Speech and language vol 11 speech and language advances in basic research and practice

Contributors to This Volume

Antonie Cohen
Donald Fucci
Sarah Hawkins
Raymond D. Kent
Linda Petrosino
Betty Jane Philips
Bruce L. Smith
Ronald S. Tikofsky
Marcel P. R. van den Broecke
Rob C. van Geel


SPEECH AND LANGUAGE
Advances in Basic Research and Practice

VOLUME 11

Edited by
NORMAN J. LASS
Department of Speech Pathology and Audiology
West Virginia University
Morgantown, West Virginia

1984

ACADEMIC PRESS, INC.

(Harcourt Brace Jovanovich, Publishers)

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COPYRIGHT © 1984, BY ACADEMIC PRESS, INC.
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This publication is not a periodical and is not
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PRINTED IN THE UNITED STATES OF AMERICA
84 85 86 87

9 8 7 6 5 4 3 2 1

Contributors
Numbers in parentheses indicate the pages on which the authors' contributions
begin.
Antonie Cohen (197), Instituut voor Fonetiek, Rijksuniversiteit Utrecht, 3512
JK Utrecht, The Netherlands
Donald Fucci (249), School of Hearing and Speech Sciences, Ohio University,
Athens, Ohio 45701
Sarah Hawkins (317), Haskins Laboratories, 270 Crown Street, New Haven,
Connecticut 06510
Raymond D. Kent (113), Department of Communicative Disorders, University
of Wisconsin-Madison, Madison, Wisconsin 53706
Linda Petrosino (249), School of Hearing and Speech Sciences, Ohio University, Athens, Ohio 45701
Betty Jane Philips (113), Language and Learning Center, Boys Town National
Institute for Communication Disorders in Children, Omaha, Nebraska
68131
Bruce L. Smith (169), Department of Communicative Disorders, Speech and
Language Pathology, Northwestern University, Evanston, Illinois 60201
Ronald S. Tikofsky (1), Department of Speech Pathology and Audiology,
School of Allied Health Professions, University of Wisconsin-Milwaukee,
Milwaukee, Wisconsin 53201 and Department of Radiology, Division of
Nuclear Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
53226
Marcel P. R. van den Broecke (197), Instituut voor Fonetiek, Rijksuniversiteit
Utrecht, 3512 JK Utrecht, The Netherlands
Rob C. van Geel (197), Instituut voor Fonetiek, Rijksuniversiteit Utrecht, 3512
JK Utrecht, The Netherlands

vii

Preface
Volume 11 of Speech and Language: Advances in Basic Research and Practice contains six contributions on a wide variety of topics. Tikofsky examines
contemporary approaches to aphasia diagnostics from both a medical and nonmedical perspective. In addition to providing a detailed description of specific
contemporary aphasia test batteries, he discusses the relationship of human neuropsychology and aphasia, neurological diagnosis and aphasia, as well as recent
developments in neurologic diagnosis in relation to aphasia. He concludes that,
The decades ahead will see a greater integration of behavioral and neurological aphasiology in
diagnosis. Much of the groundwork for such an integration has been established. What is
required now is an increased dedication to joint research efforts to increase the precision and
utility in contemporary and future aphasia assessment.

Acoustic-phonetic descriptions of speech production in speakers with cleft
palate and other velopharyngeal disorders are presented by Philips and Kent,
whose intent is to illustrate the potential application of this information in contributing to diagnostic evaluation and remedial programming. The authors provide a detailed discussion of velopharyngeal incompetence, linguistic and phonetic considerations related to velopharyngeal function, speech motor control
considerations related to velopharyngeal function, speech patterns associated
with velopharyngeal incompetence, prespeech and early speech development in
children with velopharyngeal incompetence, basic acoustic effects of nasalization, and spectrographic correlates of velopharyngeal incompetence.
Smith addresses the role of infant vocalizations as they relate to subsequent
speech and language development. Specifically, he is concerned with whether it
is possible to determine from an infant's prelinguistic vocalizations if the infant
will have a phonological disorder when he begins to produce meaningful speech.
Since the capability for such a diagnosis presently does not exist, the author
assesses contemporary research to determine whether it suggests that the development of such a reliable screening system may eventually be possible. The
methods employed to study prelinguistic sound development are discussed in
regard to their diagnostic potential for predicting future phonological disorders,
including transcription-based observations, acoustic analysis, and metaphonological observation of phonetic development. The author addresses directions for future research and concludes that "integration of a variety of techniques may provide the best method for early diagnosis of speech (and language)
disorders."
Pitch phenomena and applications in electrolarynx speech are addressed by
Cohen, van den Broecke, and van Geel. Included is a discussion of linguistic and

ix


X

Preface

instrumental approaches to pitch, a model of sentence melody, intelligibility and
naturalness in various forms of alaryngeal speech, a grammar of intonation,
development of a prototype electrolarynx with semiautomatic pitch control, and
a training program for intonated electrolarynx speech. The authors also provide
an evaluation of intonated versus monotonous electrolarynx speech as well as
implications for further research and practical applications of intonated electrolarynx speech in various languages.
Fucci and Petrosino present practical applications of neuroanatomy in an attempt to provide the speech-language pathologist with a basic understanding of
the structure and function of the human nervous system as well as an appreciation
of the necessary assessment of the integrity of the nervous system. After a
detailed discussion of the structure and function of the human nervous system,
including the central, peripheral, and autonomie nervous systems, they address
neurological considerations for the speech-language pathologist. Assessment of
nervous system integrity, including a discussion of higher cortical function, the
cranial nerves, the motor system, the sensory system, and reflexes, as well as the
disorders associated with the nervous system assessment procedures, is
provided.
Hawkins employs studies of temporal coordination to understand the development of motor control in speech and to provide a basis for testing theories on the
development of speech as a motor skill. Discussions include prosody in speech
perception and speech production, the contribution of studies of temporal coordination to understanding the development of motor control in speech, some basic
assumptions about the development of speech, acoustic-phonetic and neuromotor influences on the development of temporally coordinated speech, two
strategies for learning to produce clusters of consonants fluently, and a theory of
the developing motor control of speech. The author also addresses directions for
future research and some unresolved issues in the study of all aspects of children's speech and language development as well as in the study of the motor

control of speech, whether in development, maturity, or disintegration.
It is our intention that the contents of this volume in particular, and of this
serial publication in general, will result in increased discussion and, consequently, further investigation of a number of unresolved contemporary issues in
speech and language processes and pathologies that will ultimately lead to their
resolution.
NORMAN J. LASS


