NOTE

SIGN COMPREHENSION IN GLOBAL APHASIA

Les Schwartz

(Northport Veterans Administration Hospital)

INTRODUCTION

Brain-injured adults having a severe breakdown in all linguistic modalities are often referred to as global aphasics. Case histories on global (i.e., Group V) aphasics by Schuell, et al. (1964) revealed high incidences of cardiovascular disease, and complete thrombosis of the internal carotid and middle cerebral arteries. There were high occurrencies of (a) losses of sensation, (b) facial paralysis and (c) right hemiplegia. Electroencephalographic data showed facial involvement in 76% for the group with a high evidence of temporal lobe lesions. Frequent occurrences of hypertension (32% ), abnormal electrocar­diograms {74% ), previous cerebral lesions, weakness of the articulatory and phonatory musculature and abnormal mental states (50%) were reported under the heading of "complicating conditions." Data showed that a sub­stantial number of Group V patients, ( 1) required post hospital ambulatory care, (2) had future cerebral vascular lesions and (3) had a high incidence of death as a result of cerebral pathology.

Clinically, the global aphasics showed (a) inappropriate responses to test stimuli and (b) poor retention of stimuli which had been reinforced during therapy. They were able to repeat, copy, serially count and sing. Their lan­guage comprehension during speech therapy improved, but this improvement decreased when rehabilitation was discontinued. Smith (1971) suggested se­veral possible factors relating this lack of linguistic recovery, including (a) considerable left cerebral impairment, (b) right hemispheric disconnection, (c) reduced right hemispheric "take over" capacity, and/or (d) associated le­sions of the minor (i.e., right) hemisphere.

The global aphasic's lack of linguistic facility may be due to a more basic disorder in the comprehension and use of signs. Signs may be defined as " ... things standing for something else" (Ullmann, 1967). An essential rela­tionship between signs and "symbolic" language has been discussed by several authors, including Morris (1964) and Peirce (in Hartshore and Weiss, 1960,

Cortex (1978) 14, 112-118.

113 Sign comprehension in global aphasia

1965). These sources point out that symbols represent a class of signs, having arbitrarity, a history, require higher associative thoughts and may be syste­matic. The issue as to whether signs and symbols are independent or sub­classificative is controversial. The present author's position is that signs are intricately involved, both in linguistic and in non-linguistic phenomena. There­fore, information gathered from non-linguistic signs might be of assistance in an evaluation of the severe language disorder referred to as global aphasia.

Previous authors have discussed the relationship of signs and aphasia. Some research supports a connection between sign (i.e., associative) function­ing and language disruption (Critchley, 1970; Crocker, 1970; Dufft et al., 1973; Jackson (in Taylor et al., 1958), Jakobsen, 1966; Spinnler and Vigno­la, 1966; Ulatowska, et al., 1974; Wepman et al., 1960), while other refe­rences are nonsupportive of this connection (Geschwind, 1966; Weigel, 197 4 ); and still other authors refer to other possible causes of sign disruptions in aphasia (Goldstein, 1948; Goodglass and Kaplan, 1963 ).

In order to further explore the nature of global aphasia, Schwartz ( 1972) administered a test of sign comprehension to forty subjects, including 10 nor­mals, 10 brain-damaged nonaphasics, 10 nonglobal aphasics and 10 global aphasics. Means for the respective groups were 90%, 86%, 76% and 43% correct, suggesting a severe disorder in sign comprehension for the global aphasics. Yet, the global aphasics were not matched for residaal intel­lectual functioning with the brain-damaged nonaphasics. Thus, an interpre­tation as to whether the performance of the global aphasics was due to a language, or to an intellectual deficit could not be put forth. Therefore, the present study compared sign comprehension scores of a group of global apha­sics with those of brain-damaged nonaphasics, having a similar level of residual intellectual functioning.

MATERIAL AND METHOD

Subjects

Ten global aphasics matched with eight brain-damaged nonaphasics, with respect to etiology, residual intellectual functioning and age. A subject was classi­fied as a global aphasic if he had 91-100 percent impairment on the Sklar test for aphasia (Sklar, 1966 ). This degree of impairment was associated with a lack of correct responses to items concerning each language modality. The Sklar test does not evaluate the characteristics of fluent aphasia (Goodglass and Kaplan, 1972 ) , yet the "impression" of the current author was that none of the subjects classified as global aphasic had "fluent" speech. Their utterances, when present, were limited to one or two-word laboriously-produced phrases. Clinical histories revealed that each global aphasic (GA) had suffered a left cerebral vascular lesion and that each right brain-damaged nonaphasic ( RBDN) had sustained a lesion of the right cerebral hemisphere. Hearing and visual (with corrective lenses) acuities were within normal limits for all subjects. All subjects correctly responded to the

