341 Abstract
PHONOLOGICAL PATTERNS IN A CASE OF APHASIA* F. M. HATFIELD and K. WALTON Addenbrooke’s Hospital, Cambridge
phonemic substitutions of a patient with severe Broca aphasia were analysed whether they were sufficiently systematic to guide the design of remedial programmes. This yielded certain rules which are described and compared with data from previously reported cases of phonetic disintegration. The
to
see
INTRODUCTION In order to design and evaluate language rehabilitation programmes for use in teaching machines we found it necessary to investigate an aphasic patient’s phonological performance with greater precision than is usual when planning personal therapy. We needed to anticipate the patient’s likely difficulties and to assess his phonological abilities as preliminaries to construction of individual programmes and This their subsequent validation, as Bung (1971) has recommended (p. 116). measure of in the defective some regularity output. patient’s speech presupposed Alajouanine, Ombredane and Durand (1939) in their classical paper on &dquo; phonetic disintegration&dquo; reported certain constancies in their patients’ phonemic errors. Blumstein (1973), using a different approach, based largely on a Jakobson model (see Jakobson 1956, 1968), states firmly that her investigations and interpretations &dquo; ... established that the phonological disintegration of aphasic speech can be systematically described &dquo; (p. 54). On the other hand, Shankweiler and Harris (1966), contrasting phonetic disintegration with other disorders of articulation, including children’s articulatory defects, maintain that while the latter group are predictable in
realization, with the ’former group variability was &dquo;
(p. 289).
Lebrun
(1970)
doubts that the deviant
one
speech
of the sounds
striking ’features &dquo; occurring in this
* The authors wish to thank Mr. G. E. Mann, F.R.C.S., for permission. to publish details ofhis patient. They wish to express further gratitude to Mr. John Trim and Mr. W. Bennett (Cambridge University Department ofLinguistics) for much interest and guidance; to Dr. John Morton (MRC Unit ofApplied Psychology, Cambridge) for many helpful suggestions; and to Mrs. M. B. Elvin for carrying out psychometric tests and contributing to the general interpretation. They are also indebted to Professor O.L. Zangwill (Cambridge University Department of Experimental Psychology) for his constant support and involvement in those aspects oftheir work which relate directly or indirectly to rehabilitation. Finally they are grateful to the Board ofClinical Research, Addenbrooke’s Hospital, for a small grant to facilitate this investigation.
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342
syndrome are strictly systematic and predictable (p. 46) but concedes that they are completely random either. The syndrome of &dquo; phonetic disintegration,&dquo; as described by Alajouanine et al. involves both phonetic anomalies and phonemic errors in motor or Broca aphasia. A number of more recent workers have described similar cases and discussed, in addition, the question of the resemblance, if any, of this phonological disintegration to phonological development in children (Fry, 1959; Cohen, Dubois, Gauthier, H6caen and Angelergues, 1963; Mihailescu, 1971). We present this study, carried out within the framework of practical rehabilitation, as a contribution to this series.
not
Our
Subject:
Clinical details.
On admission to our out-patient clinic, D.C. was 29 years old, ’formerly righthanded, a chef by profession and thought to have been of low-average intelligence. Although a slow learner at school, he had been highly competent in his profession. Three years previously he had suffered a cerebrovascular accident diagnosed as a left middle cerebral artery occlusion with collateral leptomeningeal circulation. He had made a partial recovery from the effects but was left with a mild right hemiparesis, affecting the upper limb more than the lower, and some right-sided weakness of the lower part of the face. Tone in the limbs was increased, with exaggerated reflexes and extensor plantar response on the right. On routine testing there was no abnormality of the tongue, which protruded centrally and showed no wasting, or of the soft palate or pharynx in either appearance or sensation. There were no difficulties in chewing or swallowing. To confrontation there was some evidence of defect in the far right visual field but signs of sensory loss on the right Pure tone audiometry showed him to have no hearing were minimal and equivocal. deficit within the frequencies important for speech. At this time he showed signs of bucco-facial apraxia. He was, for example unable to imitate consistently any English phoneme except /m/ and /a/ and to imitate non-speech movements of the vocal apparatus, for instance, waggling the tongue from side to side and blowing to instruction (although able to blow out a real match normally). There were minimal signs of this residual apraxia extending to imitation of finger positions as in Luria’s tests (1966), but he showed no apraxia in his daily tasks. (For an account of apraxia, see Ajuriaguerra and H6caen 1964;
Zangwill, 1971.) He was now working again State
of language function
as a
cook but in
at the time
of
a
junior capacity.
admission
At this time he had retained no spontaneous speech except &dquo; Yeah &dquo;, (Yes) and &dquo;No&dquo;, the interrogative &dquo;eh?&dquo; and &dquo; ’ere &dquo; (Look here). He was unable to name any of the common objects presented to him or to repeat the simplest words and syllables and had no reactive or serial speech; his aphasia involved all modalities-compre-
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343 hension of longer utterances, speech production, reading and writing. His written communication was superior to his spoken but was limited to isolated short words, mainly nouns, often with defective spelling, and was devoid of syntax. In traditional terminology this was a motor aphasia associate with articulatory apraxia with some auditory receptive loss for more complicated instructions.
Initial
phase of
recovery
of speech
During the first year of speech therapy (approximately once a week) he gradually regained all southern English phonemes with the exception of the affricates /tf / and 1d6/, for which he substituted If I and /3/. /r/ was usually rather weakly articulated’. He learnt to combine all other consonants in initial position with vowels and diphthongs, thus making some real words, and to use spontaneously a small stock of words such as greetings, names of common objects, attributes, etc. During the next eighteen months the subject’s ability to reproduce simple phoneme combinations was consolidated. Nearly all his spontaneously produced words were open syllables (CVs or CVCVs) but he gradually began to use a final consonant in a VC or CVC syllable, especially /n/, /s/ or /z/. Many short words which he had leamt to produce very laboriously and in a roundabout way, utilizing a mirror, diagrams, etc., and with much kinaesthetic and visual adjustment, eventually became well established as smooth, natural articulations under good voluntary control. In repetition of CVC syllables, the final consonant was frequently omitted or replaced or the intial consonant was affected. Pari passu there was some improvement in his verbal comprehension and in his powers of attention and concentration. Performance on certain non-verbal tasks had improved and his score on Raven’s Matrices moved up from the 5th to the 25th percentile.