Contents of Previous Volumes
Volume 1
The Perception of Speech in Early Infancy
Patricia K. Kuhl
Acoustic-Perceptual Methods for Evaluation of Defective Speech
James F. Lubker
Linguistic and Motor Aspects of Stuttering
Kenneth O. St. Louis
Anatomic Studies of the Perioral Motor System: Foundations for Studies in
Speech Physiology
Jesse G. Kennedy HI and James H. Abbs
Acoustic Characteristics of Normal and Pathological Voices
Steven B. Davis
Synergy: Toward a Model of Language
Carol A. Pruning and Judy B. Elliott
SUBJECT INDEX

Volume 2
Functional Articulation Disorders: Preliminaries to Treatment
Ralph L. Shelton and Leija V. McReynolds
The Early Lexicons of Normal and Language-Disordered Children: Developmental and Training Considerations
Laurence B. Leonard and Marc E. Fey

The Shaping Group: Habituating New Behaviors in the Stutterer
William R. Leith
The New Theories of Vocal Fold Vibration
David J. Broad
Homonymy and Sound Change in the Child's Acquisition of Phonology
John L. Locke
Conversational Speech Behaviors
Marjorie A. Faircloth and Richard C. Blasdell
Oral Vibrotactile Sensation and Perception: State of the Art
Donald Fucci and Michael A. Crary
SUBJECT INDEX

Volume 3
Theories of Phonological Development
Donald E. Mowrer
xi


XII

Contents of Previous Volumes

Phonology and Phonetics as Part of the Language Encoding/Decoding System
Marcel A. A. Tatham
The Application of Phonological Universals in Speech Pathology
John J. Ohala
The Pédiatrie Language Specialist: An Innovative Approach to Early Language
Intervention and the Role of the Speech-Language Clinician
Sol Adler and lowana A. Whitman Tims
Speech Perception: A Framework for Research and Theory

Dominic W. Massaro and Gregg C. Oden
Velopharyngeal Structure and Function: A Model for Biomechanical Analysis
David Ross Dickson and Wilma Maue-Dickson
Use of Feedback in Established and Developing Speech
Gloria J. Borden
Delayed Auditory Feedback and Stuttering: Theoretical and Clinical Implications
William R. Leith and Claudia C. Chmiel
Biofeedback: Theory and Applications to Speech Pathology
Sylvia M. Davis and Carl E. Drichta
INDEX

Volume 4
Nonlinguistic and Linguistic Processing in Normally Developing and LanguageDisordered Children
Paula Menyuk
Phonological Development during the First Year of Life
Donald E. Mowrer
Speech Fluency and Its Development in Normal Children
C. Woodruff Starkweather
Speech Production Models as Related to the Concept of Apraxia of Speech
Anthony G. Mlcoch and J. Douglas Noll
Aspects of Speech and Orthognathic Surgery
William G. Ewan
Velopharyngeal Function: A Spatial-Temporal Model
Frederika Beil-Berti
Variations in the Supraglottal Air Pressure Waveform and Their Articulatory
Interpretation
Eric M. Müller and W. S. Brown, Jr.
INDEX

Volume 5

A Critical Review of Developmental Apraxia of Speech
Thomas W. Guyette and William M. Diedrich


Contents of Previous Volumes

xiii

Relapse following Stuttering Therapy
Franklin H. Silverman
Analysis and Measurement of Changes in Normal and Disordered Speech and
Language Behavior
Merlin J. Mecham
Physiological, Acoustic, and Perceptual Aspects of Coarticulation: Implications
for the Remediation of Articulatory Disorders
Donald J. Sharf and Ralph N. Ohde
An Empirical Perspective on Language Development and Language Training
Scott F. McLaughlin and Walter L. Cullinan
Elements of Voice Quality: Perceptual, Acoustic, and Physiologic Aspects
Raymond H. Colton and Jo A. Estill
The Resolution of Disputed Communication Origins
Murray S. Miron
INDEX

Volume 6
Auditory Discrimination: Evaluation and Intervention
Charlena M. Seymour, Jane A. Baran, and Ruth E. Reaper
Evaluation and Treatment of Auditory Deficits in Adult Brain-Damaged Patients
Thomas E. Prescott
A Pragmatic Approach to Phonological Systems of Deaf Speakers

D. Kimbrough Oiler and Rebecca E. Eilers
Speech and Language Characteristics of an Aging Population
Virginia G. Walker, Carole J. Hardiman, Dona Lea Hedrick, and Anthony
Holbrook
Language and Cognitive Assessment of Black Children
Harry N. Seymour and Dalton Miller-Jones
Effect of Aberrant Supralaryngeal Vocal Tracts on Transfer Function
Sally J. Peterson-Falzone and Karen L. Landahl
The Human Tongue: Normal Structure and Function and Associated Pathologies
Donald Fucci and Linda Petrosino
From an Acoustic Stream to a Phonological Representation: The Perception of
Fluent Speech
Z. S. Bond
Estimation of Glottal Volume Velocity Waveform Properties: A Review and
Study of Some Methodological Assumptions
Robert E. Hillman and Bernd Weinberg
INDEX


XIV

Contents of Previous Volumes

Volume 7
To Hear Is Not to Understand: Auditory Processing Deficits and Factors Influencing Peformance in Aphasie Individuals
Cynthia M. Shewan
Auditory Processes in Stutterers
Hugo H. Gregory and James Mangan
A Review of Research on Speech Training Aids for the Deaf
Richard P. Lippmann

