APHASIA STUDIED IN PATIENTS WITH MISSILE WOUNDS

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Abstract
47 convalescent cases of penetrating missile wounds of the dominant hemisphere having some symptoms of aphasia were selected and subjected to 20 tests to evaluate spontaneous speed and its understanding, reading, writing, and calculation as well as general intelligence. The findings were classified as to degree of impairment of 30 different disturbances of speech functions and neurological deficits which might be involved in local damage to a dominant hemisphere. The extent of the lesion as estimated by the surgeon was plotted on the brain surface and an attempt made to correlate the site of the lesions in patients who had related disabilities. The areas of greatest density produced by the superimposed wound contours plotted on a cumulative diagram of the dominant hemisphere was interpreted as the area most commonly affected in patients suffering that particular aspect of aphasia. The analysis of the findings confirmed the mixed nature of most aphasic disorders, their ill-defined and transitional character, and their relative dependence on personal and other pretraumatic factors. In all cases with true aphasia there was difficulty in word finding ("nominal" aphasia), regardless of the site of the lesion within the "speech area." This essential feature is, therefore, considered the least valuable for localization. Spelling was likewise affected in all but 7 cases. Follow-up studies showed that the earlier pattern of speech disorder persists, though great improvement in the degree of disability occurs. The grading of the severity and the relative prominence of each feature was considered important, but no rigid dichotomy into afferent and efferent types of disorder could be established. Frontal lesions tended to impair most the speaker''s initiative, the speed of his enunciation, the articulation of his words, and the inflection of his voice. Temporal lesions hampered the understanding of spoken language, both of what the patient was saying and what was said to him. The structure and interpretation of words and sentences suffered (paraphasia, jargon, and agrammatism) by the loss of auditory control on a high level. Posterotemporal and temporoparietal lesions interfered mainly with the interpretation of visual symbols of speech (reading and writing). Parietal lesions in particular caused a disturbance of all those faculties related to orientation in space and appreciation of shape; the pattern of the word or proposition to be said, read or written became distorted. Stammer and perseveration were also common. Lesions of the posterior part of the Sylvian area were the most deleterious to the more highly organized intellectual aspects of speech function. The bulk of brain tissue destroyed was proportional to the severity and extent of the disorder involving both speech and intelligence. Two left-handed patients with transrolandic right hemisphere wounds had difficulty not with speaking, but with writing, counting, and constructing.

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