State
of language function
at
the time
of
the
investigation
After two and a half years he had regained a vocabulary o’f about 80 words, some of which were pronounced defectively. He produced clear. vowels and diphthongs without any misplaced nasality, good /s/ and If I, particularly in final position, and 1
The order
ofreappearance ofphonemes and phonemic oppositions was ofinterest, it did the approximate order suggested by Jakobson (1968) as characteristic ofchildren in language acquisition and, reversed, ofaphasics in dissolution. Thus the /m-p/ and /m-n/ oppositions were acquired early, followed by /p-t/ and /n-t/, /p-f/ and /t-k/ many months after the foregoing, in spite of much attention to this distinction. Vocalic distinctions were acquired early and remained remarkably stable. /s/, then /∫/ came soon after /k/, followed by /&thetas;/, but this last phoneme remained inconsistent. For some time he had difficulty with the voiced/voiceless opposition although he could produce either type after a few repetitions (for more details see Hatfield, 1972). reflecting
as
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344 &dquo; few somewhat phonetically complicated words such as coffee &dquo;. Evidence of such articulatory control supported the conclusion that dysarthria22 was not a primary factor in the speech disorder. (Shankweiler and Harris, 1966, regard ability to &dquo; reproduce vowels correctly as contra-indicating selective impairment of the tongue &dquo;, in other words a specific dysarthria.) Tests for praxis (Ajuriaguerra and H6caen, 1964) revealed only minimal traces of apraxia. Among other motor skills regained, he could now whistle powerfully and
a
musically on request. We diagnosed a motor aphasia with breakdown at phonological, morpho-syntactical and lexical levels. Improvement in vocabulary was accompanied by gains in written language and auditory comprehension; some associative speech had returned. His auditory phonemic discrimination was quite good, and he could, for instance, discriminate the words mat and map or bat and back reliably. We now began our investigation of the subject’s phonological errors. METHOD
The patient sat facing the tester and was asked to repeat syllables read singly from a list. Each list consisted of up to twenty CV, VC or CVC syllables (for examples, see Tables 1 and 2 and Hatfield, 1972) which were read at five per minute to minimize any gross perseverative effect. The first response only was used in the results. Much of the testing was done with a set of only four vowels, /i/, /u/, /a/ and 1al/, representing extremes of high-low and back-front positions. This simplification was introduced because early results suggested that the vowel did not have an important effect on consonant articulation apart from some regressive effect on /t/ and /k/ in CVs (see below). The selection of consonants in many lists was deliberately restricted to all combinations of voiceless plosives for the purpose of understanding a relatively simple system of interactions first. This had the drawback that the subject was using a very small response set which limited the range of errors but afforded good comparison of the interaction of different consonants. Our observations were checked from time to time with tape-recorder and sound
spectrograph. 2
Footnote on dysarthria : In British terminology, dysarthria denotes a neuromuscular disorder involving the speech apparatus itself, commonly extending to non-speech functions such as deglutition. Articulation is impaired in a constant manner, particularly ofphones requiring precise positioning, such as /s/, or rapid mobility, such as l / or /t/, in words like probability, reliability, institution, destitution. Knowledge ofthe language code itselfis not impaired and the subject should be able to realize the code in written substance ifnot in speech. Different types of dysarthria are associated with lesions in different parts of the CNS. Although in theory the distinction between dysarthria and aphasia is fairly clear, in practice it is sometimes difficult to make a firm diagnosis particularly in the case ofcortical dysarthria (see Critchley 1970, p. 212). The two conditions ofcourse may co-exist.
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345 TABLE 1 Samples of VC test list
TABLE 2
Sample
of CVC
test
list
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346 RESULTS The responses (repetitions) were analysed according to the effects of different phonetic environments on individual phonemes, as set out in Tables 3, 4, 5, and 6. Previous work on aphasia has suggested that unfamiliar words are affected before familiar ones (Newcombe, Oldfield and Wingfield, 1965), so that common words Our subject might there‘fore have been are retrieved more easily than uncommon. in to encounter less difficulty repeating syllables which coincided with real expected a words. However, this was not gross effect as measured by the proportion of real words correctly repeated compared with nonsense syllables; or by the extent to which nonsense syllables were misrepeated as similar words. No distinction has therefore been made between the two types of stimulus in the analysis. A small proportion of errors were not directly related to the stimulus syllable and were possibly due to factors such as inattention or perseveration from words occurring earlier: for example, one week when testing ’followed practice of the words &dquo; cook &dquo; and &dquo; cake &dquo;, many more responses than usual contained an incorrect /k/. To avoid this, testing was usually carried out at the start of the session or after a rest. However, most of the time the subject’s performance was remarkably stable and his responses were related to the stimulus word by a small number of principles set out below. Vowels. There were strikingly few errors in vowel repetition. Out of 880 items there were only five vowel errors and they involved small mutations. E ff ect off vowels on consonants. Vowels had little effect on the succeeding consonant. However, there were some small effects on the preceding consonant in the cast of alveolars and velars (see Table 3). In CVs, alveolar plosives were well repeated before /i/ and /u/ but often replaced by velars before /a/. Velars were well repeated before /a/ but often replaced by alveolars before /i/ and /u/. The same effect was noticed occasionally with CVCs. These tendencies were also observed by Cohen et al. Consonants : the feature of voice. By this time the patient had acquired some sort of voiced/voiceless opposition; however, his voiceless plosives lacked the amount of aspiration normal to southern English. In repetition the voice feature of the stimulus was usually well preserved. Other factors affecting consonant repetition. In addition to the above, certain trends emerge from analysis of Tables 4, 5 and 6 (see also Figs. 1-6). We shall refer to these as ’ ‘ rules ’, using the word in a relative rather than literal sense; his responding was never entirely regular. The main rules are : (i) /t-k/ con f usion : there was some interchangeability between /t/ and /k/. In CVs this was governed by the vowel effects already mentioned (see Table 3 and Fig. 1); in CVCs it was marked in syllables containing /t/ and /k/ only (see Fig 3). (ii) /t/ rule : In VCs and CVCs, final /t/ was frequently substituted incorrectly while syllables already ending in /t/ were well repeated (see Figs. 2 and 4). (iii) Consonant harmony in CVCs : in syllables with dissimilar initial and final
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347
TABLE 3
Effect of vowels
on
consonants
in CVs
TABLE 4 to CV stimuli
Responses
Note:
Figures give the number of responses
in each category
as a
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percentage.
348
TABLE
Responses
Note :
to
5
VC stimuli
the number of responses in each category as a percentage. ’Other’ include some where the VC form was not preserved. responses
Figures give
z
&dquo; ’
TABLE 6
-
’ ’ ’
_.