114 L. Schwartz

visual matching items of Eisenson's Examining for aphasia (1954). The "perform­ance" scale of the Wechsler Adult Intelligence Scale (Wechsler, 1955) were used to evaluate the residual intellectual functioning of the GAs. Additional time was given in order to allow for responses with the non-preferred hand. The "verbal" scale was employed to examine the RBNDs' residual capacity. The reader should be cautioned on this matter, in that the intelligence factor was matched on different operational abilities and responses. Thus, the GA and RBDN groups were somewhat equated for residual intellectual functioning. Mean average scores for intellectual were 67.1 and 67.6 for the GAs and RBNDs, respectively, with concomitant ranger of 49.80 and 58.86. The respective mean ages of the GAs and of the RBDN's were 61.0 and 61.3 years, with associated ranges of 48-73 and 46-71 years. Mann-Whitney Us (Siegel, 1956) for group rank comparisons, were 48 for intellectual measures and 41.5 for age. Both Us were significant at the .05 level of confidence. Patient data is presented in Table I.

TABLE I

Patient Daf!l

Groups

Global aphasics Right brain-damaged nonaphasics Age I.Q. score** Age I.Q. score*

48 62 61 65 63 71 61 63 49 49 60 65 66 77 71 63 70 63 60 58 67 56 64 67 58 68 60 74 73 80 46 86 60 79 56 '66

* Performance battery of the Wechsler Adult Intelligence Scale. ** Verbal battery of the Wechsler Adult Intelligence Scale.

MATERIALS AND PROCEDURES

The test of sign comprehension consisted of 30 signs (See Table II). Each was accompanied by three (referential) choices. According to Ullmann (1967) signs were classified as natural (N = 10), animal (N = 10) and human (N = 10). Five of the ten signs within each sign classification were presented audito­rially and five were visually presented.

Each visual sign, as well as the three choices for the referent of the sign were hand drawn by an art student. All visual stimuli were mounted on an 18" by 12" photograph album. The auditory signs were taken from the Elektra Sound Effects record. The record was placed on a Garrard Model Laboratory 80 turn­table and played through a Grason-Stadler Model 162 Speech Audiometer, which

115 Sign comprehension in global aphasia

TABLE II

The Sign Test

ChoicesSign Type Referent (N = 3)

Clouds Smoke Dark room Bandage Ground seeing his shadow Surf Rain Fire Water falling Howling wind Dog scratching on door Dog sitting up Cat frightened Dog bowing Honey Dog barking Rooster Seagulls Crickets Mean cat One finger Numerical one Little sign Person hands up Word one Baby crying Telephone Car horn Word baseball Whistle for pretty girl

Natural- Visual Natural- Visual Natural- Visual Natural - Visual Natural- Visual Natural- Auditory Natural- Auditory Natural- Auditory Natural- Auditory Natural- Auditory Animal- Visual Animal - Visual Animal - Visual Animal- Visual Animal- Visual Animal- Auditory Animal - Auditory Animal- Auditory Animal- Auditory Animal- Auditory Human -Visual Human- Visual Human -Visual Human -Visual Human - Visual Human - Auditory Human - Auditory Human - Auditory Human- Auditory Human- Auditory

Rain Visual Fire Visual Night Visual Scar Visual Winter Visual Beach Visual Rain Visual Fire Visual Waterfall Visual Snowstorm Visual Door being opened Visual Someone eating Visual Dog Visual Dog scolded Visual Bees Visual Burglar Visual Dawn Visual Seagulls Visual Woods Visual Dog Visual One object Visual One object Visual Something small Visual Hold up Visual One object Visual Baby Visual Telephone Vimal Car Visual Baseball Visual Pretty girl Visual

was connected to an Ampex Tape Recorder Model 2160. The tape, conslstmg of auditory signs, was then played to each subject on a Wollensak Model 1520 Tape Recorder. The signs were randomized in six randomizations in order to control learning and/or fatigue effects.

The sign test was administered by placing a sign (i.e. visual sign) before each subject with accompanying choices of visual referents. When an auditory sign was presented the subject was encouraged by gesture to listen and to choose one of the visual choices. The loudness was set at "9" and the tape recorder was placed 12" from the subject.

