. Psycho/. 37, 8-19, 1946. 9. KREINDLER,A. and FRADIS,A. Performances in Aphasia. Gauthier-Villars, Paris, 1968. 10. THORNDIKE,E. L. and LORGE, I. The Teachers Word Book of 30,000 Words. Columbia University, New York, 1944. II. BOLLER,F. and DE RENZI, E. Relationship between visual memory defects and hemispheric locus of lesion. Netrrology 17, 1052-1058, 1967. Resume-Les performances d’un groupe de sujets dysphasiques et d’un groupe de sujets non dysphasiques dont beaucoup avaient des lesions verifiees unilaterales Ctaient comparees selon leurs rtsultats a des tests de: apprentissage de phrases, rappel de phrases, apprentissage de rythmes, rappel de rythmes, denomination verbale et tests d’intelligence non-verbale. Dans une deuxieme experience, on apprenait a un petit groupe de sujets dysphasiques a r&peter une sequence de 5 noms d’objets (immediatement apres avoir echo& a nommer ces 5 objets), et ces sujets etaient retest& sur leur capacite a nommer les objets qui n’avaient pu Ctre anterieurement denommts. 11fut trouvt que les patients dysphasiques Ctaient deficitaires de facon significative dans l’apprentissage des phrases, le rappel de phrases et la denomination, mais qu’il n’existait seulement qu’une tendance au deficit dans l’apprentissage de rythmes et qu’aucun deficit n’ttait constate dans le test de rappel de rythmes et dans les tests d’intelligence non-verbale. L’experience no 2 montrait que l’apprentissage des sequences de noms d’objets facilitait, sans cependant permettre une performance totalement correcte, la denomination verbale ulttrieure. Ces constatations suggerent que deux deficits pourraient coexister dans la dysphasie: l’un portant sur l’apprentissage verbal, et l’autre sur le rappel verbal. Zusammenfassung-Das Leistungsvermijgen einer Gruppe aphasischer Kranker und einer solchen nicht-aphasischer Patienten (die meisten davon hatten eine verifizierte einseitige cerebrale Schldigung) wurde anhand folgender Tests untersucht: Lernen von Satzen, Wiedergabe von Sltzen, Lemfahigkeit fiir Rhythmen, Rtickerinnerung an Rhythmen, Wortfindung sowie Prtifung der nichtverbalen Intelligenz. In einem 2. Experiment wurde einen kleiner Gruppe von aphasischen Patienten beigebracht, eine Folge van 5 Namen ftir Objekte zu wiederholen (und zwar unmittelbar, nachdem sie bei BeneMuna dieser 5 Obiekte versagten), im Anschluss paran wurde die Fahigkeit der Objektbenennung geprtift, die vorher misslang.
414
G. ETTLINGER
and A. M.
MOFFETT
Es ergab sich, dass aphasische Kranke in signifikanter Weise zur Erlernung von Satzen sowie zur Wiedererinnerung an Satze und zur Wortfindung unfahig waren, dagegen fand sich nur ein leichter Trend zum Versagen beim Erlernen von Rhythmen. Beim Rtickerinnern an Rhythmen und such bei Prtifung der nicht-verbalen Intelligenz war dieser Trend nicht festzustellen. In dem 2. Experiment zeigte es sich, dass die Erlernung einer Objektnamensreihe die Objektbenennung erleichtert, aber keineswegs eine perfekte Leistung garantiert. Die Ergebnisse sprechen dafur, dass es zwei koexistierende Storungssyndrome bei Aphasischen gibt, nimlich fur sprachgebundenes Lernen und sprachliches Zurtickerinnern.
1970, Vol.
8, pp. 465 to 474.
Pergamon
LEARNING
Press.