.
Responses
to
Note : Each 3 x 3 matrix
stimulus
CVC stimuli,
gives
using
consonants
/p, t, k/ only.
the percentage distribution of responses for
syllable.
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a
particular
349
Fig.
1.
Transformation of CV syllables. The figure in the box represents the percentage of items correctly repeated, while the figure against the arrow represents the percentage of items repeated as the syllable to which the arrow points. Infrequent responses have been omitted.
Fig.
2.
Transformations of VC
syllables. (For explanation,see Fig. 1.)
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350
,
confusion in CVC syllables. Figures give the percentage of mistakes in the direction shown for each syllable.
Fig.
3.
/t-k/ going
Fig.
4.
/t/ rule in CVC syllables. Figures give the percentage of mistakes the direction shown ’for each syllable.
Fig.
5.
Inversion in CVCs. Figures give the percentage of mistakes direction shown for each syllable.
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going in
going
-
in the
351 consonants, these consonants were frequently misrepeated to create identical Cs; syllables having the same initial and final consonant were well repeated (see Tables 2 and 6). (iv) Plosivisation of consonants: this was seen to occur with CVs and ’VCs and is illustrated in Figs. 1 and 2; since the consonants in CVCs were restricted to oral plosives this phenomenon obviously could not be observed with these syllables. (v) Inversion (metathesis) : inversion of consonants did occur but was not one o’f the main tendencies (see Fig. 5). Given the restricted range of consonants used, the same error could be accounted for by more than one rule.
Distribution
of
mistakes in CVCs
For CVCs the mistakes may be attributed to the different rules 7. The subject’s main errors are shown in Fig. 6.
’
as
shown in Table
DISCUSSION
In terms of the made. Vowels. With
more
specific findings reported above,
certain
comments
should be
striking ’discrepancy between consonant and vowel Fry’s patient (Fry, 1959) showed almost as many vowel errors as consonant errors, Shankweiler and Harris’s patient, like ours, produced many more consonant errors. (&dquo; The vocalic portion of the word is produced with greater accuracy than the non-vocalic portions &dquo;, Shankweiler and Harris, 1966, p. 285). This might suggest a different cortical handling of vowel and consonant production and it is interesting to recall the perceptual experiment of Shankweiler and Studdert-Kennedy (1967), who, comparing identifications of dichotically presented pairs of synthetic CV syllables and pairs of steady-state vowels, found a significant right-ear (and therefore left hemisphere) advantage for CV syllables but not for steady-state vowels. Concerning reproduction of voice quality in consonants the relative lack of aspiration in initial voiceless plosives, particularly the bilabial plosive, sometimes gave the impression, with our subject, of the corresponding voiced plosive or of an intermediate plosive (i.e., intermediate between /p/ and /b/). Three of the patients of Alajouanine, Ombredane and Durand apparently showed the opposite tendency: these authors state that the errors were more in the direction of devoicing their voiced plosives. Fry’s patient, contrary to ours, showed a strong tendency to replace voiced plosives by voiceless. This discrepancy between Alajouanine et al.’s patients and ours could be accounted for by the difference between the two phonological systems (in particular, the existence of aspiration as a distinctive feature for English plosives but The difference between our patient and Fry’s in this respect needs of not French). course another interpretation.
repetition,
to the that whereas
regard
we note
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352 .
TABLE 7
Distribution of CVC mistakes attributable
to
each rule.
Fig. 6. Transformations of CVC syllables. (For explanation, see Fig. 1.) Percentages are taken from Table 6.
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353
Next, concerning
some
of
our
suggested
five ‘ rules ’ :
will be seen in Tables 3, 4 and 6 and Figs. 1 and 3, this (i) /t-k/ con f usion : occurred in CVs and CVCS. Alajouanine et al.’s patients, especially E.B., like only ours in the early stages of re-acquisition, found posterior consonants dii~cult; when not omitted they were replaced by /t/ or /p/. They instance képi...¿tépi, gauche...¿doche, caf,é...¿pafé. Fry’s patient made many errors in /t/ and /d/, which were frequently replaced by velar articulations, but few instances of /k/ (or /g/) being transformed into /t/ (or /d/). as
(ii) /t/ rule : this may /k/ (see Fig. 4); for predict the same errors.
seen in VC errors (Fig. 2) and CVCs with initial /p/ CVCs with initial /t/, the consonant harmony rule will In VCs alveolar positions were more often correct than labial or velar and mistakes tended to go to the alveolar position. Among CVCs final /t/ was also frequently substituted for other final plosives, and syllables with final /t/ were well repeated. Alajouanine et al. recorded a somewhat different phenomenon in their patient Maurice Poig., who tended to close his open syllables with a plosive, especially /t/ or /k/. (With our patient there were no cases of a CV syllable acquiring a final C in error.)
be
and
(iii) Consonant harmony : this ‘ rule ’ mistakes for stimuli of the form C1 VG2 :
accounts
for the
following percentages
of
However, the majority of
cases of the second type are better described by /t-k/ of the form /pVk/--7/kVkj. Thus it seems best mistakes confusion, leaving only to regard the effect of consonant harmony on errors as progressive assimilation of the initial consonant on the final, and figures given in Table 7 are for this only. Examples from repetition of voiced plosives suggest that consonant harmony and /t/ rule are place rules and that the voicing of the target phoneme is often retained,
e.g.Jbut/ --7 /bup j. The rule may be
compared with that formulated by Lecours and Lhermitte (1969) discussing phonemic paraphasias: they found that although error and target phonemes were usually closely related, 80% of the errors could be understood in terms of assimilation. Alajouanine et al. report many instances of consonant harmony transformations (/papo/ for chapeau, /papa/ ~for patte, etc.: Marie-Louise Chap.). Cohen et al. too speak of many ’ assimilations’, e.g. /raret/ for barrette, always retrogressive. (As assimilations can occur between adjacent consonants, we have preferred the term consonant harmony, referring to an effect across a distance of two phonemes and operating only on consonants.) (iv) Plosivisation : this was particularly marked in final position (VCs). Data from CVCs are scanty. Alajouanine’s patient, Maurice Poig., is reported as nearly always using a plosive to begin a syllable; his patient René W. substituted plosives frequently for fricatives in all positions. This tendency seems to have been in
Downloaded from las.sagepub.com at UCSF LIBRARY & CKM on March 30, 2015
354 stronger in the patients of Alajouanine et cal. than in
patient /f/
never went to
/p/ (This
was
recorded
as
subject. But with Fry’s happening with our patient,
our
Tables 4 and 5.) (v) Inversion : there was a small group of errors of inversion. This type accounts for 10% of mistakes of stimuli C1 VC~ in our data and occurs with all stimuli except /pVt/ (which would give the unstable syllable /tVp/). Thus it seems a small but quite general tendency (see also Fig. 6). Alajouanine et al. and other workers suggest that inversion of consonants often occurs, e.g. from Cohen et al.: vallie->Iavi; tarko-¿karto. see
ERRORS
IN SPONTANEOUSLY
PRODUCED WORDS
We have many fewer examples of the articulation of spontaneously produced words (that is to say, words produced in conversation or in naming tasks, etc., without repetition) than of repeated syllables, but some of the same principles may be seen for CVC target words.
