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P x J22 S The Assessment of Aphasia and Related Disorders HAROLD GOODGLASS, Ph.D. with the collaboration o f EDITH KAPLAN, Ph.D. Boston Veterans Administration Hospital and Aphasia Research Center, Department of Neurology, pr*<;fop TTn ivpfcitv LEA & FEBIGER i Philadelphia 10 The Assessment of Aphaslo and Related Disorders auditory language almost invariably impair reading --particularly reading of connected material. The most striking apparent excep tion to this rule is in the case of pure worddeafness (described above), where reading is preserved. The anatomic reason proposed for this exception is that (lie auditory associa tion area is essentially intact, but discon nected from its input front the primary auditory areas. 'The relation between reading and auditory comprehension levels is often confusing in the Wernicke's aphasic. These patients, as we have observed, may fail to grasp a word spoken to them out of context, even while repealing it eorreetly. On seeing the same word written, they often understand it at once. Thus, at the one-word level, reading is superior to auditory comprehension. When the written message increases to sen tence length, its didiculty increases enor mously, while comprehension of the spoken message is sometimes facilitated by the sentence context. May not reading comprehension be auton omous from the auditory comprehension system' Wc know that dear-mutes learn to read and grasp meaning without ever having had an auditory experience of the word. It is plausible that this mode of reading plays at least a secondary role in normal reading, as well. Supporting evidence shows (hat some apliasics grasp meaning while saying the wrong word aloud. Conversely, some patients will point to(a written word related in meaning, but not in sound, to a spoken model. The analytic examination o f reading re quires determination of whether letters and words are recognized as familiar configura tions, quite apart from lheir meaning. Can spoken and written words be mulched on the basis of phonic associations, still without concern for meaning? Uolli of these func tions arc examined by means of multiplechoice subtests. In the rare cases of alexia caused purely by disconnection of the visual input from the cortical language area, [lie patient continues to understand oral spelling. ' Comprehension o f oral spelling may be lost either because o f impaired recognition or limited auditory span for letter names or be cause o f disturbance of the audio-visual associations on which reading is based. The simplest level of reading for meaning is that o f pairing written words with cor responding concepts, usually in the form of pictures. In the present examination, a multiple-choice selection of pictures is used. Comprehension of connected text is then tested by means of a graded scries o f multiplechoice sentence completion items, increasing from tlircc-word sentence to paragraph length. Writing Writing is the most complex of the language modalities and has a correspondingly large number of dimensions for examination. At the level of mere motor execution, writing may fail with respect to the recall oTthe form of letters or oT the movements involved in producing them. As in speech, there are automatized, serial tasks such as one's name and address, or the alphabet, which may be preserved when all oilier writing is lost. Slavish copying from a printed model may still be possible when (he subject cannot transcribe into cursive script. While, in the speaker's mind, the smallest significant units oT oral speech arc mor phemes, when wc deal with writing, letters have much more autonomy. The recall of letters to dictation is, therefore, tested prior to examining the ability to write words to dictation. When a word is written to dictation, wc do not know whether the process involved is primarily one oT phonetic translation from sound to spelling or whether comprehension o f the meaning or (he word has played ail intermediary role. However, when the pa tient is required to write the names of pictured objects, wc know that the initiating process is (he concept of the object and we are testing "written word-finding." Observa- The Nolure of Ihe Deficit! I 11 lion of ihe writing process and oT patient's errors indicate tliat three types oT association arc at work. One is the automatic translation of sounds into the motor sequences Tor letters, following the phonic rules of the language; another is the recall of syllables and short words as complete graphic motor sequences, bolstered by a visual model o f the word configurations; a third is the avail ability o f oral spelling as a guide to writing, because oral spelling is unhampered by (he slowness o f recalling and writing individual letters, we often find oral spelling a bit superior to written spelling to dictation. Only by specifically testing each process do we obtain an inkling as to how they arc interacting in the patient's performance o f a complex writing task. As we raised the question about reading, we may ask how independent written expres sion is from formulated oral language. Is there a direct association between concept and written expression that docs not go through the intermediary o f auditorily formulated inner speech? The performance of aphasics indicates such autonomous writing may occur at the one-word level, when. Tor example, a patient writes or spells orally a word which lie cannot recall in speech. Further evidence is seen in patients who, on dictation of a given word, write another which is related 11 meaning, but not in sound (paragraphia). However, the vast preponderance o f aphasic performance indi cates that writing is built on Ilie capacity 10 formulate spoken language. Thus, the ability to write may approach, but rarely exceed| the capacity to speak. As in the case of reading, the exception to this rule is in patients whose disorder is purely articulatory and apparently spares the speech formula tion system. The medium of writing does not provide the melodic and rhythmic sentence contour which helps the aphasic to organize his grammatical sequences and, particularly, to lit in the small connectives and inflectional forms, because writing is a slower, wordby-word process, sentence-writing makes a heavy demand oil knowledge of grammatical rules and on retention of the string of pro jected words, along with recall of what has already been written. Consequently, gram mar may be more primitive in written language than in speech. In the present aphasia battery, ihe writing of connected material is elicited by dictation and by presentation of a story-picture which the patient is asked to describe 11 writing.