Printed
in England
IN DYSPHASIA
G. ETTLINGER and A. M. MOFFETT Institute of Psychiatry, London, S.E.5 and the National Hospital, London, W.C.l (Received 14 March 1970)
Abstract-The performance of a group of dysphasic patients and of a group of non-dysphasic patients (many of whom had verified unilateral cerebral lesions) was compared on tests of: sentence learning, sentence recall, rhythm learning, rhythm recall, word finding and of nonverbal intelligence. In Experiment II a small group of dysphasic subjects was taught to repeat a sequence of 5 names of objects (immediately after failing to name these 5 objects), and was thereafter tested for the ability to name the objects which previously could not be named. It was found that the dysphasic patients were significantly impaired at sentence learning, sentence recall and word finding, but showed only a trend towards impairment at rhythm learning and not even a trend at rhythm recall nor on the test of non-verbal intelligence. In Experiment II it was found that learning a sequence of object names facilitates, but generally does not ensure perfect performance at, object naming. The findings suggest that there might co-exist two disabilities in dysphasia: verbal learning and verbal recall. 1. INTRODUCTION RECENT work on the cerebral organisation of language has various origins. Neurologists have chiefly studied the effects of restricted lesions on different kinds of performance, verbal or “non-verbal”. Thus RUSSELL and ESPIR [I] and HBCAEN and ANGELERGUES [2] have systematically analysed the incidence of different forms of dysphasiain association with the locus of cerebral injury or disease. Or, to take another example, DE RENZI et al. [3] have considered the relationship between dysphasia and impairment on a “non-verbal” sorting task. Linguists, for instance and JAKOBSON [4] and their associates (e.g. GOODGLASS and HUNT [5]) have brought the methods of linguistic analysis to bear on the disordered speech of dysphasics. Psychologists of a statistical inclination have aimed at the classification of the disorders of language in dysphasia by using factor analysis to extract “factors” supposed to underly verbal performances [6, 71. Following the methods of experimental psychology our aim has been more limited: to study learning and recall of two kinds of material (verbal and “non-verbal”) in dysphasic patients and to determine whether rote memorisation of a sequence of words that could not be individually produced as the names of objects will facilitate subsequent naming of the same objects. With our case-material we wish to draw no conclusions regarding the localisation of the responsible lesions. Nor is it our intention to explore the nature of the dysphasic disturbances in our cases by reference to qualitative observations (although responses were recorded verbatim). Our point of departure was the report by ZANGWILL [8] that earlier findings and his own observations indicated a severe impairment of verbal learning in cases with evidence of (or a history of) dysphasia. Although much evidence has accumulated since 1946 that left-sided cerebral lesions (particularly of the temporal lobe) are associated with such a verbal learning defect in non-dysphasic subjects, we have been able to find only in the recent 46.5
466
G. ETTLINGERand A. M. MOFFETT
review by KREINDLER and FRADIS [9] an extension of ZANGWILL’S work for dysphasic patients. (Insufficient information is however provided by KREINDLER and FRADIS to allow a proper understanding defect in the dysphasic
of their findings.) Various questions arise: (i) is the verbal learning patient merely a component of a more general disorder of learning,
extending also to “non-verbal” material? (The evidence for non-dysphasic left-sided cases is strongly for a selective verbal defect not associated with impaired learning of “non-verbal” material.)
(ii) Can the verbal learning
defect be shown to exist reliably (i.e. other than by
chance) in an un-selected (i.e. consecutive) series of dysphasic patients? (iii) Is there a relationship between the defect of verbal learning in dysphasia and the level of performance on a “non-verbal” intelligence test? (iv) If the dysphasic patient has memorised verbal material in a standard manner to a criterion (so that any excessive number of trials required to learn can now be argued to be irrelevant), ficiently as the non-dysphasic subject ? dysphasic patients, can this impairment
is he able to recall what he has learnt as pro-
(v) If performance at verbal recall is impaired in be regarded as largely secondary to the defect of
verbal learning, or is there evidence for an independent defect in the process of verbal recall ? (vi) To what extent is it possible to demonstrate defects of verbal learning and/or recall in dysphasia
by the use of familiar
We have attempted
(i.e. previously
learnt) material
such as object-names?
to find answers to all of these questions.