The main difference from repetition is the number of syllables leftt open. Alajouanine et al. also cite several instances of this, especially with their patient Elodie B. If, however, the frequency of open syllables in word structure is different in French from English, this tendency would have a somewhat different significance for each language. It will have been noted that earlier on our patient had a strong tendency to create open syllables out of closed ones, especially in spontaneous speech, and that this tendency persisted to a certain extent with spontaneously produced
words. Consonant clusters were usually simplified by omission of one consonant, but some clusters did occur, e.g. hand-correctly repeated; and box?/bops/. Vowels were again well realized by our patient, with the occasional exception of the replacement of a final schwa /a/ by /I/, e.g. paper~/pelpt/.
’.’ ’
CONCLUSIONS
.
’~ - ,...
,,
_
1. Reliability of ’ ‘ system ’ Analysis
of both the
on
correct
which Remedial
repetitions
Programmes could
and the
misrepetitions
Downloaded from las.sagepub.com at UCSF LIBRARY & CKM on March 30, 2015
be based of
syllables by
our
355 enabled us to discern the pattern of his phonological behaviour. There is considerable stability for his vowels and for certain of his consonants in specific phonetic environments. When and where errors occur, the great majority (78% in CVCs) can be accounted for by five rules’ or trends, as enumerated above. We therefore feel justified in claiming that our subject’s responses are on the whole However, even if our patient’s phonological behaviour is stimulus-dependent. ’ rule-governed ’, generally speaking, the government is not sufl’iciently strict for us to predict at every point whether a given phoneme (consonant) will be repeated correctly or incorrectly; all we can do is to state a degree of probability for the ’ form which its errors will take, in the case of incorrect repetition. In addition, in a less specific way, we have observed definite recurrent features, such as a partial devoicing of the voiceless plosives, a tendency towards open syllables, etc. Thus our findings confirm various other studies, involving one or more cases, which have pointed to the existence of a system operated by patients with phonetic disintegration’ syndrome. As Alajouanine et al. comment, &dquo; Les mutations phon6tiques et les simplifications verbales que l’on constatait se classaient sozss un nombre limite de principes &dquo; (our italics), p. 28. Moreover, however ragged the system which we have perceived beneath our patient’s deviations, it has provided a reliable and useful basis for remedial programmes on videotape and through other media.
subject
II.
Resemblance
to
Children’s
speech patterns
,
We now look cursorily at the resemblance of this system’ to phonological deviations in young children, bearing in mind the findings of Fry, who, using Morley’s (1957) table of children’s sound patterns at the age of three years and nine months, found little in common between his patient’s speech and the ifeatures of child speech. In respect of several of the features mentioned above-plosivisation (especially /f-7p I), consonant harmony, inversion, reduction o’f clusters, opening of syllables, late acquisition of /k/ and /g/-we were able to see a parallel between our patient’s speech and child speech. Fry, commenting on his patient’s voiced/voiceless confusion, remarks that this is practically unknown in children’s speech. Alajouanine et al., on the other hand, say in their section on la phonétique pu~erile ’ : &dquo; Les sonores tendent a Etre remplac6es par les sourdes correspondantes &dquo; (p. 124). Jakobson (1968) also implies a confusion or coalescence of voiced/voiceless consonants at a certain stage of child development (&dquo; So long as stops in child language. are not split according to the behaviour of the glottis, they are generally pronounced as voiceless and unaspirated &dquo;, p. 14). This is most likely a feature of the speech of children considerably younger than those referred to by Fry, according to our own observations. Fry goes on to point out that speech involves activity at several interdependent levels and maintains that if disintegration &dquo; ... mirrors development then the effects must be discernible at all these levels &dquo; (p. 52). We were, in ’fact, able ...
....
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356
subject’s linguistic performance of breakdown at morphemic (e.g. complete partial loss of plural morpheme in more than one modality), syntactic (emissively and receptively) and lexical, levels. It is not our intention to generalize from a single case, although some of these observations have been confirmed in other, less thoroughly studied, patients of ours. Obviously, in many respects the patient’s speech differed from that of a child and showed many residues of a fully acquired speech system. to
accumulate evidence in
our
or
III.
Comparison
with
findings of
our
predecessors
The data published by our forerunners, including those of Alajouanine et al. (1939), Blumstein (1973) and Fry (1959), are presented in a form too disparate from ours to allow a detailed comparison. All four of Alajouanine’s patients and Fry’s patient clearly had a much greater speech output than ours and were able to read much better out loud. The neurological picture of at least one of Alajouanine’s patients differs from our subject’s. Fry does not supply ifull neurological details and it is possible that the pathology differs. Fry’s data, although very complete, do not provide a breakdown enabling a positive or negative confirmation of features such as consonant harmony, inversion, etc., nor information as to the place (initial or final) of omission of consonants where this occurs. Where, however, comparison is possible it would seem that there are greater similarities between our patient’s speech and some of the patients described by Alajouanine et al. than between our subject and Fry’s. We noted several tendencies in our subject’s speech which Alajouanine et al. had described in their patients, although D.C. had less speech and a rather better control of phoneme production, particularly in initial position and in respect of fricatives. On the other hand, there were marked discrepancies between our patient’s speech and Fry’s patient’s, especially in vowel production and in voicing of plosives. Such differences are not surprising considering the complexity of aphasic breakdown and the rarity of two patients sharing even the greater part of their symptoms. Moreover, our data were obtained almost in which Alajouanine et al.’s and Fry’s were not. exclusively repetition, interest of educing (a number of trends or rules’ and the theoretical ’from Apart a ’ the existence of system’, the main application of our findings has been confirming as a therapeutic tool.