A New Era in Language Assessment: Data or Evidence
John R. Muma, Rosemary Lubinski, and Sharalee Pierce
Quantification of Language Abilities in Children
Rachel E. Stark, Paula Tallal, and E. David Mellits
Communication Behavior Assessment and Treatment with the Adult Retarded:
An Approach
Nathaniel O. Owings and Thomas W. Guyette
Distribution and Production Characteristics of /s/ in the Vocabulary and Spontaneous Speech of Children
John V. Irwin
Speech Processes in Reading
Charles A. Perfetti and Deborah McCutchen
Structure and Mechanical Properties of the Vocal Fold
Minoru Hirano, Yuki Kakita, Koichi Ohmaru, and Shigejiro Kurita
Jitter and Shimmer in Sustained Phonation
Vicki L. Heiberger and Yoshiyuki Horii
Boundary: Perceptual and Acoustic Properties and Syntactic and Statistical
Determinants
Noriko Umeda
INDEX

Volume 8
Toward Classification of Developmental Phonological Disorders
Lawrence D. Shriberg
Patterns of Misarticulation and Articulation Change
Patricia A. Broen
The Development of Phonology in Unintelligible Speakers
Frederick F. Weiner and Roberta Wacker
Determining Articulatory Automatization of Newly Learned Sounds
Walter H. Manning and Edward A. Shirkey
Conversational Turn-Taking: A Salient Dimension of Children's Language

Learning
Louis J. DeMaio


Contents of Previous Volumes

XV

Ontogenetic Changes in Children's Speech-Sound Perception
Lynn E. Bernstein
Speech Production Characteristics of the Hearing Impaired
Mary Joe Osberger and Nancy S. McGarr
Anxiety in Stutterers: Rationale and Procedures for Management
K. Dale Gronhovd and Anthony A. Zenner
Critical Issues in the Linguistic Study of Aphasia
Hugh W. Buckingham, Jr.
INDEX

Volume 9
New Prospects for Speech by the Hearing Impaired
Samuel G. Fletcher
Integrated Speech and Language Instruction for the Hearing-Impaired
Adolescent
Joanne D. Subtelny
Laryngectomee Rehabilitation: Past and Present
Robert L. Keith and James C. Shanks
Sensory and Motor Changes during Development and Aging
Ann Palmer Curtis and Donald Fucci
The Phonetic Structure of Errors in the Perception of Fluent Speech
Z. S. Bond and Randall R. Robey

Multiple Meanings of A'Phoneme" (Articulatory, Acoustic, Perceptual, Grapheme) and Their Confusions
Richard M. Warren
Perception of Consonant Place of Articulation
Ann K. Syrdal
INDEX

Volume 10
Apraxia of Speech: Articulatory and Perceptual Factors
Anthony G. Mlcoch and Paula A. Square
The Prevention of Communicative Disorders in Cleft Palate Infants
Kenneth R. Bzoch, F. Joseph Kemker, and Virginia L. Dixon Wood
The Relationship between Normal Phonological Acquisition and Clinical
Intervention
Mary Elbert
Auditory Timing: Its Role in Speech-Language Pathology
Robert L. McCroskey
On Speakers' Abilities to Control Speech Mechanism Output: Theoretical and
Clinical Implications
Gary Weismer and Denise Cariski


XVI

Contents of Previous Volumes

Categorical Perception: Issues, Methods, Findings
Bruno H. Repp
Speech Perception as a Cognitive Process: The Interactive Activation Model
Jeffrey L. Elman and James L. McClelland
INDEX

Contemporary Aphasia
Diagnostics
RONALD S. TIKOFSKY
Department of Speech Pathology and Audiology
School of Allied Health Professions
University of Wisconsin-Milwaukee
Milwaukee, Wisconsin and
Department of Radiology
Division of Nuclear Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin

I.
II.

Introduction
Historical Background
A. Diagnostic Issues prior to the 1940s
B. Diagnostics from the 1940s to the 1960s
III. Aphasia Testing Post-1960
A. Language Modalities Test for Aphasia (LMTA)
B. Minnesota Test for Differential Diagnosis of
Aphasia (MTDDA)
C. Porch Index of Communicative Ability (PICA)
D. Boston Diagnostic Aphasia Examination (BDAE)
E. Western Aphasia Battery (WAB)
F. Communicative Activities in Daily Living (CADL) and
Functional Communication Profile (FCP)

IV. Where Have the Tests Taken Us?
A. Has Diagnostic Precision Increased?
B. Do Aphasia Tests Really Differ One from the Other?
C. What Are We Diagnosing?
V. Human Neuropsychology and Aphasia
A. General Concepts of Human Clinical Neuropsychology
B. Aphasia as Part of the Brain Damage Symptom Complex
VI. Neurodiagnostics: Neurological Diagnosis and Aphasia
A. Nonscanning Approaches
B. Recent Developments in Neurologic Diagnosis in Relation
to Aphasia
VII. Conclusions and Projections
References

2
3
3
11
15
15
19
22
27
33
43
50
50
52
53
59

59
61
64
64
74
100
101

1
SPEECH AND LANGUAGE: Advances in Basic
Research and Practice, Vol. 11

Copyright © 1984 by Academic Press, Inc.
All rights of reproduction in any form reserved.
ISBN 0-12-608611-7


2

Ronald S. Tikofsky

I. INTRODUCTION
Diagnosis and assessment hold a prominent place in historical and contemporary aphasiology. Diagnostics provide the data base for clinicians and researchers. Since Broca (1861) presented his paper almost a century and a quarter
ago, aphasiologists have continued to seek answers to many of the questions he
and his followers raised with respect to language and brain. The passage of time
and advances in psychometrics, linguistics, and medicine as well as computer
technology have done much to clarify the issues raised by the early scholars.
These advances have led to new and perhaps even more difficult questions to
challenge the contemporary aphasiologist.
Aphasiologists have taken some liberties in their use of the term diagnosis.