METHODS Subiects Group A comprises 27 patients, all dysphasic, drawn from the National Hospital, the Guys-Maudsley Neurosuraical Unit or from the Department of Neurosurgery - _ of the Whittington Hospital. These patients were seen-in the period June 1961-july 1964 and formed a pilot group for w&k to be done with Group B. A patient from Group A is included in this report only when examined for the ability to learn names (see Expt. II). Group B comprises 73 patients, all seen at the National Hospital between February 1966 and May 1969. Thirteen patients were excluded because either they were found to have evidence of bilateral cerebral lesions or of secondary carcinoma, or were found to be over 60 years of age, or were inadequately examined or failed to complete the examination; a further patient was excluded for lack of evidence of an intracerebral lesion. The remaining 59 patients were all: aged between 16-60 yr inclusive; able to pass two screening tests (naming the days of the week and months of the year); either dysphasic or judged to have an intracerebral lesion on surgical or radiological evidence; without evidence (surgical, radiological, EEG or clinical) of bilateral cerebral involvement or of secondary deposits. Clinical details of these patients are available from the authors on request. The great majority of patients were seen at 5-21 days after surgery (e.g. removals of glioma, angioma, meningioma or haematoma), but some after vascular accidents, and a few before surgery. On final review of the case notes, 5 patients (3 dysphasic, 2 non-dysphasic) were thought possibly to have bilateral involvement. Classification of dysphasia In most cases there was no doubt whether dysphasia was present or not, and if present of its kind. In some cases there was uncertainty: agreement was then sought between the opinion of the author examining the patient and the opinion stated in the hospital notes (neurological and/or psychological). If there remained a discrepancy of opinion (which might be expected for patients rapidly deteriorating or recovering) then the patient was carefully tested for interpretation of proverbs or for naming with the “microscope”, “telescope”, “periscope” series and on other tests. If there still remained genuine doubt concerning the presence of dysphasia, the patient was classified as not dysphasic: if concerning the kind of dysphasia, as mixed. The 59 patients were by this method subdivided into 31 cases of dysphasia and 28 patients without dysphasia. Examination for Experiment I Tasks. (1) Correct learning of a sentence, (2) correct reproduction of a rhythm, (3) naming of 12 individual objects, (4) performance of a non-verbal test of intelligence, (5) recall of the sentence previously learnt, and (6) recall of the rhythm previously learnt.
LEARNING
46-l
IN DYSPHASIA
Materials. For tasks (1) and (5) the sentence “Tom Brown’s dog ran quickly down the road with a huge bone in his mouth” (Terman-Merrill Scale, XIII, 3); for tasks (2) and (6) the rhythm l*l.l.l-1--1~1~1~1-1-1-1~1~1~1, where a vertical stroke represents a tap andthedotsand dashes of varying length indicate the durations between taps; for task (3) ring, watch, ball, dog, toy-car, shoe (all oc&r iO0 0; more times/million words), flag, apple (50_99/million)i sponge, thermometer (12/ million). bicycle (ll/million). kite (IO/million)-all freauencies from Thorndike and Lorae UOl-all were solid objects; seen bbt not t&ched,- except fo; bicycle aid kite which were line drawings _ fir task (4) the standard coloured blocks and designs of the Passalong Test (a non-verbal test of intelligence). Order of tasks: sentence learning was given to half the subjects before rhythm reproduction, and in the reverse order for the remainder, but a particular sequence was always retained for both initial learning and subsequent recall; tasks (3) and (4) were always presented in that order between tasks (2) and (5). Procedure. Sentences were repeated and rhythms reproduced (alternately by the examiner and the patient) until the patient was correct once, up to a maximum of 15 trials; for stages (5) and (6) the patient was asked : “Do you remember you learnt a sentence (rhythm) earlier on? I would like to see how much of it you can remember; please repeat any words (tap any parts) you can remember”; after this “zero” trial, the original learning procedure was resumed until performance was again correct. The time was recorded at the beginning and end of all tasks; and at least 30 min were allowed between the end of task (2) and the beginning of task (5), so that on the average there was an interval of about 35 min between learning of a task and recall of the same task. (Impairment at learning task (2) or at recall of task (5) would add, at most, a few minutes to the interval between tasks (1) and (5) or tasks (2) and (6) respectively.) Examination for Experiment II Only those patients in Groups A or B who failed to name 6 of the 10 or 12 objects correctly became subjects in this experiment. The 10 objects to be named by patients of Group A were: soap, chalk, paperclip, electric plug, sealing-wax, button, buckle, lock, cork, lip-stick; the 12 objects used with patients of Group B have already been described. Procedure. (1) The patient was asked to name again 6 objects he had failed to name in task (3) of Experiment I: (2) after the objects had been removed the names of 5 objects which were incorrectly named at this second attempt were repeated in the same order trial by trial alternately by the examiner and by the patient until 2 successive repetitions of the 5-name sequence by the patient were correct; (3) the 5 objects were individually presented for naming two times in new orders (different from the sequence used during learning of the names), or twice in the original order (the same sequence as during learning), or in some combination of new and original sequences.
