Also common in global or multifocal cerebral diseases are defects in prosody, both expressive and receptive. These appear in numerous states that affect global cerebral function, such as Alzheimer disease as well as with lesions of the nondominant (right) perisylvian region, as noted in Chap. 21.
Severe developmental delay often results in failure to acquire even spoken language, as pointed out in Chaps. 27 and 37. If there is any language skill, it consists only of the understanding of a few simple spoken commands. The subject of developmental dyslexia is discussed in “Developmental Dyslexia” in Chap. 27.
Treatment of Aphasia
The sudden onset of aphasia would be expected to cause great apprehension, but except for cases of pure or almost pure motor disorders of speech, most patients show remarkably little concern. It appears at times that the very lesion that deprives them of speech also causes at least a partial loss of insight into their own disability. This reaches almost a ludicrous extreme in some cases of Wernicke aphasia, in which the patient becomes indignant when others cannot understand his jargon. Nonetheless, as improvement occurs, many patients do become discouraged. Reassurance and a program of speech rehabilitation are the best ways of helping the patient at this stage.
Whether contemporary methods of speech therapy accomplish more than can be accounted for by spontaneous recovery is still uncertain. Most aphasic disorders are caused by vascular disease and trauma, and they are nearly always accompanied by some degree of spontaneous improvement in the days, weeks, and months that follow the stroke or accident. A Veterans Administration Cooperative Study (Wertz et al) has suggested that intensive therapy by a speech pathologist does hasten improvement. Also, Howard and colleagues have shown increased efficacy of word retrieval in a group of chronic stable aphasics treated by two different techniques. More studies of this type, which control for the effects of time, of the patient’s motivation and the interest of family and therapist, are needed. In an interesting personal experiment by Wender, a classicist who had become aphasic, practice of Greek vocabulary and grammar led to recovery in that language, but there was little recovery of her facility with Latin, which was not similarly exercised.
The methods of language rehabilitation are specialized, and it is advisable to call in a person who has been trained in this field. However, inasmuch as a part of the benefit is also psychologic, an interested family member or schoolteacher can be of help if a speech therapist is not available in the community. Frustration, depression, and paranoia, which complicate some aphasias, may require psychiatric evaluation and treatment. The developmental language disorders of children pose special problems and are considered in Chap. 27.
In general, recovery from aphasia that is due to cerebral trauma is usually faster and more complete than that from aphasia because of stroke. The type of aphasia and particularly its initial severity (extent of the lesion) clearly influence recovery: global aphasia usually improves little, and the same is true of severe Broca and Wernicke aphasias (Kertesz and McCabe). Minimal or “mini” Broca aphasia characterized by slightly effortful and halting speech, recovers quickly. The various dissociative speech syndromes and pure word mutism also tend to improve rapidly and often completely. In general, the outlook for recovery from any particular aphasia is more favorable in a left-handed person than in a right-handed one. Characteristically, in the course of recovery, a severe aphasia of one type may evolve into another type (global into severe Broca; Wernicke, transcortical, and conduction into anomic), which are patterns of recovery that may be attributed to the effects of therapy.