They have broadened the concept to one that encompasses matters relating aspects of linguistic impairment to alterations in brain function and the determination of the site of the lesion producing the impairment. Approaches to diagnostics
in the study of aphasia are often determined by the motivations and demands of
the several disciplines that view aphasia and the aphasie as their province.
In the period from World War II to the present, two primary trends in aphasia
diagnostics emerged, one related to the development of neuroradiographic techniques as a means to establish the site of lesion and the other, from speech
pathology-psychology, in the area of psychometric assessment of aphasia. There
has been increased effort to bring together the findings of contemporary neurology as it pertains to aphasia and those of speech pathology, psychology, and
neurolinguistics to establish better understanding of the intriguing phenomenon
presented to us by aphasia. This article examines contemporary approaches to
aphasia diagnostics from the nonmedical and medical perspectives.
The physician must address the question of whether the symptom complex of
which aphasia is but a part is the result of a completed or ongoing process. A
decision based on the clinical evidence including laboratory tests must be made
as to etiology. It is at this point in time that the physician begins to probe in a
general fashion the language behavior of the patient. The goal is to determine
locus of lesion and to make a general assessment of the medical status of the
patient.
The domain of questions reaches beyond the confines of localization, however. Basic to the discussion are questions pertaining to the matter of what is really
being localized. Hughlings Jackson (1878) long ago recognized that to localize
the site of a lesion producing a given language deficit is not the same thing as
localizing normal language function. Even the seminal work of Penfield and
Roberts (1959) on cortical stimulation and that of current workers have not truly
localized language. They have been able to arrest language in already impaired
brains, but there is no evidence to suggest that they evoked normal language
behavior on the operating table.
Techniques for assessing and determining the site of lesion-producing aphasie


Contemporary Aphasia Diagnostics

3

symptoms with greater precision are certainly more powerful now than they were
only a decade or two ago. It is no longer necessary to wait for an autopsy to
obtain a picture of the lesion, because of the use of brain scan techniques.
Advances in neuroradiology have made it possible to visualize with great accuracy the locus, size, and depth of an infarct producing aphasia. This increase in
precision allows the physician to ask questions relative to aspects of the lesion
and its effects on behavior in a somewhat different fashion. The possibility of
testing hypotheses regarding the relation of change in structure and physiology to
change in performance is closer to realization. If such relations could be determined by radiologie techniques, more powerful diagnostic tools would become
available to the physician and speech-language pathologist.
The role of the speech-language pathologist with respect to aphasia has undergone a remarkable shift in the years since World War II. When concerned with
the structure and locus of the lesion, many aphasiologists focused on devising
appropriate means by which to assess, classify, and describe the alterations in
language function that arise as a consequence of physical change in the brain. It
should be obvious, therefore, that issues relative to the determination of the
consequences of focal and diffuse brain lesions require the integration of the
diagnostic tools of both physician and language pathologist.
This article is devoted to an examination of several approaches to the question
of diagnostics and aphasia. A brief historical perspective will be presented followed by a glimpse into the future. Psychometric and neurologic approaches to
aphasia diagnostics will be examined in some detail.

II. HISTORICAL BACKGROUND
A. Diagnostic Issues prior to the 1940s
Early reports dealing with aphasia were based on data from one or two cases.
Determination of the symptom patterns presented by the aphasie patient were not
based on precise and well-standardized tests. Rather, descriptions of the symptom complex emerged from clinical examinations constructed by physicians. As
Benton (1967) noted, questions determining whether aphasia involved a deficit
in intelligence led not only to controversy but to the recognition of the need for
special tests. With Wernicke's (1874) description of sensory aphasia, the need to

distinguish between general reductions in comprehension as might be observed
with the dementias and specific descriptions of language comprehension was
increasingly felt.
Early discussions and debates focused on the description of the impaired
behaviors, the underlying language mechanisms, and reasons why the damaged
brain yields the observed symptoms. Broca's (1861) essay goes into elaborate
detail concerning the nature of articulate language and the mechanism of impair-


4

Ronald S. Tikofsky

ment, which he called "aphemia." The other central focus in this early period
was to establish the site of lesion. This was achieved through postmortem and
inference. Early works attempted to establish centers that were correlated with
specific language functions. They also hypothesized the interrelations between
and among the centers. It was this approach that led Head (1926) to invoke the
pejorative term "diagram makers" upon the efforts of these early scholars.
Emerging from the trend in localization was the concept of a "center." Thus, it
was possible to argue on the basis of focal pathology and the attendant behavioral
deficits that there were centers for various faculties of language such as auditory
comprehension and articulate speech.
Conceptualization of centers within the cortex for specific psychological functions during the period from 1861 to the mid-1900s fit well with the then
contemporary approaches to psychological theory. It was during this period that
concepts of faculty psychology and associationism were taking form. Boring
(1950) presents the work of Gall and the early localizationists in the light of an
emerging physiological psychology. The link between specific mental functions
and correspondingly specific cortical sites was forged. It was a linkage that was
to be challenged in the decades that followed Broca's attack on Flourens' concept

of "communal action" of the brain. In Boring's view, Broca and Flourens
brought the genesis of an experimental method to the study of aphasia. It is in the
context of an emerging clinical and experimental science that one must view
early approaches to diagnosis. As Benton (1967) points out, the use of psychometrically sound instruments as we understand them today was nonexistent in
Broca's time. Standardization and norms were not available. This situation was
not only true for aphasia but also for all mental functions. Test batteries were in
use, but data could not be compared easily from laboratory to laboratory. Benton
(1967) stated in regard to test construction in aphasia that "it is not inaccurate to
say that we are today where intelligence testing was in 1900, i.e., the pre-Binet
stage" (p. 35). This is a strong assertion but Benton's evaluation of the tests
available to assess the aphasie showed them to be psychometrically weak.
Weisenburg and McBride's (1935) attempt at development of a standardized
battery led them to conclude that while the examination procedures should be
standardized, "examinations for aphasia can never be routine procedures . . .
but the standard tests must sometimes be altered to throw more light on unusual
difficulties" (1964 reprint, p. 132). This view prevailed since it reflected the
widespread belief that, as Eisenson (1954) put it, "Aphasie patients are characteristically too inconsistent in their responses to permit formal scoring standards
to be developed and meaningfully applied" (p. 31). This was his position, when
he commented in the first edition of Examining for aphasia (Eisenson, 1946)
that, "the examiner will need to use the best approach he can devise for the
particular patient he is testing" (p. 7). Eisenson's Examining for aphasia and the
Halstead-Wepman aphasia screening test (Halstead & Wepman, 1949) were the
first two commercially produced aphasia tests. These instruments, and many that


