Aphasia: The Cruelest Language Barrier

Imagine the following scenario: You wake up one morning and instead of speaking English, everyone
around you--including your family and friends--is speaking Hungarian. This is a problem because you
don't speak Hungarian and you don't have a clue what they're saying. You become frustrated. The people
around you become frustrated, too, but instead of switching back to English, they speak Hungarian more
loudly.

Somebody gets the bright idea of writing you a note. You take the note in your hands and study it.
Unfortunately, it's in Hungarian, too, and you can't read it. So they write you another note, still in
Hungarian, but this time with large, block letters. You can't read the second note, either.

This strange scenario is almost exactly what happens to people who have a stroke (circulation impairment)
to the left side of the brain, except that the family and friends aren't really communicating in Hungarian.
They're speaking and writing English--same as ever--but to the stroke victim their words are suddenly
incomprehensible. This sudden disruption in language-processing is called aphasia.

Different patterns of aphasia occur with damage to different parts of the left side of the brain. The
preceding scenario, in which comprehension of language is impaired, is called a receptive aphasia and is
associated with injury to the upper portion of the brain's left temporal lobe, roughly adjacent to the temple
and top of the ear. In receptive aphasia the affected individuals can still produce sentences, but, in an odd
twist of fate, they can't make sense of or properly monitor their own words, so their output is riddled with
errors.

A pattern of language impairment opposite of receptive aphasia is called expressive aphasia, in which
individuals can understand what others say or write, but cannot produce much, if any, speech or writing of
their own. In 1861 Pierre Paul Broca, a French surgeon, recognized a case of expressive aphasia and
followed through with an autopsy of the patient's brain.

For much of the nineteenth century most scientists and physicians believed that the brain was
homogenous, and that its different actions were spread diffusely throughout the entire brain. They did not
believe that functions were localized to specific regions of the brain. (The phrenologists believed
otherwise, but that is a story of its own.)

However, when Broca treated a patient who lost his power of speech (the only word he could still say was
"tan") he was able to correlate this language impairment with damage to the left side of the man's brain.
Instead of being in the temporal lobe, the destroyed brain-tissue was in the frontal lobe in an area now
referred to as Broca's area. In fact, expressive aphasia is also known as Broca's aphasia. Dr. Broca's case
was the principal salvo in a reversal of understanding about how the cerebral cortex (the brain's wrinkled
gray surface) operates. Now we realize that many functions--not just language--are localized to specific
regions of the cortex.

Receptive and expressive aphasias are not the only patterns of language impairment, but nicely convey
the basic idea of a sudden disconnect in language processing. What becomes of these cases? As is seen
with strokes affecting other parts of the brain--for example, those causing weakness or paralysis of
muscles on the opposite side of the body--recovery varies widely among patients. Some patients become
normal again and others don't improve at all, but the usual outcome is somewhere in between.

Improvement in language function that occurs within the first week or two following a stroke is due to brain
cells that were sick from the stroke--but not quite dead--becoming healthy and operational again. By
contrast, improvement in language function occurring over ensuing weeks, months and even years is due
to the retraining of surviving brain cells that take over for their fallen comrades. A younger stroke patient
with more brain cells in reserve has a better chance for recovery than an older patient with fewer reserves.

Is there anything that can be done to improve outcome? First of all, there is the management of the stroke
itself which generally takes place in a hospital. One important point to emphasize is that a stroke causing
aphasia is no less a stroke than one causing paralysis of muscles. Sometimes it seems that the latter
receives more serious attention than the former. Management of fundamental issues--like blood pressure,
body temperature and blood sugar--can set the stage for the best possible outcome.

Following a first stroke, physicians also implement "secondary stroke prevention" to decrease the odds of
a second stroke. In cases of stroke due to hardening of the arteries (atherosclerosis) this often takes the
form of ratcheting down blood pressure, blood sugar and cholesterol, along with elimination of smoking
and other unhealthy behaviors. Also, the doctor usually prescribes a medicine to reduce blood-clotting.
Other causes of stroke might call for other measures.

Does speech therapy help stroke-patients with aphasia? So far, this form of treatment has not been
proved beneficial. Randomized, controlled trials (the standard of proof in clinical medicine in which patients
receiving the treatment are compared to similar patients receiving either a dummy-treatment or no
treatment) have not clearly demonstrated that speech therapy is better than either no treatment or
treatment provided by family or friends.

Sometimes patients with aphasia are perceived as "confused" in the sense of having a delirium or
dementia. But this is not the case. Acutely aphasic patients need to be recognized as having suffered a
stroke to a specific part of the brain so they can be triaged for appropriate medical care. Over the longer
term, family and friends need to remember that the stroke victim is still a perceiving, self-aware human
being who happens to have a communication problem. He or she should be loved, appreciated and
otherwise included in activities just as before.

(C) 2005 by Gary Cordingley