RESULTS Experiment
I
Performance scores for subjects of Group B are shown in Tables 1 and 2. The scores in columns (i)-(iv) represent trials to one correct reproduction. If performance was incorrect on the 15th trial the patient was given a score of 16. In columns (ii) and (iv) scores represent trials to one correct reproduction but exclude the “zero” trial, so that a score of 1 signifies that performance was incorrect on the “zero” trial but correct after the examiner had once read the sentence or tapped the rhythm. It should be noted that scores for recall [columns (ii) and (iv)] are available only for patients who learnt within 15 trials; and that the scores in columns (i)-(v) are neither normally nor continuously distributed. Statistical analyses. The mean age of the dysphasic patients was greater (at 45.5 yr) than that of the controls (39.5). Therefore learning and recall were treated by ana!yses of covariance with age as the controlled variable:
1. The dysphasic patients 56, 1, 1, p=
were significantly
impaired
at sentence
2. Considering only patients giving recall scores for both sentences phasic patients were significantly impaired at sentence recall p=
learning
(F=25.6,
cif
and rhythms, the dys(F= 10.3, df 27, I, 1,
G. ETTLINGER and A. M. MOFF~TT
46X
Table 1. Results of Experiment
(ii)
(i) Serial No. 2 3 10 12 13 16 17 20 21 22 25 26 27 29 31 32 35 37 38 41 43 45 48 49 50 53 55 56 59 60
(iii)
Sentence Learning 16 16 6 16 2 16 16 1 16 16 5 16 16 1 16 16 16 16 2 2 2 3 5 16 7 5 1
16 16 16
I for dysphasic subjects
(iv) Rhythm
Recall
Learning 16 16 10 16 3 16 8 2 16 16 2 16 16 16 16 6 16 16 2 16 3 3 14 9 4 4 16 16 16 16 16
(v) Words
(vi) Passalong
Recall
1
1 1 5 6
10 3 12 3 12 10 2 12 8 12 12 1 5 12 9 8 12 11 11 12 8 11 10 12 12 12 12 9 7 9 3
40 41 55 45 41 50 17 43 18 26 31 7 0
4.9 5 61 14 17 43 60 43 53 73 33 56 49 25 67 44 28 17
Figures in columns (i)-(iv) represent trials to one correct reproduction, in column (v) the number of objects correctly named, and in column (vi) the score on the Passalong Test.
3. The dysphasic patients tended towards worse performance at rhythm learning (F= 3.1, cff 56, 1, I,p=
LEARNING
Table 2. Results of Experiment (ii)
6) Serial No. 1 4 5 6 8 9 11 14 15 18 19 23 24 28 30 33 34 36 40 42 44 46 47 51 52 54 57 58
1 2 1 3 1 3 1 1 1 1 1 1 1 1 2 2 16 1 16 2 2 3 2 1 1 1 1 1
I for non-dysphasic
(iii)
Sentence Learning
469
IN DYSPHASIA
(iv) Rhythm
Recall 3 1 1 2 1 2 1 1 1 2 1 1 1 1 1 1 1 1 1 1 2 1 1 1
1 1
Learning
subjects
(v) Words
(vi) Passalong
12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 11 11 12 12 12 12 12 12 12 12 12 12 12
4 56 45 14 10 12 44 53 45 44 68 14 78 5 48 29 16 46 9 18 42 40 58 9 49 61 14 37
Recall 1 1 1
4 5 2 16 2 16 16 7 1 5 1 3 4 16 14 9 16 7 16 8 4 6 5 16 16 6 2 7
1 16 2 2 1 2 4 1 11+ 5 8 0 6+ 0 1 1 4
Figures have the same meaning as in Table 1. The symbol incorrect on the stated trial.