Contemporary Aphasia Diagnostics

5

were developed during this period, remained close to the conception of aphasia

as a disorder of symbolic formulation (Head, 1926) and the classification system
devised by Weisenburg and McBride (1935). No significant effort was made in
this period to relate test findings to etiology or locus of lesion. The one major
exception was Luria's extensive investigation of traumatic aphasia first published
in Russian in 1947 and later translated to English (Luria, 1970). His central
emphasis was on questions of the "topical diagnosis of aphasia" and analysis of
different types of speech disorders that result from "focal brain damage."
Although Boring (1950) suggests that Broca's report represented the beginnings of an experimental science for human mental function, close examination
of the reports and commentaries of the time suggests that many of the methodological requirements of such a science were lacking. Unlike their counterparts who worked with animals, the neurologists could not then and cannot now
control the site of lesion. Those working in the area of mind-brain or languagebrain relations were dependent solely on the disease process to place the lesion
for them. Furthermore, in the period of Broca through the 1940s, the major
method of determining site and depth of lesion was the postmortem examination
of the brain. Even in the case of autopsy, the techniques for examining the brain
in detail (and in particular intrahemispheric connections) were severely limited
by the neuropathologist's available technology. The only available in vivo material was the patient who came to surgery with focal trauma or penetrating wounds
to the head. In these cases it was possible to view the brain in a subject where the
lesion was fresh. Often, however, the precision of localization was blurred by
fragmentation, uncertain trajectory, intracranial bleeding, etc. Lacking also was
any truly systematic approach to careful correlation of symptom analysis with
focus of lesion or longitudinal studies of the course of the aphasia and changes in
the lesion.
It is interesting to note that in the preface to the second edition of On aphasia
published in 1890, Bateman (1890) commented on the status of the precision
with which localization of function could be achieved. When he completed the
first edition of the work, he stated that "localization of cerebral function was in
its infancy, and our knowledge of actual pathological changes occurring in nerve
tissue was vague and unsatisfactory." Although Bateman felt that great strides in
neuropathology were made between 1870 and 1880, he believed that the workers
of the time were still "on the threshold of the inquiry . . . that much is still to be
learnt, before we can speak with anything like mathematical precision, of certain

functions of the wonderful piece of mechanism—the human brain." Bateman's
discussion of etiology and differential diagnosis would not have been adequate
even in the early twentieth century. He does, however, address questions of
differential diagnosis and cerebral pathology.
Collins (1898), one of the first Americans to write a major treatise on aphasia,
devoted chapters to diagnosis, etiology, and the morbid anatomy of aphasia.
Although not presenting any formal test, Collins outlines an approach to exam-


6

Ronald S. Tikofsky

ination that has a strong contemporary ring to it. He notes that "the constitution
of the speech faculty . . . . consists of two parts, the receptive and emissive"
(p. 324), noting that the symptoms may predominate in either dimension, "in
true aphasia, that is, dependent upon a lesion of the speech centers, neither can
be the medium of manifestation of the spee h defects" (p. 324). Collins, in his
discussion of the morbid anatomy, makes a valiant effort to relate the various
disease processes to the disturbance of cortical function. He points to the necessity of studying morbid changes accompanying "motor aphasia" to separate it
from "motor image aphasia" and to show that when disease is limited to Broca's
area there is no secondary degeneration in projection tracts. The discussion goes
on to raise questions concerning the extent of cortical and subcortical involvement in the different diseases yielding aphasie symptoms. Collins makes clear,
even in this early work, the need for careful and exacting postmortem examination of the brain to correlate disease, behavior, site, and extent of lesion.
The trend of a continual massing of data based on autopsy continues through
the present time. Two relatively modern sources that support classical localization theory are the studies by Henschen in the 1920s and Nielsen in 1936 and
1948. According to Nielson, Henschen, who analyzed 1500 cases which had
been reported in the literature, "discarded all psychologic factors and based his
studies on localization entirely on autopsy material. Anatomic localization was
carried to the nth degree" (Nielson, 1962 reprint, p. 11). In his report of

Henschen's study, Nielson notes that the statistical procedures he used "determine not only the rule for each function but also the exceptions." Furthermore,
he states "to establish any principle, therefore, it is necessary to present a
number of instances and to discover the generalizations which are valid"
(Nielsen, 1962, pp. 3 and 4). Nielsen pays more attention to pathology than
behavior. His approach to examination is not well documented or even suggestive of standardization.
The workers cited above represent an approach to diagnosis that centers on
determination of site of lesion to support hypotheses relating symptoms to localization of function. Their evidence for support was based solely on the
postmortem examinations of brains of patients who demonstrated language impairment following disease which affected the cortex and subcortical pathways.
Another major source of data employed to corroborate the relationship of the
different forms of aphasia to sites of damage comes from studies of patients who
sustained gunshot wounds to the head. Data on missile wounds to the head in
relation to aphasia come from only a few sources. Studies of patients from World
War I are reported by Kleist (cf. Russell and Espir, 1961), Head (1926), and
Goldstein (1948). The second major source of data derives from the work carried
out on patients from World War II. Among the major contributors are Luria
(1970), Goldstein (1948), and Conrad (1954) as well as Russell and Espir (1961).
Head (1926, Vol. 1, p. 442) raises the question of being able to "discover