’ ’
PHONOLOGICAL PATTERNS IN A CASE OF APHASIA* F. M. HATFIELD and K. WALTON Addenbrooke’s Hospital, Cambridge
phonemic substitutions of a patient with severe Broca aphasia were analysed whether they were sufficiently systematic to guide the design of remedial programmes. This yielded certain rules which are described and compared with data from previously reported cases of phonetic disintegration. The
to
see
INTRODUCTION In order to design and evaluate language rehabilitation programmes for use in teaching machines we found it necessary to investigate an aphasic patient’s phonological performance with greater precision than is usual when planning personal therapy. We needed to anticipate the patient’s likely difficulties and to assess his phonological abilities as preliminaries to construction of individual programmes and This their subsequent validation, as Bung (1971) has recommended (p. 116). measure of in the defective some regularity output. patient’s speech presupposed Alajouanine, Ombredane and Durand (1939) in their classical paper on &dquo; phonetic disintegration&dquo; reported certain constancies in their patients’ phonemic errors. Blumstein (1973), using a different approach, based largely on a Jakobson model (see Jakobson 1956, 1968), states firmly that her investigations and interpretations &dquo; ... established that the phonological disintegration of aphasic speech can be systematically described &dquo; (p. 54). On the other hand, Shankweiler and Harris (1966), contrasting phonetic disintegration with other disorders of articulation, including children’s articulatory defects, maintain that while the latter group are predictable in
realization, with the ’former group variability was &dquo;
(p. 289).
Lebrun
(1970)
doubts that the deviant
one
speech
of the sounds
striking ’features &dquo; occurring in this
* The authors wish to thank Mr. G. E. Mann, F.R.C.S., for permission. to publish details ofhis patient. They wish to express further gratitude to Mr. John Trim and Mr. W. Bennett (Cambridge University Department ofLinguistics) for much interest and guidance; to Dr. John Morton (MRC Unit ofApplied Psychology, Cambridge) for many helpful suggestions; and to Mrs. M. B. Elvin for carrying out psychometric tests and contributing to the general interpretation. They are also indebted to Professor O.L. Zangwill (Cambridge University Department of Experimental Psychology) for his constant support and involvement in those aspects oftheir work which relate directly or indirectly to rehabilitation. Finally they are grateful to the Board ofClinical Research, Addenbrooke’s Hospital, for a small grant to facilitate this investigation.
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342
syndrome are strictly systematic and predictable (p. 46) but concedes that they are completely random either. The syndrome of &dquo; phonetic disintegration,&dquo; as described by Alajouanine et al. involves both phonetic anomalies and phonemic errors in motor or Broca aphasia. A number of more recent workers have described similar cases and discussed, in addition, the question of the resemblance, if any, of this phonological disintegration to phonological development in children (Fry, 1959; Cohen, Dubois, Gauthier, H6caen and Angelergues, 1963; Mihailescu, 1971). We present this study, carried out within the framework of practical rehabilitation, as a contribution to this series.
not
Our
Subject:
Clinical details.
On admission to our out-patient clinic, D.C. was 29 years old, ’formerly righthanded, a chef by profession and thought to have been of low-average intelligence. Although a slow learner at school, he had been highly competent in his profession. Three years previously he had suffered a cerebrovascular accident diagnosed as a left middle cerebral artery occlusion with collateral leptomeningeal circulation. He had made a partial recovery from the effects but was left with a mild right hemiparesis, affecting the upper limb more than the lower, and some right-sided weakness of the lower part of the face. Tone in the limbs was increased, with exaggerated reflexes and extensor plantar response on the right. On routine testing there was no abnormality of the tongue, which protruded centrally and showed no wasting, or of the soft palate or pharynx in either appearance or sensation. There were no difficulties in chewing or swallowing. To confrontation there was some evidence of defect in the far right visual field but signs of sensory loss on the right Pure tone audiometry showed him to have no hearing were minimal and equivocal. deficit within the frequencies important for speech. At this time he showed signs of bucco-facial apraxia. He was, for example unable to imitate consistently any English phoneme except /m/ and /a/ and to imitate non-speech movements of the vocal apparatus, for instance, waggling the tongue from side to side and blowing to instruction (although able to blow out a real match normally). There were minimal signs of this residual apraxia extending to imitation of finger positions as in Luria’s tests (1966), but he showed no apraxia in his daily tasks. (For an account of apraxia, see Ajuriaguerra and H6caen 1964;
Zangwill, 1971.) He was now working again State
of language function
as a
cook but in
at the time
of
a
junior capacity.
admission
At this time he had retained no spontaneous speech except &dquo; Yeah &dquo;, (Yes) and &dquo;No&dquo;, the interrogative &dquo;eh?&dquo; and &dquo; ’ere &dquo; (Look here). He was unable to name any of the common objects presented to him or to repeat the simplest words and syllables and had no reactive or serial speech; his aphasia involved all modalities-compre-
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343 hension of longer utterances, speech production, reading and writing. His written communication was superior to his spoken but was limited to isolated short words, mainly nouns, often with defective spelling, and was devoid of syntax. In traditional terminology this was a motor aphasia associate with articulatory apraxia with some auditory receptive loss for more complicated instructions.
Initial
phase of
recovery
of speech
During the first year of speech therapy (approximately once a week) he gradually regained all southern English phonemes with the exception of the affricates /tf / and 1d6/, for which he substituted If I and /3/. /r/ was usually rather weakly articulated’. He learnt to combine all other consonants in initial position with vowels and diphthongs, thus making some real words, and to use spontaneously a small stock of words such as greetings, names of common objects, attributes, etc. During the next eighteen months the subject’s ability to reproduce simple phoneme combinations was consolidated. Nearly all his spontaneously produced words were open syllables (CVs or CVCVs) but he gradually began to use a final consonant in a VC or CVC syllable, especially /n/, /s/ or /z/. Many short words which he had leamt to produce very laboriously and in a roundabout way, utilizing a mirror, diagrams, etc., and with much kinaesthetic and visual adjustment, eventually became well established as smooth, natural articulations under good voluntary control. In repetition of CVC syllables, the final consonant was frequently omitted or replaced or the intial consonant was affected. Pari passu there was some improvement in his verbal comprehension and in his powers of attention and concentration. Performance on certain non-verbal tasks had improved and his score on Raven’s Matrices moved up from the 5th to the 25th percentile.