+ signifies that performance
was still
of the controls at 34.6 (t =0.52, p= ~0.25). There was a significant difference between the dysphasic and non-dysphasic patients at word naming (means of 9-l words against 11.9 words t = 4.49, p = < 0.001,when allowance is made in assessing the degrees of freedom for unequal variances). It should be noted that a different outcome is obtained when comparing the sentence and rhythm recall of the two groups if account is taken of learning performance in evaluating recall. Thus the mean savings for all the dysphasic subjects are 16-l and 25.9 per cent respectively for sentences and rhythms, compared with 6.6 and 30.5 per cent for sentences and rhythms for the non-dysphasic patients. (These values are computed by using the formula : learning
score -retention
score x 1o.
learning
score + retention
score
for each subject, and then finding savings of the dysphasic subjects at of original learning scores of I in when there is no real possibility of
the group mean.) It is possible to interpret the higher sentence learning as due to either (a) the higher incidence the control group, lowering the savings for this group re-learning in “zero” trials, or (b) contamination of the
G. ETTLINGERand A. M. MOFFETT
470
savings measure for the dysphasic subjects by their significantly worse performance at learning, giving a savings value which is too high. No statistical analyses have compared dysphasic patients with non-dysphasic patients, taking non-dysphasic cases of left-sided and right-sided cerebral lesions separately, because we lack confidence in the precise lateralisation of the lesions in all of our patients. However, we have sub-divided the dysphasic group into four types of disability; the analyses of covariance against age then show: 1. No difference
between
sub-groups
at sentence
learning
(F= 1.02, df26,
1, 3, p
2. Significant variation between sub-groups at sentence recall (F=20.6, df 5, 1, 3, I’=
between
sub-groups
at rhythm
learning
(F=0.56,
4. No difference
between
sub-groups
at rhythm
recalf (F=0.099,
df 26, 1, 3, p= ~0.65).
df5,1,3, p= <0.96).
Experiment II It was not possible to include all patients making 6 or more errors at word naming in Experiment II (for lack of time, tiredness, etc.). However, 5 patients of Group A and 4 of Group B became subjects in this experiment. (The higher proportion of Group A patients is accounted for by the greater difficulty of the objects used with Group A than Group B, so that more Group A patients made errors at naming objects.) Of the 9 subjects, 1 in Group A and 1 in Group B (case 3) failed to learn a sequence of 5 object names after 15 repetitions. Another patient of Group B (case 10) gave up after 7 repetitions of the 5-name sequence. (In general, patients found it more distressing to be unable to learn a 5-name sequence than to fail to learn the longer sentence of Experiment I.) These 3 patients were not tested for object naming after failing to learn the names. Details of the performance of the remaining 6 patients are shown in Table 3. The findings can only be considered as tentative owing to variations in procedure and differences in the severity and kind of dysphasia shown by the different patients. Given such reservations, it appears that: (1) learning a sequence of 5 names facilitates immediately subsequent naming of 5 objects (which, prior to the learning, could not be named on two occasions); (2) even when a sequence of names has twice been repeated without error, naming of real objects can still be impaired (only one case, No. A21, made no error with real objects); (3) the order of testing with real objects is not important (e.g. Case A6 made both of her 2 errors when the order of presentation was the same as the order of learning the names; and no other differences emerged in relation to the order of the presentation of the objects); (4) the facilitation of object naming consequent upon learning the sequence of names is not merely a non-specific result of increased frequency of hearing the names (because Case Al3 did no better after 11 repetitions than Cases A6, A8 or A21 after 2 or 3 repetitions; and Cases B16 and B60, who had failed to learn, did rather worse than the remaining cases when tested for naming of real objects). DISCUSSION Our findings are in agreement with those of ZANGWILL [S] that dysphasic patients are more severely impaired than at least certain other categories of neurological patient (e.g.