Contemporary Aphasia Diagnostics

7

what relation the site of lesion, when it can be determined, bears to the clinical
manifestations." He notes that material presented by gunshot wounds is not as
valuable for establishing localization as in brains where there has been a full
microscopic examination. However, he goes on to say that such patients "are of
infinitely greater scientific interest for determining the exact nature of the phenomenon during life, than those broken-down wrecks in whom disease is terminated by death" (p. 442). Of course, the great advantage in using gunshot wound
patients lay in the fact that many remained alive and there was resolution of the
aphasie symptoms. Thus, it was possible to obtain longitudinal data as to the

course of recovery.
In establishing the procedures to determine site of lesion, Head makes an
important, but sometimes overlooked, diagnostically significant observation. He
asserts that the effects of diachasis must be taken into account to understand the
change that occurs in the initial symptoms which are replaced by the permanent
consequences of anatomical destruction. Secondly, Head observes that a lesion
which affects a small area of tissue can produce "profound and widespread
defects" (p. 476) if it is acute or progressive, whereas a large area of destruction
of old and slow onset may yield only minor disturbances of function.
Head used his own terminological system to classify defective language and
his serial tests to characterize impaired behavior. While it is possible to argue
over terminology, testing, and behavioral analysis, it is clear, even to Head
(1926, Vol. 1, p. 476), who is considered as the archetype antilocalizationist,
that "A lesion at some appropriate place on the surface of the brain can interrupt
speech for a time. " He does recognize that different forms of aphasia result from
lesions in different parts of the brain. The areas he identifies are essentially those
which early workers such as Broca and Wernicke observed to be damaged. What
is different in Head's approach is his belief that "No one part of this wide area on
the surface of the brain is associated exclusively with the processes of speech"
(Head, 1926, p. 477). He asserts that there are no "centers" for the behaviors
which constitute the activities of "normal language function" but he does accept
the notion that there are areas of the brain "within which structural injury can
produce disorders of symbolic formulation and expression" (Head, 1926, Vol.
1, p. 478). He also believed strongly that both "cortical and subcortical mechanisms participate in every act of language" (p. 478). Such views have found
their way into the thinking of Lashley (1951) in his attempt to characterize and
integrate psychoneurologic concepts of brain function, as well as those of Goldstein (1948) and Luria (1966, 1970, 1973). Possibilities of subcortical mechanisms generating aphasie symptoms such as suggested by Head have been confirmed to some extent by Van Buren and Borke (1969), Van Buren (1975), and
Ojemann and his co-workers (Ojemann, Fedio, & Van Buren, 1968; Ojemann,
1976).
Two important trends emerge from this relatively early work with respect to

8

Ronald S. Tikofsky

diagnostics. One stresses an evolution of a large number of clinical syndromes
which could be related to relatively well-defined and small areas of cortical
damage. Thus, an accurate portrayal of the symptom or symptom complex
should, if this concept were correct, lead to the diagnosis of a circumscribed area
of cortical damage producing the disturbed language function. The second trend
does not refute the central concept of clinical localization in its entirety. Rather,
the view taken is that one cannot with accuracy achieve a one-to-one correlation
between disturbed language function and narrowly specified areas of cortical
damage. The relationship then is seen as one in which certain aspects of language
impairment are more susceptible to disruption as a consequence of a lesion to
broadly defined cortical or subcortical regions. Those holding this view also take
the stance that the destruction of cortical tissue produces a disruption of the
general organizational activities of the brain, and that the behavioral symptom
complexes are a reflection of the system's attempt at reorganization. Accepting
this position requires a dynamic conceptualization of both brain function and
language behavior, one which posits interactions between cortical and subcortical regions that enable the organism to engage in linguistic behaviors. Thus, the
diagnostic issue here is less one of predicting specific site of lesion and more one
of suggesting how the effects of a particular lesion can account for the altered
language.
One can summarize this early period of scholarship as having laid the foundations of the central issues relative to diagnostics in aphasia. That the foundations
were not well secured by statistically established data is not really relevant. What
emerges from analysis of these reports and theories of mind-language-brain
relationships are the questions in diagnostics that have become the touchstone for
contemporary students of aphasia.
One aspect of diagnostics continues to follow the tradition of the structuralists,

that of a continuing search for verification that lesions of specific cortical areas
produce specific alterations of language behavior. The link between symptom,
aphasia in its varied forms, lesion, and disease or trauma remains a valid arena
for research.
Another and equally important aspect of aphasia diagnostics emerged in the
effort to understand better the nature of the language disturbance called aphasia.
Head's (1926) concept of aphasia as disorder of *'symbolic formulation and
expression" based on Jackson's work (1878) held sway into the late 1950s. As a
corollary, the question of aphasia as being a ' 'disorder of basic mental function' '
(Weisenburg & McBride, 1964 reprint, p. 39) arose. Perhaps the most important
influence on those who took this position derived from the influence of the
"Gestalt psychology" of the period. Weisenburg and McBride (1964, p. 39)
summarize Goldstein, the leading proponent of this point of view, as stating that
"the various symptoms of aphasia are the manifestation of a single functional
disorder, loss of the ability to grasp the essential nature of a process." They go


Contemporary Aphasia Diagnostics

9

on to interpret Goldstein as believing that aphasia was not dependent upon a
specific locus of lesion but rather on the disruption of a 4 'cortical function. ' ' This
concept is not necessarily incompatible with the view that lesions in relatively
focal regions will determine the particular form which the behavioral disturbance
will take. This concept, which allows for both a holistic and a specifistic approach to aphasia, is seen in the contemporary works of Luria and others. In fact,
as will be shown later a reinterpretation of this concept in the light of sophisticated neuropsychologic and neuroradiolographic techniques provides a clearer
understanding of the diagnostic issues in aphasia.
The movement toward a neuropsychologic approach to aphasia diagnosis was
advanced by the publication of Aphasia: A clinical and psychological study