State
of language function
at
the time
of
the
investigation
After two and a half years he had regained a vocabulary o’f about 80 words, some of which were pronounced defectively. He produced clear. vowels and diphthongs without any misplaced nasality, good /s/ and If I, particularly in final position, and 1
The order
ofreappearance ofphonemes and phonemic oppositions was ofinterest, it did the approximate order suggested by Jakobson (1968) as characteristic ofchildren in language acquisition and, reversed, ofaphasics in dissolution. Thus the /m-p/ and /m-n/ oppositions were acquired early, followed by /p-t/ and /n-t/, /p-f/ and /t-k/ many months after the foregoing, in spite of much attention to this distinction. Vocalic distinctions were acquired early and remained remarkably stable. /s/, then /∫/ came soon after /k/, followed by /&thetas;/, but this last phoneme remained inconsistent. For some time he had difficulty with the voiced/voiceless opposition although he could produce either type after a few repetitions (for more details see Hatfield, 1972). reflecting
as
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344 &dquo; few somewhat phonetically complicated words such as coffee &dquo;. Evidence of such articulatory control supported the conclusion that dysarthria22 was not a primary factor in the speech disorder. (Shankweiler and Harris, 1966, regard ability to &dquo; reproduce vowels correctly as contra-indicating selective impairment of the tongue &dquo;, in other words a specific dysarthria.) Tests for praxis (Ajuriaguerra and H6caen, 1964) revealed only minimal traces of apraxia. Among other motor skills regained, he could now whistle powerfully and
a
musically on request. We diagnosed a motor aphasia with breakdown at phonological, morpho-syntactical and lexical levels. Improvement in vocabulary was accompanied by gains in written language and auditory comprehension; some associative speech had returned. His auditory phonemic discrimination was quite good, and he could, for instance, discriminate the words mat and map or bat and back reliably. We now began our investigation of the subject’s phonological errors. METHOD
The patient sat facing the tester and was asked to repeat syllables read singly from a list. Each list consisted of up to twenty CV, VC or CVC syllables (for examples, see Tables 1 and 2 and Hatfield, 1972) which were read at five per minute to minimize any gross perseverative effect. The first response only was used in the results. Much of the testing was done with a set of only four vowels, /i/, /u/, /a/ and 1al/, representing extremes of high-low and back-front positions. This simplification was introduced because early results suggested that the vowel did not have an important effect on consonant articulation apart from some regressive effect on /t/ and /k/ in CVs (see below). The selection of consonants in many lists was deliberately restricted to all combinations of voiceless plosives for the purpose of understanding a relatively simple system of interactions first. This had the drawback that the subject was using a very small response set which limited the range of errors but afforded good comparison of the interaction of different consonants. Our observations were checked from time to time with tape-recorder and sound
spectrograph. 2
Footnote on dysarthria : In British terminology, dysarthria denotes a neuromuscular disorder involving the speech apparatus itself, commonly extending to non-speech functions such as deglutition. Articulation is impaired in a constant manner, particularly ofphones requiring precise positioning, such as /s/, or rapid mobility, such as l / or /t/, in words like probability, reliability, institution, destitution. Knowledge ofthe language code itselfis not impaired and the subject should be able to realize the code in written substance ifnot in speech. Different types of dysarthria are associated with lesions in different parts of the CNS. Although in theory the distinction between dysarthria and aphasia is fairly clear, in practice it is sometimes difficult to make a firm diagnosis particularly in the case ofcortical dysarthria (see Critchley 1970, p. 212). The two conditions ofcourse may co-exist.
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345 TABLE 1 Samples of VC test list
TABLE 2
Sample
of CVC
test
list
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346 RESULTS The responses (repetitions) were analysed according to the effects of different phonetic environments on individual phonemes, as set out in Tables 3, 4, 5, and 6. Previous work on aphasia has suggested that unfamiliar words are affected before familiar ones (Newcombe, Oldfield and Wingfield, 1965), so that common words Our subject might there‘fore have been are retrieved more easily than uncommon. in to encounter less difficulty repeating syllables which coincided with real expected a words. However, this was not gross effect as measured by the proportion of real words correctly repeated compared with nonsense syllables; or by the extent to which nonsense syllables were misrepeated as similar words. No distinction has therefore been made between the two types of stimulus in the analysis. A small proportion of errors were not directly related to the stimulus syllable and were possibly due to factors such as inattention or perseveration from words occurring earlier: for example, one week when testing ’followed practice of the words &dquo; cook &dquo; and &dquo; cake &dquo;, many more responses than usual contained an incorrect /k/. To avoid this, testing was usually carried out at the start of the session or after a rest. However, most of the time the subject’s performance was remarkably stable and his responses were related to the stimulus word by a small number of principles set out below. Vowels. There were strikingly few errors in vowel repetition. Out of 880 items there were only five vowel errors and they involved small mutations. E ff ect off vowels on consonants. Vowels had little effect on the succeeding consonant. However, there were some small effects on the preceding consonant in the cast of alveolars and velars (see Table 3). In CVs, alveolar plosives were well repeated before /i/ and /u/ but often replaced by velars before /a/. Velars were well repeated before /a/ but often replaced by alveolars before /i/ and /u/. The same effect was noticed occasionally with CVCs. These tendencies were also observed by Cohen et al. Consonants : the feature of voice. By this time the patient had acquired some sort of voiced/voiceless opposition; however, his voiceless plosives lacked the amount of aspiration normal to southern English. In repetition the voice feature of the stimulus was usually well preserved. Other factors affecting consonant repetition. In addition to the above, certain trends emerge from analysis of Tables 4, 5 and 6 (see also Figs. 1-6). We shall refer to these as ’ ‘ rules ’, using the word in a relative rather than literal sense; his responding was never entirely regular. The main rules are : (i) /t-k/ con f usion : there was some interchangeability between /t/ and /k/. In CVs this was governed by the vowel effects already mentioned (see Table 3 and Fig. 1); in CVCs it was marked in syllables containing /t/ and /k/ only (see Fig 3). (ii) /t/ rule : In VCs and CVCs, final /t/ was frequently substituted incorrectly while syllables already ending in /t/ were well repeated (see Figs. 2 and 4). (iii) Consonant harmony in CVCs : in syllables with dissimilar initial and final
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347
TABLE 3
Effect of vowels
on
consonants
in CVs
TABLE 4 to CV stimuli
Responses
Note:
Figures give the number of responses
in each category
as a
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percentage.
348
TABLE
Responses
Note :
to
5
VC stimuli
the number of responses in each category as a percentage. ’Other’ include some where the VC form was not preserved. responses
Figures give
z
&dquo; ’
TABLE 6
-
’ ’ ’
_.
