As a result of damage to the adjacent prerolandic motor area, the arm and lower part of the face are usually weak on the right side. The tongue may early on deviate away from the lesion, that is, to the right, and be slow and awkward in rapid movements. For a time, despite the relative preservation of auditory comprehension and the ability to read, commands to purse, smack, or lick the lips, or to blow and whistle and make other purposeful orolingual and facial movements are poorly executed, which signifies that an apraxia has extended to certain acts involving the lips, tongue, and pharynx. In these circumstances, imitation of the examiner’s actions is performed better than spontaneous execution of acts on command. Self-initiated actions and spontaneous emotional expressions of the face, by contrast, may be normal or better preserved. From imaging findings in patients with this type of speech, it is apparent that the coordination of orolingual movements that are responsible for articulation takes place in the left anterior insular cortex (see Dronkers) rather than primarily in the Broca area. Positron emission tomography (PET) shows activation of the insular region as well as of the lateral premotor cortex and the anterior pallidum during repetition of single words (Wise et al).
In the milder forms of Broca aphasia and in the recovery phase of the severe form, patients are able to speak aloud to some degree, but the normal cadence and parsing of speech is choppy or lacking. Words are uttered slowly and laboriously, and enunciated poorly. Missing is the normal inflection, intonation, phrasing of words in a series, and pacing of word utterances. The overall impression is one of a lack of fluency, a term that has come to be almost synonymous with aphasias that derive from damage in and around the Broca area (nonfluent aphasia). This labored, uninflected speech stands in contrast to the fluent speech of Wernicke aphasia described later, but there are exceptions in which nonfluency extends to Wernicke aphasia.
Language is clearly affected in a restricted way in Broca aphasia. Speech is sparse (10 to 15 words per minute as compared with the normal 100 to 115 words per minute) and consists mainly of nouns, transitive verbs, or important adjectives; phrase length is abbreviated and many of the small words (articles, prepositions, conjunctions) are omitted, giving the speech an abbreviated, telegraphic character (so-called agrammatism). The substantive content of the patient’s language permits the crude communication of ideas, sometimes despite gross expressive difficulties. Repetition of the examiner’s spoken language is as abnormal as the patient’s own speech. If a patient with nonfluent Broca aphasia has no difficulty in repetition, the condition is termed transcortical motor aphasia (see further on). Furthermore, a true defect in language production is evidenced by impairment in the content of written words and sentences. Should the right hand be paralyzed, the patient cannot print with the left one, and if the right hand is spared, the patient fails as miserably in writing to dictation or replying to questions in written form. Letters are malformed and words misspelled. Although writing to dictation is impossible, letters and words can still be copied. The dysgraphia usually corresponds in degree to the severity of the spoken disturbance, but there are exceptions in which one is far more affected.