(Weisenburg & McBride, 1935). This work was the result of a 5-year study of
234 patients and served as the major reference work for American students of
aphasia through the middle 1950s. In the processes of developing their own
battery of tests, Weisenburg and McBride reviewed in detail the then extant
approaches and tests used to assess aphasia with particular attention to Head's
well-known battery. Their review of diagnostic testing following World War I
reflected the growing influence of the ' 'mental testing" and "educational testing" approaches of the time. They note "few tests of higher mental processes in
the language field" (Weisenburg & McBride, 1964, p. 85) were used with
aphasies and observe that "nonlanguage intelligence tests" were developed after
World War I. As a result of their exhaustive review, Weisenburg and McBride
(1935) concluded that "what was needed most was a study of the actual nature of
the psychological changes occurring in aphasie conditions" (p. 2). To fill this
need they sought to attack the problem with four basic objectives to be accomplished (Weisenburg & McBride, 1964, p. 2):
1.
aphasie
2.
3.
4.

The establishment of a battery of tests satisfactory for the determination and analysis of
disorders.
The study of psychological changes in aphasia.
The classification of types of aphasia.
The study of the nature and location of the lesions present in aphasia.

It is interesting to note, in light of contemporary efforts to find short tests, that
these authors caution that one could use less extensive batteries for ordinary
diagnostic purposes "but this is not adequate if . . . reeducation is contemplated
or if a research study is to be made." They make the point that "the greater the
simplification, the less complete is the knowledge of the aphasie changes"

(Weisenburg & McBride, 1964, p. 3). Schuell (1965) reiterates this point in
developing her battery.
Thus, the Weisenburg and McBride (1964) study held great promise as a
major step forward in establishing the methodological foundations for aphasia


10

Ronald S. Tikofsky

diagnostics. They presented a mass of data based on a test performance using the
available test instruments. No special tests of language function were developed
for the battery. In their effort to establish a coherent approach to diagnostic
classification, they recognize, even after extensive but not statistical analysis, the
complexity of classification based on test performance, independent of anatomic
and physiologic issues, and that "it would be possible to make more than one
classification on a purely psychological basis" (Weisenburg & McBride, 1964,
p. 142). What emerged from their effort overcame the biases of traditional
terminology. Weisenburg and McBride pointed out that patients could be
grouped or classified on the basis of symptom prominence. Four major classes of
symptoms were described: predominantly expressive, predominantly receptive,
expressive-receptive, and amnesic. To their credit, they recognized the inherent
disadvantages of their simplification of the diversity of aphasie patterns. Unfortunately, the disadvantages were not always kept in mind by those who adopted
this classification system.
Diagnostics in aphasia demand that anatomic and physiologic as well as behavioral questions be addressed. Although they did not carry out extensive and
meticulous neurological evaluations of their subjects or have the benefit of large
numbers of autopsied brains to support their inferences, Weisenburg and
McBride tackled the problem of localization. They agreed and gave full support
to the contention that "extent and nature of the aphasia varies with the site, the
extent, and the nature of the pathological lesion but cannot be understood in these

terms alone" (p. 435). It is a view that compelled Weisenburg and McBride to
take heed of Jackson's concept of positive and negative aspects of aphasie
language behavior. They raise the point in discussing physiological adaptation
that can now be investigated using technologies that were not available when
their findings were published. However, the question of determining the dynamics of physiological response to pathology is an essential aspect of aphasia
diagnostics. They state "that in contrast to the negative or pathological aspects,
we are dealing with a dynamic or live physiological activity which it is impossible to measure or define. All we know is that it cannot produce normal language,
but what it does produce is the result of the activity of the uninjured brain"
(Weisenburg & McBride, 1964, p. 477). Although these authors admit that their
work contributed little to the problem of localization, they do note that relationships between their grouping of patients and general regions of lesion could
be established. Their results in this regard show that the predominantly expressive patients tend to have the primary site of lesion in the anterior cortex with
some involvement of posterior regions. In the receptive cases the reverse was
true. For the expressive-receptive group and amnesics no specific mention of
locus is made. They do however suggest that in the former classification group
there is some evidence suggesting a greater and more permanent lesion to both
anterior and posterior cortex with more involvement in anterior regions. As for


Contemporary Aphasia Diagnostics

11

the amnesic, they felt nothing definite with regard to localization could be
established. Given that most workers in the field now acknowledge that naming
disorders occur with all other forms of aphasia, one would not expect to find a
well-defined region yielding this type of problem. Weisenburg and McBride's
general assessment of the relation of type of aphasia to locus of lesion has its
contemporary counterparts in the work of those who describe two general categories of aphasia: nonfluent (Broca's) with anterior lesions, and fluent (Wernicke's) with posterior lesions. However, few contemporary investigators would
accept the conclusion reached by Weisenburg and McBride, that because of the
physiological conditions imposed by cerebral insult "it is impossible to localize

speech disturbances" (1964, p. 468). They try to make the case that the residual
language of the aphasie is the result of activity of uninjured brain which is "a
live dynamic electrical function and cannot be measured" (p. 468). This is no
longer the case, and the means of measuring and assessing that activity, electrical, chemical, and circulatory, is near at hand.
Further work on diagnostics was not to appear until the mid-1940s, which
ushered in the beginnings of a new era in the study of aphasia. Early efforts at
diagnostics sought to establish the nature and forms of aphasia and to correlate
such descriptions with site of lesion as a means of substantiating theories of
cerebral localization. In only a few instances was the matter of diagnostic testing
related to predicting the course or possible resolution of the aphasie symptoms. It
was also the case that most investigators appeared to assume that the lesions
generating the aphasie symptoms were relatively static and that whatever spontaneous recovery took place occurred because adjacent areas or the right hemisphere took over such functions as best they could. It was the advent of World
War II that brought about a resurgent interest in aphasia. Young men who
sustained and survived gunshot wounds to the head producing aphasia required
attention and rehabilitation. It became the task of the psychologist-speech pathologist, in the military services and later in Veterans' Administration Hospitals, to devise appropriate diagnostic and rehabilitative techniques to deal with
these patients. At the same time the incidence of stroke was increasing, and with
better medical care the survival rate also improved adding additional impetus to
the rehabilitative aspects of diagnosis.
B. Diagnostics from the 1940s to the 1960s
This section examines the development of diagnostics from the early 1940s to
the beginning of the 1960s. This period serves as the prelude to the rapid
expansion of current studies of aphasia.
Although Chesher (1937), Robbins (1939), and Someberg and Ingram (1944)
reported tests for aphasia, no standard diagnostic approach was accepted. In
1945, the United States War Department, in a Technical Bulletin, attempted to


