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Summary A study is presented which is concerned with a new form of language therapy for aphasia called Melodic Intonation Therapy. This program involves sung intonation of propositional sentences in such a way that the intoned pattern is similar to the natural prosodic pattern of the sentence when it is spoken. The method and scoring system are described. Results are based on eight severely, but not globally, impaired, right-handed aphasic subjects with left hemisphere damage resulting from cerebro-vascular accidents. Each patient acted as his own control by having shown no improvement in verbal expression for at least six months during which time he had received other language therapy. Recovery of some appropriate propositional language occurred for six of the eight patients as a result of Melodic Intonation Therapy. It is suggested that both dominance for music and existence of less developed language areas in the right hemisphere are perhaps being used to support the damaged left hemisphere which continues to be language-dominant. Although candidancy for MIT is still subject to further investigation it is suggested that pre-requisites should include less impaired auditory comprehension than verbal expression, evidence of self-criticism, good attention span, and evidence that on-going recovery in some language modalities has or is occurring. Efficacy of MIT for chronically global aphasics is probably subject to question.

We were formally introduced to the phenomenon of acquired stuttering in 1976 when a 33-yr-old patient was admitted to the AphasiaNeurobehavior Unit of the Boston Veterans Administration Hospital with a seizure disorder which developed following a head injury. Along with the seizure the patient had developed a profound stutter, characterized by phonemic repetitions of virtually every syllable. He had no history of developmental speech or language problems. The clinicians responsible for this patient’s treatment were confronted with the problem of determining whether the etiology was psychogenic or neurogenic. This prompted us to investigate the problem of acquired stuttering. With little effort seven additional patients with adult onset of stuttering were recalled. In characterizing their speech problem we were drawn to the definition presented by Espir and Rose (1970) who characterized stuttering as “a deviation of speech which affects adversely the speaker or listener because of an interruption of the normal rhythm of speech by an involuntary repetition, prolongation or arrest of sounds.” Definitions which implied a developmental etiology were rejected because our patients clearly began to stutter subsequent to neurolgical injury during adulthood. At the same time we began a retrospective examination of these seven patients, a literature search was undertaken. It was striking to find that while a single bibliography in developmental stuttering may run over 600 references (Bloodstein, 1969) we were able to locate less than a dozen references to acquired stuttering, since this phenomenon was first

Palilalia is a speaking disorder that has been likened to the festinating gait of Parkinsonian patients. This report describes a pacing device developed as a means of controlling the severely palilalic output of one patient. The device is modeled after Luria’s suggestion that a treatment program for such patients can be developed successfully by transferring automatic motor acts to a conscious, reactive level.

In a short examination for dysphasia six language skills should be tested: spontaneous speech, repetition, naming, comprehension of spoken language, reading, and writing. The following examination can be completed in 10–15 minutes at the bedside.

Language is a means by which people communicate with each other using verbal symbols. Dysphasia may be defined as a disorder of language due to brain damage. This monograph deals with disorders of language, not disorders of speech. Speech refers to the mechanical process of articulation, which can be disturbed by weakness, slowness, or incoordination of the muscles of the glossopharyngeal apparatus. Such disturbances would be termed dysarthria, dysphonia, or mutism. The term dysphasia is applied to a neurological disorder resulting from damage to those regions of the cerebral hemispheres which form the anatomical basis for the human capacity for language.

Aphasiologists are no longer satisfied with impressionistic judgements as to the effectiveness of dysphasia rehabilitation. Instead they seek scientific evidence, through formal studies, that treatment has a significantly positive effect on dysphasic patients. When undertaking any treatment study, certain variables which may confound the results must be identified and controlled. The most potent of the variables to be considered in dysphasia rehabilitation is the phenomenon known as spontaneous recovery. This is the period during which structurally undamaged portions of the brain regain function following insult. If treatment is administered during the period of natural recovery, then the investigator has the task of differentiating effect of treatment from effect of spontaneous improvement. There is, however, little agreement as to exactly how long spontaneous recovery takes place. Vignolo (1964) retrospectively examined the evolution of dysphasia in 69 non-traumatic patients and found that patients seen after 2 months had only a limited possibility of spontaneous recovery compared to patients seen before 2 months. Culton (1969) studied the recovery patterns of 21 dysphasics and concluded that the greatest degree of recovery takes place in the first month post onset, and that little more occurs after 2 months. Butfield and Zangwill (1946) and Luria (1963), on the other hand, State that spontaneous recovery takes place for as long as six months, particularly in traumatic dysphasias. Other authors use a 3 month cut off point (Sarno and Levita, 1971). Despite the disagreement as to the length of the spontaneous recovery period, the phenomenon is real, and must be reckoned with in any dysphasia treatment study.