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IN DYSPHASIA
Table 3. Effect of learning object names on naming objects
Gp.
Serial No.
Type of Dysphasia
Clinical Diagnosis
Errors in Naming before Learning
Trials to learn 5 Names
Errors in Naming after Learning
Order (see legend)
A
6
Nominal
?L. Hem. glioma
5 in 10
2
2 in 10
5 original 5 new
A
8
Mixed
L. parietotemporal atrophy
6 in 10
3
1 in 10
10 original
A
13
Nominal
L. temporal lobectomy
6 in 10
11
2 in 10
10 new
21
Mixed
?L. Hem. V.A.
6in 10
2
Oin 10
5 original 5 new
16
Mixed
L. temporal angioma
10 in 12
15+ (failed)
2 in 5
5 new
60
Receptive
L. temporoparietal haematoma
9 in 12
5+ (gave up)
3 in 5
5 original
Patients of Gp. A and Gp. B were tested on different objects (see text). Errors made in naming objects before learning are for a series of 10 objects (Gp. A) or 12 objects (Gp. B). Trials to learn a sequence of 5 object names are given to the first of 2 successively correct repetitions. The symbol + indicates that the patient failed to give 2 correct repetitions within the stated number of trials. After learning, the 5 objects were presented for naming either once or twice, and either in the same order as used for learning of the 5 names (=“original” order) or in a different order (=“new” order).
non-dysphasics) at verbal learning. (Our findings do not, however, extend to amnesic patients.) In addition, we have new evidence that dysphasic subjects are significantly impaired at recalling a sentence after an interval of about 3.5 min. Our procedure was designed to ensure that the sentence had, apparently, been learnt as proficiently (i.e. to one correct repetition) by the dysphasic as by the non-dysphasic patients (even though more trials might be required by one group to achieve this level of performance). Moreover, to the extent that our dysphasic subjects were not significantly slower than the control patients in learning to reproduce rhythms, their verbal learning defect can be argued not to reflect a non-specific disorder of learning extending to all classes of material. (This argument is weakened, however, because (a) with larger groups of subjects the dysphasic patients might have been shown to be significantly impaired at rhythm learning; and because (b) the significant correlations between sentence learning and both Passalong score and rhythm learning may indicate that some of the variance at sentence learning may be related to non-verbal abilities.) Since our dysphasic patients recalled rhythms as proficiently as the non-dysphasic patients (considering only subjects giving recall scores for both sentences and rhythms), their impaired recall of sentences does not reflect a non-selective disorder of recall or retention, extending to all classes of material.
472.