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Ronald S. Tikofsky

establish standardized diagnostic procedures to be used with aphasie patients in
military hospitals. This was a four-part battery and included the AGCT (Army
General Classification Test) or Basic Battery I, Wechsler-Bellevue Intelligence
Scale, Goldstein-Scheerer Cube Test, as well as a language test. The bulletin
urged that examiners make note of the frequency of "slips of the tongue,"
tendency to fatigue, and frustration level. No data based on the use of the battery
have ever been published, and it is clear that this battery was not satisfactory.
Two screening instruments resulted from this dissatisfaction. One was part of a
more general manual for conducting mental evaluations (Wells & Ruesch,
1945), and the other evolved into what became a commonly used instrument for
screening based on a test developed by Sail and Wepman (1945) to aid military
officers needing to make evaluations of brain-injured servicemen. Halstead, an
early worker in neuropsychology, published an aphasia test (Halstead, 1947) and
later collaborated with Wepman to create the Halstead-Wepman Aphasia
Screening Test (Halstead & Wepman, 1949). Recognizing the importance that
the study of aphasia holds for generating evidence of "far-reaching neurological,
psychological, and psychiatric significance," Halstead suggested establishing an
international registry of all brain injured persons and special research centers
"with adequate facilities for the application of diverse methodologies and techniques for investigation" (1947, pp. 89 and 90). At the same time, Eisenson
(1946, 1954) published a more extensive aphasia test battery. Both these tests
served as the major diagnostic instruments for evaluating adult aphasies until the
mid 1960s.
The tests were intended to serve as diagnostic tools for speech pathologists.
Their authors did not intend them as devices by which to test theories of aphasia
or cerebral localization. Rather, they seemed to provide examiners with systematic approaches by which to explore various aspects of communicative function
which could be impaired by brain damage. The authors of the tests relied on the
classification model developed by Weisenburg and McBride (1935) and Head's
(1926) conceptual framework of aphasia as a disorder of symbolic formulation
and expression as well as the psychological analysis of behavioral change associated with aphasia developed by Goldstein (1948). Thus, for the working speech

pathologist in the late 1940s and early 1950s a systematic means for assessing
aphasia and the related problems of agnosia and apraxia was at hand. Although
these tests were quickly accepted and used, they however lacked a firm psychometric foundation. The authors presented little data to support their selection of
items, standards by which to determine placement into diagnostic categories, or
criteria for establishing degree of impairment. Their data base was careful observation of large numbers of aphasies, and although the tests may "possess great
clinical utility" (Benton, 1967, p. 36), they did not achieve the levels of reliability, validity, and standardization that were the criteria by which other psychological tests were measured.


Contemporary Aphasia Diagnostics

13

An alternate approach to aphasia diagnostics had its genesis in a paper published by Brown and Schuell in 1950. Four levels of performance were evaluated: (1) primary associations, (2) symbol associations, (3) elaboration, and (4)
conceptual processes. Although Brown and Schuell (1950) presented little statistical confirmation as to the validity of their test, they did measure reliability and
found it to be satisfactory. In addition, they reported that evaluations based on
their tests correlated with clinical evaluations made by others who had evaluated
clinically the patients who served as subjects.
Schuell continued her work to develop an effective diagnostic instrument until
her death in 1970. A second stage in the development of her test, "The Minnesota Test for Differential Diagnosis of Aphasia" (MTDDA), came in 1953
(Schuell, 1953). She reported on tests designed to determine the aphasies' ability
to understand spoken language. Using items that ranged from understanding of
single words through complex information, she tested 138 patients.
She established four prognostic groups based primarily on degree of difficulty
in understanding single words plus difficulty in other areas tested. The group
having the best potential for recovery had no difficulty in understanding single
words and little or no impairment in other areas, whereas all subjects who had
great difficulty in this and other areas had no recovery of functional speech. The
four prognostic groups that she reported served as the forerunners of the diagnostic categories on the current revision of the MTDDA (Schuell, 1973). Continuing in her efforts to establish a comprehensive diagnostic instrument, Schuell
(1955) published results obtained on a broader battery of tests. She suggested
that aphasia symptoms be considered in relation to three language processes:

auditory, visual, and sensory-motor, and four language modalities: comprehension of auditory material, reading, speaking, and writing. Schuell was careful to
caution that these results were preliminary and the test items were in the developmental stage. The MTDDA had been conceived in the Brown and Schuell (1950)
paper and in the mid-1950s was undergoing its birth pangs. The test was made
available for experimental use in 1955. In 1957 Schuell published the "Short
Examination for Aphasia" (Schuell, 1957), which was designed as "a clinical
tool and not a standardized test" (Schuell, 1966, p. 137). The purpose was to
provide the neurologist with a tool for assessing aphasia symptoms as part of the
routine neurological examination. This shortened version of the then experimental MTDDA became popular and was used so widely by speech pathologists that
Schuell (1966) wrote a paper reevaluating the test because of her concern for
sources of reliability of the original version, suggesting alternate procedures
when using the Short Examination. This paper appeared a year after the formal
publication of the MTDDA (Schuell, 1965).
Schuell's approach to diagnostics emphasized only the behavioral aspects of
aphasia. She did little to relate her findings to the underlying neurological basis
of the aphasie symptoms. Thus, Schuell followed in the tradition established by