Speech pathologists are called upon to rehabilitate adults with disorders which range from global dysphasia with severe impairment in all language modalities, to anomic dysphasia with impairment only in substantive word finding. There is little reason to expect that disorders which vary widely in nature should or can be treated in a similar manner. There are, of course, some general principles which can be applied to any rehabilitative process and dysphasia is no exception. Such clinicians as Backus (1937) and Schuell, Jenkins and Jimeniz-Pabon (1964) provide us with general principles of treatment, and these principles are no less appropriate today than when they were written. Few of us would dispute, for example, that speech processes operate with greater facility when the individual experiences a reasonable degree of social adequacy (Backus, 1937), or that the clinician should elicit and not force the response (Schuell, Jenkins and Jimenez-Pabon, 1964). But while such principles may guide us in the treatment process, we must have a specific method in mind when sitting across from the patient.

The formal, clinical assessment of dysphasia encompasses at least five aspects. Depending on the circumstances, all may be given equal weight, one may be dominant to the exclusion of all the others, or any distribution of emphasis between these extremes may obtain. These aspects are the following: 1. dysphasia testing as an inventory of language input and Output modalities, 2. linguistic aspects, 3. diagnostic aims, 4. the dysphasia examination as a case study, 5. quantitative aspects.

A review of early accounts of dysphasia (Benton and Joynt, 1960) credits Valerus Maximus in 30 A.D. with the earliest description of acquired dyslexia: a case of head injury producing an isolated acquired dyslexia. After an interval of almost two millenia, sporadic reports of acquired dyslexia became more common in the 1800’s but definitive steps toward understanding the acquired disorders of written language were not made until Dejerine (1891, 1892). His descriptions of the clinical findings and anatomical correlations of acquired dyslexia, with and without dysgraphia, remain essentially unaltered as the foundation of the study of disorders of written language.

The preceding short examination for dysphasia can be used to provide a rough clinical guide to Classification of dysphasic syndromes. Formal language evaluation should be carried out to refine the initial impression. We emphasize that many patients with dysphasia do not have signs which can be easily or neatly categorized, regardless of the technical skill or years of experience of the examiner; in such cases a thoughtful description of the Observation is more helpful than an attempt to force the clinical findings to conform to a pre-conceived category.

It is traditional that a review of the anatomy of language disorders commences with a summary of the history of the disputes between the proponents of the two main streams of thought about brain-language relationships. The ebb and flow of popularity of various localizationist and globalist theories is colorful and instructive, but it is well reviewed elsewhere (Hecaen and Albert, 1978). This issue is no longer relevant in the sense considered by previous generations. Clearly brain functions are not equally represented in all regions. Interhemispheric differences exist in 1) the perception and manipulation of higher level sensory information, 2) the Organization of axial, limb and buccofacial movements and 3) the ability to generate speech and language. These interhemispheric differences are based in part on anatomical asymmetries which are evident in fetal life (Wada et al., 1975). There is intrahemispheric specialization in brain function as well, and within the left hemisphere, much of this specialization in function constitutes the anatomy of language. Even many ostensible critics of the localizationist theories resorted to a system of language Classification that carried implicit functional localization which strongly resembled the classical formulations of Wernicke (1874) and Dejerine (1914). For example, Marie (1917), Head (1926), and Goldstein (1948), despite their reputations as antilocalizationists, utilized systems of Classification based on functional anatomy.

Syndromes of dysphasia may vary from the forms described in the preceding sections, or certain aspects of dysphasic syndromes may appear more prominently than others, depending on associated clinical conditions, language background of the patient, history of left-handedness, lesion localization, or individual differences. In this section we consider clinical features of some of these special forms of dysphasia.

The Syndrome of Broca’s dysphasia often evolves over a period of months and sometimes years from an initial stage of global dysphasia, but may occasionally appear in its own right as an acute dysphasia. In the completely developed picture of Broca’s dysphasia, spontaneous speech is nonfluent and agrammatic, while auditory comprehension is preserved at levels adequate for understanding most conversation and even at nearly normal levels in some patients. Sentence repetition is seriously impaired, although repetition of one- or two-word segments may be possible. Writing is usually on a par with speech. Reading aloud parallels the limited Output of spontaneous speech but reading for meaning, though sometimes slow and painstaking, is usually preserved at the level of auditory comprehension. Naming on visual confrontation is often slightly superior to the ability to generate names in spontaneous speech or in response to word definitions. Right hemiparesis affecting the arm more than the leg, buccofacial apraxia, and ideomotor apraxia of the motorically spared left Upper extremity are common. In the acute stage, if the initial deficit of auditory comprehension is mild, disturbances of writing are minimal and hemiparesis is not marked, and rapid improvement from a State of severe nonfluency is to be expected over several days or weeks. In these latter patients, agrammatism, as measured in handwriting samples or in a story completion task in which the patient is required to supply the proper grammatical form of a word that completes a sentence, is not prominent.

A new form of language therapy has been used successfully with aphasic patients who had severe, long-term, stable defects and for whom other forms of therapy had failed. One explanation for these results suggests that latent language capacities of the nondominant hemisphere may be stimulated.