G. ETTLINGER and A. M. MOFFETT
If we have, then, evidence for impaired verbal learning and recall in our dysphasic group, we can ask to what extent the disorder of recall is dependent upon the defect of learning. There is no clear-cut answer. However, the savings measures suggest that if account is taken of retarded verbal learning then the retardation of verbal recall is commensurate in degree (so that the mean savings for sentences is, if anything, greater for the dysphasic than non-dysphasic patients). In contrast, inspection of performance on the “zero” trial of sentence recall (where the patient was asked to say what he remembered of the sentence before hearing it again from the examiner) suggests a different outcome: spontaneous (i.e. unprompted) recall seems much more disorganised in many of the dysphasic than the nondysphasic records. If, then, we might entertain the possibility that separable disorders of verbal learning and of verbal recall co-exist in dysphasia, can the findings of Experiment II be held to be contributory? The subjects of this experiment were few, and their experimental treatment diverse. Subject to the qualification that our findings in this experiment can, at best, be considered merely suggestive, it seems that rote memorisation of object names can overcome, but only in part, the defect of dysphasic patients in naming the appropriate object. No attempt was made to teach the dysphasic subjects to associate objects with their names. Instead, 5 object names were repeated by the examiner (always in the same order) until the patient was able to repeat these names on 2 consecutive attempts. Successful learning of such a sequence of object names generally failed to ensure correct naming of the actual objects (presented one at a time) immediately after the learning procedure. This finding supports the notion that dysphasic patients have defective verbal recall (the requirements of learning names and of naming objects were sufficiently different to preclude successful perfomrance on the naming task through rote recall of the learnt sequence). Moreover, the difficulty of many dysphasic subjects in learning a sequence of 5 names supports the evidence from Experiment I for an impairment of verbal learning. With the reservations already stated it appears, then, that certain of our dysphasic patients may have shown defects of both verbal learning and verbal recall. Brief mention should be made of the trend for dysphasic patients to be impaired at rhythm learning. BOLLER and DE RENZI [l l] have discussed their own and earlier findings tasks (e.g. finding hidden figures, of impairment by dysphasic patients on “non-verbal” recognising meaningless figures, etc.). Impaired learning of rhythms might be attributed to a “verbal” component in a “non-verbal” task. However, there was no trend towards Instead, there was a tendency towards a worse rhythm recall by the dysphasic patients. correlation between poor rhythm learning and increasing age (for all subjects). The significance of these findings is not clear. However, this test has proved both simple and meaningful as a measure of recall (the savings scores of both groups are superior for rhythms than for sentences, although sentences were learnt more rapidly by both groups). In analysing the results we sub-divided the dysphasic patients by the type of their dysphasia. Such classification was done less confidently than assignment to the dysphasic/ non-dysphasic groups. Only one analysis reaches significance: sentence recall. This finding relies, however, on groups of only 3, 3, 2 and 2 patients (because in the analyses of recall only patients giving recall scores on both sentences and rhythms were included). We are therefore reluctant to place too much weight on this finding (ahhough it could have occurred by chance only 3 times in 1000 cases); and more particularly because the subgroup with the more severe impairment of sentence recall, the “mixed” dysphasics, also included the most severe cases of dysphasia in our sample.
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473
In conclusion, we have confirmed the findings of ZANGWILL [8] and extended them to a series of patients unselected by defect, comparing their performance on a verbal and nonverbal task; and we have, perhaps, provided suggestive if not compelling evidence for an impairment of verbal recall in addition to that of verbal learning in dysphasia. Ackno~~[edgementse are grateful to the Physicians and Surgeons of the National Hospital, to Mr. M. A. FALCONERof the Guys-Maudsley Neurosurgical Unit and to Mr. I. MCCAUL of the Whittington Hospital for permission to examine patients under their care. To Dr. R. T. C. PRATTwe are especially grateful for making all our facilities at the National Hospital available to us, and for help with the preparation of this paper. We thank Mr. B. EVERIT~and Mr. 0. WHITE for help with the statistical computations and Mr. kindly commented A. D. MILNERand Mr. R. E. PASSINGHAM for stimulating discussion. Dr. H. H~~CAEN on an early draft of the paper. Miss A. M. MOFFETTwas supported by a grant from the M.R.C.
REFERENCES 1. RUSSELL,W. R. and ESPIR, M. L. E. Traumatic Aphasia. Oxford University Press, Oxford, 1961. R. Pathologie du Language. Larousse, Paris, 1965. 2. HBCAEN,1-I. and ANGELERGUES, 3. DE RENZI, E., FAGLIONI,P., SAVOIARDO,M. and VIGNOLO,L. A. The influence of the hemispheric side of the cerebral lesion on abstract thinking. Cortex 2, 399420, 1966. 4. JAKOBSON,R. Towards a linguistic typology of aphasic impairments. In Disorders of Language,A.V.S. DE REUCK and M. O’CONNOR(Eds.). Churchill, London, 1969. 5. GOODGLASS,H. and HUNT, J. (19%) Grammatical complexity and aphasic speech. Word 14, 197-207, 1958. 6. SCHUELL,H., JENKINS,J. L. and CARROLL,J. B. A factor analysis of Minnesota Test for Differential Diagnosis of Aphasia. J. Speech Hear. Dis. 27, 349-369, 1962. 7. JONES,L. V. and WEPMAN,J. M. Dimensions of language performance in aphasia. J. Speech Hear. Dis. 26, 220-232,
1961.