The initial sign in the series was presented to a subject and the examiner pointed to the sign (or gestured to the subject to listen). The examiner then pointed, one by one, to the possible choices of a referent. This procedure was

116 L. Schwartz

continued until the subject pointed to one of the choices or there were three presentations of the stimulus. If an incorrect choice was made the stimulus was presented a second time. The subject was again encouraged to make a decision. This procedure was repeated until the subject made a response. Once a response was made to the initial item the remainder to the items were given. Each subject had one response allowed per item after the initial response.

RESULTS

Comparisons were carried out between the groups on the sign test scores. In addition, scores between the groups were compared on the natural, animal and human sign categories, but not between the visual and auditory signs. Mean total scores were 43% and 63% correct for the global aphasics and the brain-damaged nonaphasks. Inferential comparisons were carried out with the Mann-Whitney U test. A significant difference was found between the sign test scores for the two groups. Significant differences were also found for the animal and human signs, but not the natural signs. A summary of the findings is presented in Table III.

TABLE III

Comparisons Between the Scores of the Global Aphasics and the Right Brain-Damaged Nonaphasics

Comparison Mann-Whitney U score

Sign test scores 18.5*

Natural signs 21.5***

Animal signs 19.0*

Human signs 7.0*

A U of less than 20 is required for significance at the .05 level, N, = 10 and Nz = 8. * Significance at the .05 level. *'' Significance at the .01 level. *;'* Not significant at

the .05 level.

DISCUSSION

Previously ( 1972 ), the present author administered the test of signs to ten normals, ranging in age from 40-72 years. Eight of the normals scored 100% and the remaining two received a score of 93%. There were no signi­ficant differences between left brain-damaged nonglobal aphasics and right brain-damaged nonaphasics on the sign test. Two of the ten were ruled as having "fluent" speech (Goodglass and Kaplan, 1972) by a team of three

117 Sign comprehension in global aphasia

speech pathologists. These "fluent" subjects received scores of 100% and 97%. The current investigation showed a comparatively greater problem in comprehending signs for the left brain-damaged severely language impaired adults than in right nonaphasic brain-damaged adults with similar levels of residual intellectual functioning. Thus, it appears that sign comprehension impairment was not related directly to the presence of a language impairment per se or per se to level of tested residual intelligence, but possibly to global aphasia.

One might then re-considered whether global aphasia is a severe language disorder, which disrupts sign comprehension, or a sign disorder, which inter­feres with linguistic processing, or a severe language disorder accompanied by a severe problem in sign comprehension. Future studies focusing on the degree of independence between language comprehension and sign compre­hension by normals as well as clinical groups appears indicated. The current study suggests that, besides processing linguistic data, the left hemisphere stores and retrieves sign information.

Alternative hypotheses for the poor performance by the global aphasics include ( 1) the inability of the global aphasics to understand the instructions and/or (2) more extensive left, commissural and/or right brain pathology in these patients. The severe disorder in linguistic comprehension must always be considered when interpreting the performance of global aphasic. The pre­sent research attempted to circumvent this problem by giving gestural instruc­tions, and conditioning the patient to respond to a referent's sign. Yet, the examiner could not be thoroughly certain that the global aphasics understood what they were instructed to do. In reference to extent of brain pathology, Smith ( 1971) pointed out that extensive brain lesions in patients saffering from global aphasia is highly likely. Additional anatomical data appears ne­cessary in order to delineate ( 1) the extent of brain damage in global aphasia, and (2) the relationship between extent of brain pathology and impairment of sign comprehension.

The above findings may indicate why success in language therapy for global aphasic has been limited. When therapy is oriented toward visual matching, success may be obtained, but functional language is not reacquired. When therapy is linguistically oriented, results are not appreciable (Schuell et al., 1964). Controlled studies contrasting the effects of stimulation and intervention with signs as opposed to traditional methods appear clinically useful.

In summary, the conclusion of the investigation is that a severe sign comprehension disorder is demonstrated by left brain-damaged adults with severe language impairment. Therefore, global aphasia might be reconsidered as a disorder in sign comprehension.

118 L. Schwartz

SUMMARY

Ten global aphasics and eight brain-damaged non-aphasics were given a test of sign comprehension. The test contained natural, animal and human signs. Sub­jects were matched for etiology, age and residual intellectual functioning. The global aphasics scored significantly lower than the nonaphasics on the test of sign comprehension, indicating that global aphasia might be reconsidered as a disorder of sign comprehension.

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L. Schwartz, Ph.D., Northport Veterans Administration Hospital, Northport, New York, 11768, U.S.A.