.
Responses
to
Note : Each 3 x 3 matrix
stimulus
CVC stimuli,
gives
using
consonants
/p, t, k/ only.
the percentage distribution of responses for
syllable.
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a
particular
349
Fig.
1.
Transformation of CV syllables. The figure in the box represents the percentage of items correctly repeated, while the figure against the arrow represents the percentage of items repeated as the syllable to which the arrow points. Infrequent responses have been omitted.
Fig.
2.
Transformations of VC
syllables. (For explanation,see Fig. 1.)
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350
,
confusion in CVC syllables. Figures give the percentage of mistakes in the direction shown for each syllable.
Fig.
3.
/t-k/ going
Fig.
4.
/t/ rule in CVC syllables. Figures give the percentage of mistakes the direction shown ’for each syllable.
Fig.
5.
Inversion in CVCs. Figures give the percentage of mistakes direction shown for each syllable.
Downloaded from las.sagepub.com at UCSF LIBRARY & CKM on March 30, 2015
going in
going
-
in the
351 consonants, these consonants were frequently misrepeated to create identical Cs; syllables having the same initial and final consonant were well repeated (see Tables 2 and 6). (iv) Plosivisation of consonants: this was seen to occur with CVs and ’VCs and is illustrated in Figs. 1 and 2; since the consonants in CVCs were restricted to oral plosives this phenomenon obviously could not be observed with these syllables. (v) Inversion (metathesis) : inversion of consonants did occur but was not one o’f the main tendencies (see Fig. 5). Given the restricted range of consonants used, the same error could be accounted for by more than one rule.
Distribution
of
mistakes in CVCs
For CVCs the mistakes may be attributed to the different rules 7. The subject’s main errors are shown in Fig. 6.
’
as
shown in Table
DISCUSSION
In terms of the made. Vowels. With
more
specific findings reported above,
certain
comments
should be
striking ’discrepancy between consonant and vowel Fry’s patient (Fry, 1959) showed almost as many vowel errors as consonant errors, Shankweiler and Harris’s patient, like ours, produced many more consonant errors. (&dquo; The vocalic portion of the word is produced with greater accuracy than the non-vocalic portions &dquo;, Shankweiler and Harris, 1966, p. 285). This might suggest a different cortical handling of vowel and consonant production and it is interesting to recall the perceptual experiment of Shankweiler and Studdert-Kennedy (1967), who, comparing identifications of dichotically presented pairs of synthetic CV syllables and pairs of steady-state vowels, found a significant right-ear (and therefore left hemisphere) advantage for CV syllables but not for steady-state vowels. Concerning reproduction of voice quality in consonants the relative lack of aspiration in initial voiceless plosives, particularly the bilabial plosive, sometimes gave the impression, with our subject, of the corresponding voiced plosive or of an intermediate plosive (i.e., intermediate between /p/ and /b/). Three of the patients of Alajouanine, Ombredane and Durand apparently showed the opposite tendency: these authors state that the errors were more in the direction of devoicing their voiced plosives. Fry’s patient, contrary to ours, showed a strong tendency to replace voiced plosives by voiceless. This discrepancy between Alajouanine et al.’s patients and ours could be accounted for by the difference between the two phonological systems (in particular, the existence of aspiration as a distinctive feature for English plosives but The difference between our patient and Fry’s in this respect needs of not French). course another interpretation.
repetition,
to the that whereas
regard
we note
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352 .
TABLE 7
Distribution of CVC mistakes attributable
to
each rule.
Fig. 6. Transformations of CVC syllables. (For explanation, see Fig. 1.) Percentages are taken from Table 6.
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353
Next, concerning
some
of
our
suggested
five ‘ rules ’ :
will be seen in Tables 3, 4 and 6 and Figs. 1 and 3, this (i) /t-k/ con f usion : occurred in CVs and CVCS. Alajouanine et al.’s patients, especially E.B., like only ours in the early stages of re-acquisition, found posterior consonants dii~cult; when not omitted they were replaced by /t/ or /p/. They instance képi...¿tépi, gauche...¿doche, caf,é...¿pafé. Fry’s patient made many errors in /t/ and /d/, which were frequently replaced by velar articulations, but few instances of /k/ (or /g/) being transformed into /t/ (or /d/). as
(ii) /t/ rule : this may /k/ (see Fig. 4); for predict the same errors.
seen in VC errors (Fig. 2) and CVCs with initial /p/ CVCs with initial /t/, the consonant harmony rule will In VCs alveolar positions were more often correct than labial or velar and mistakes tended to go to the alveolar position. Among CVCs final /t/ was also frequently substituted for other final plosives, and syllables with final /t/ were well repeated. Alajouanine et al. recorded a somewhat different phenomenon in their patient Maurice Poig., who tended to close his open syllables with a plosive, especially /t/ or /k/. (With our patient there were no cases of a CV syllable acquiring a final C in error.)
be
and
(iii) Consonant harmony : this ‘ rule ’ mistakes for stimuli of the form C1 VG2 :
accounts
for the
following percentages
of
However, the majority of
cases of the second type are better described by /t-k/ of the form /pVk/--7/kVkj. Thus it seems best mistakes confusion, leaving only to regard the effect of consonant harmony on errors as progressive assimilation of the initial consonant on the final, and figures given in Table 7 are for this only. Examples from repetition of voiced plosives suggest that consonant harmony and /t/ rule are place rules and that the voicing of the target phoneme is often retained,
e.g.Jbut/ --7 /bup j. The rule may be
compared with that formulated by Lecours and Lhermitte (1969) discussing phonemic paraphasias: they found that although error and target phonemes were usually closely related, 80% of the errors could be understood in terms of assimilation. Alajouanine et al. report many instances of consonant harmony transformations (/papo/ for chapeau, /papa/ ~for patte, etc.: Marie-Louise Chap.). Cohen et al. too speak of many ’ assimilations’, e.g. /raret/ for barrette, always retrogressive. (As assimilations can occur between adjacent consonants, we have preferred the term consonant harmony, referring to an effect across a distance of two phonemes and operating only on consonants.) (iv) Plosivisation : this was particularly marked in final position (VCs). Data from CVCs are scanty. Alajouanine’s patient, Maurice Poig., is reported as nearly always using a plosive to begin a syllable; his patient René W. substituted plosives frequently for fricatives in all positions. This tendency seems to have been in
Downloaded from las.sagepub.com at UCSF LIBRARY & CKM on March 30, 2015
354 stronger in the patients of Alajouanine et cal. than in
patient /f/
never went to
/p/ (This
was
recorded
as
subject. But with Fry’s happening with our patient,
our
Tables 4 and 5.) (v) Inversion : there was a small group of errors of inversion. This type accounts for 10% of mistakes of stimuli C1 VC~ in our data and occurs with all stimuli except /pVt/ (which would give the unstable syllable /tVp/). Thus it seems a small but quite general tendency (see also Fig. 6). Alajouanine et al. and other workers suggest that inversion of consonants often occurs, e.g. from Cohen et al.: vallie->Iavi; tarko-¿karto. see
ERRORS
IN SPONTANEOUSLY
PRODUCED WORDS
We have many fewer examples of the articulation of spontaneously produced words (that is to say, words produced in conversation or in naming tasks, etc., without repetition) than of repeated syllables, but some of the same principles may be seen for CVC target words.