8. ZANGWILL,0. L. Some qualitative observations on verbal memory in cases of cerebral lesion. Br. J. Psycho/. 37, 8-19, 1946. 9. KREINDLER,A. and FRADIS,A. Performances in Aphasia. Gauthier-Villars, Paris, 1968. 10. THORNDIKE,E. L. and LORGE, I. The Teachers Word Book of 30,000 Words. Columbia University, New York, 1944. II. BOLLER,F. and DE RENZI, E. Relationship between visual memory defects and hemispheric locus of lesion. Netrrology 17, 1052-1058, 1967. Resume-Les performances d’un groupe de sujets dysphasiques et d’un groupe de sujets non dysphasiques dont beaucoup avaient des lesions verifiees unilaterales Ctaient comparees selon leurs rtsultats a des tests de: apprentissage de phrases, rappel de phrases, apprentissage de rythmes, rappel de rythmes, denomination verbale et tests d’intelligence non-verbale. Dans une deuxieme experience, on apprenait a un petit groupe de sujets dysphasiques a r&peter une sequence de 5 noms d’objets (immediatement apres avoir echo& a nommer ces 5 objets), et ces sujets etaient retest& sur leur capacite a nommer les objets qui n’avaient pu Ctre anterieurement denommts. 11fut trouvt que les patients dysphasiques Ctaient deficitaires de facon significative dans l’apprentissage des phrases, le rappel de phrases et la denomination, mais qu’il n’existait seulement qu’une tendance au deficit dans l’apprentissage de rythmes et qu’aucun deficit n’ttait constate dans le test de rappel de rythmes et dans les tests d’intelligence non-verbale. L’experience no 2 montrait que l’apprentissage des sequences de noms d’objets facilitait, sans cependant permettre une performance totalement correcte, la denomination verbale ulttrieure. Ces constatations suggerent que deux deficits pourraient coexister dans la dysphasie: l’un portant sur l’apprentissage verbal, et l’autre sur le rappel verbal. Zusammenfassung-Das Leistungsvermijgen einer Gruppe aphasischer Kranker und einer solchen nicht-aphasischer Patienten (die meisten davon hatten eine verifizierte einseitige cerebrale Schldigung) wurde anhand folgender Tests untersucht: Lernen von Satzen, Wiedergabe von Sltzen, Lemfahigkeit fiir Rhythmen, Rtickerinnerung an Rhythmen, Wortfindung sowie Prtifung der nichtverbalen Intelligenz. In einem 2. Experiment wurde einen kleiner Gruppe von aphasischen Patienten beigebracht, eine Folge van 5 Namen ftir Objekte zu wiederholen (und zwar unmittelbar, nachdem sie bei BeneMuna dieser 5 Obiekte versagten), im Anschluss paran wurde die Fahigkeit der Objektbenennung geprtift, die vorher misslang.
414
G. ETTLINGER
and A. M.
MOFFETT
Es ergab sich, dass aphasische Kranke in signifikanter Weise zur Erlernung von Satzen sowie zur Wiedererinnerung an Satze und zur Wortfindung unfahig waren, dagegen fand sich nur ein leichter Trend zum Versagen beim Erlernen von Rhythmen. Beim Rtickerinnern an Rhythmen und such bei Prtifung der nicht-verbalen Intelligenz war dieser Trend nicht festzustellen. In dem 2. Experiment zeigte es sich, dass die Erlernung einer Objektnamensreihe die Objektbenennung erleichtert, aber keineswegs eine perfekte Leistung garantiert. Die Ergebnisse sprechen dafur, dass es zwei koexistierende Storungssyndrome bei Aphasischen gibt, nimlich fur sprachgebundenes Lernen und sprachliches Zurtickerinnern.