The main difference from repetition is the number of syllables leftt open. Alajouanine et al. also cite several instances of this, especially with their patient Elodie B. If, however, the frequency of open syllables in word structure is different in French from English, this tendency would have a somewhat different significance for each language. It will have been noted that earlier on our patient had a strong tendency to create open syllables out of closed ones, especially in spontaneous speech, and that this tendency persisted to a certain extent with spontaneously produced
words. Consonant clusters were usually simplified by omission of one consonant, but some clusters did occur, e.g. hand-correctly repeated; and box?/bops/. Vowels were again well realized by our patient, with the occasional exception of the replacement of a final schwa /a/ by /I/, e.g. paper~/pelpt/.
’.’ ’
CONCLUSIONS
.
’~ - ,...
,,
_
1. Reliability of ’ ‘ system ’ Analysis
of both the
on
correct
which Remedial
repetitions
Programmes could
and the
misrepetitions
Downloaded from las.sagepub.com at UCSF LIBRARY & CKM on March 30, 2015
be based of
syllables by
our
355 enabled us to discern the pattern of his phonological behaviour. There is considerable stability for his vowels and for certain of his consonants in specific phonetic environments. When and where errors occur, the great majority (78% in CVCs) can be accounted for by five rules’ or trends, as enumerated above. We therefore feel justified in claiming that our subject’s responses are on the whole However, even if our patient’s phonological behaviour is stimulus-dependent. ’ rule-governed ’, generally speaking, the government is not sufl’iciently strict for us to predict at every point whether a given phoneme (consonant) will be repeated correctly or incorrectly; all we can do is to state a degree of probability for the ’ form which its errors will take, in the case of incorrect repetition. In addition, in a less specific way, we have observed definite recurrent features, such as a partial devoicing of the voiceless plosives, a tendency towards open syllables, etc. Thus our findings confirm various other studies, involving one or more cases, which have pointed to the existence of a system operated by patients with phonetic disintegration’ syndrome. As Alajouanine et al. comment, &dquo; Les mutations phon6tiques et les simplifications verbales que l’on constatait se classaient sozss un nombre limite de principes &dquo; (our italics), p. 28. Moreover, however ragged the system which we have perceived beneath our patient’s deviations, it has provided a reliable and useful basis for remedial programmes on videotape and through other media.
subject
II.
Resemblance
to
Children’s
speech patterns
,
We now look cursorily at the resemblance of this system’ to phonological deviations in young children, bearing in mind the findings of Fry, who, using Morley’s (1957) table of children’s sound patterns at the age of three years and nine months, found little in common between his patient’s speech and the ifeatures of child speech. In respect of several of the features mentioned above-plosivisation (especially /f-7p I), consonant harmony, inversion, reduction o’f clusters, opening of syllables, late acquisition of /k/ and /g/-we were able to see a parallel between our patient’s speech and child speech. Fry, commenting on his patient’s voiced/voiceless confusion, remarks that this is practically unknown in children’s speech. Alajouanine et al., on the other hand, say in their section on la phonétique pu~erile ’ : &dquo; Les sonores tendent a Etre remplac6es par les sourdes correspondantes &dquo; (p. 124). Jakobson (1968) also implies a confusion or coalescence of voiced/voiceless consonants at a certain stage of child development (&dquo; So long as stops in child language. are not split according to the behaviour of the glottis, they are generally pronounced as voiceless and unaspirated &dquo;, p. 14). This is most likely a feature of the speech of children considerably younger than those referred to by Fry, according to our own observations. Fry goes on to point out that speech involves activity at several interdependent levels and maintains that if disintegration &dquo; ... mirrors development then the effects must be discernible at all these levels &dquo; (p. 52). We were, in ’fact, able ...
....
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356
subject’s linguistic performance of breakdown at morphemic (e.g. complete partial loss of plural morpheme in more than one modality), syntactic (emissively and receptively) and lexical, levels. It is not our intention to generalize from a single case, although some of these observations have been confirmed in other, less thoroughly studied, patients of ours. Obviously, in many respects the patient’s speech differed from that of a child and showed many residues of a fully acquired speech system. to
accumulate evidence in
our
or
III.
Comparison
with
findings of
our
predecessors
The data published by our forerunners, including those of Alajouanine et al. (1939), Blumstein (1973) and Fry (1959), are presented in a form too disparate from ours to allow a detailed comparison. All four of Alajouanine’s patients and Fry’s patient clearly had a much greater speech output than ours and were able to read much better out loud. The neurological picture of at least one of Alajouanine’s patients differs from our subject’s. Fry does not supply ifull neurological details and it is possible that the pathology differs. Fry’s data, although very complete, do not provide a breakdown enabling a positive or negative confirmation of features such as consonant harmony, inversion, etc., nor information as to the place (initial or final) of omission of consonants where this occurs. Where, however, comparison is possible it would seem that there are greater similarities between our patient’s speech and some of the patients described by Alajouanine et al. than between our subject and Fry’s. We noted several tendencies in our subject’s speech which Alajouanine et al. had described in their patients, although D.C. had less speech and a rather better control of phoneme production, particularly in initial position and in respect of fricatives. On the other hand, there were marked discrepancies between our patient’s speech and Fry’s patient’s, especially in vowel production and in voicing of plosives. Such differences are not surprising considering the complexity of aphasic breakdown and the rarity of two patients sharing even the greater part of their symptoms. Moreover, our data were obtained almost in which Alajouanine et al.’s and Fry’s were not. exclusively repetition, interest of educing (a number of trends or rules’ and the theoretical ’from Apart a ’ the existence of system’, the main application of our findings has been confirming as a therapeutic tool.
’ ’
