Brain (1978), 101, 381-401

BILATERAL TACTILE APHASIA: A TACTO-VERBAL DYSFUNCTION by MARIE-FRANCE BEAUVOIS, BRIGITTE SAILLANT, VINCENT MEININGER and FRANCOIS LHERMITTE

INTRODUCTION

FOR nearly a century the existence of a stimulus-specific object-naming defect has been discussed (Freund, 1889). Despite this, the published details of such a defect without others, such as agnosia or asymbolia, are quite rare. Following the first report of optic aphasia by Freund (1889), many cases of visual namingdefects were reported. However, a close analysis of these cases permitted Wolff (1904), followed by Kleist (1916,1934) to emphasize that in all there was an aphasia or an agnosia, and for this reason, they challenged the use of the term optic aphasia. Until today, except for Freund's case, only two observations may be considered as examples of true optic aphasia (Spreen, Benton and van Allen, 1966; Lhermitte and Beauvois, 1973). With regard to the existence of an auditory anomia, Denes and Semenza (1975) reported the only case of a non-aphasic patient who was unable to name a sound properly but was still able to designate the proper image of the object producing the sound. As for tactile anomia, except for the tactile aphasia of the right hand reported by Raymond and Egger (1906), often claimed to be an astereognosia by many authors (Dejerine, 1906, 1907; Claparede, 1906; Delay, 1935), the only convincing observations of tactile anomia seem to be those concerning left-hand object-naming defects encountered in patients with callosal lesions (Geschwind and Kaplan, 1962; Gazzaniga and Sperry, 1967; Gazzaniga, 1970; Lhermitte, Chain, Chedru and Penet, 1976). If some cases of bilateral astereognosia have been reported (Oppenheim, 1906; Goldstein, 1916; F.oix, 1922; Lhermitte and Ajuriaguerra, 1938) we have been unable to find evidence of the existence of bilateral tactile anomia. The only exception seems to be that of Geschwind (1965), who reported an unpublished observation by Kaplan. The object of this article is to report a case of bilateral tactile aphasia.

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(From the Laboratoire de Neuropsychologie INSERM U 84, Hopital de la Salpetriere, 47, Boulevard de I'Hopital, 75634 Paris Cedex 13)

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MARIE-FRANCE BEAUVOIS AND OTHERS CASE REPORT

History R. G., a right-handed 62-year-old man, without previous symptoms, was found in a state of stupor on March 7, 1974. On examination, a right hemiplegia and probable aphasia were found. Angiography demonstrated in the left hemisphere a parieto-occipital angioma and a haematoma without modification of the anterior cerebral artery (fig. 1). The angioma was removed and the haematoma evacuated at immediate operation. After three weeks of stupor, clinical examination showed a right hemiplegia with aphasia, both of which regressed rapidly.

FIG. 1. Left parieto-occipital angioma. Pre-operative angiography.

Between April 1974 and May 1975 the patient lived at home, far from Paris. He was unable to work because of serious reading disability. After one year of unsuccessful re-education, the patient was admitted to Hopital de la Salpetriere in May 1975. The chief complaint was not motor or aphasic but reading disability. He was able to write correctly, but he was unable to read what he wrote. He was unable to tell the time, and he complained of difficulties with mathematical calculation and memory. After complete neurological and neuropsychological studies, the patient decided to go home and return to Paris later for re-education. He came back in October 1976, that is, two-and-a-half years after the operation. In October 1976 the neurological and neuropsychological examinations were unchanged from May 1975. Only the latter will therefore be reported.

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Neurological Examination (October 25,1976)

Neuropsychological Examination (1) Intellectual efficiency. The patient had worked as an agricultural machinery representative. His intellectual level appeared only slightly diminished, as shown by IQ on WAIS (Verbal IQ 90, Performance IQ 85) and by the 38 Progressive Matrices range (between the 25th and 50th percentiles). (2) Calculation. The patient wrote numbers from dictation correctly; he knew multiplication tables fairly well; he was able to perform mathematical calculation mentally with numbers up to three decimals; he knew and performed mathematical operations correctly and in the correct sequence; he quickly found the solution to verbally proposed problems. Mathematical calculation, however, was abnormal, partly due to his reading troubles, and partly due to difficulties in solving problems with complex data; this last difficulty was typical in other situations (see later, comprehension of speech orders). Even though the patient had some difficulties in calculating, one cannot speak of an 'acalculia', since the troubles can be explained by a much more general disturbance of processes which are not specific to calculation. (3) Memory. The patient suffered from some memory disturbances, without serious clinical consequences. However, these troubles dramatically affected learning ability and also disturbed delayed recall. Recall of events before the illness was fairly good, better in content than in their timing. Recall of events after the illness was a little less effective but not sufficient to interfere with daily activity; the recall of dates, however, was much impaired. On immediate retrieval tests (Beauvois and Lhermitte, 1975), the patient achieved a normal score, for each tested modality, auditory-verbal, visual and gestural; but the three learning tests corresponding to these three modalities were impaired. This impairment was also observed for the retrieval of the Rey Complex Figure test and for some subtests of the Wechsler Memory Scale. Therefore, the patient had a normal short-term memory but impairment of memory processing capacity and of middle and long term retention. (4) Praxis. Handling of objects and imitation of using objects without their presence were carried out correctly, either in one hand or in both together. Symbolic acts were also correctly performed. However, imitation of actions without significance was difficult when these actions involved hands, fingers, face and mouth. The patient showed a slight constructional apraxia when he drew a cube, a bicycle, and when he copied the Rey Complex Figure. (5) Body Image. The patient exhibited disturbances in his body image and a finger agnosia, but these disturbances were observed only during verbal tests: he pointed out correctly on himself any part of the body pointed out on the examiner, and conversely; but some mistakes were made when the examiner named a part of the body and asked the patient to point it out, or when the examiner touched a part of the body and asked the patient to name it (either on the patient or on the examiner); these disturbances

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The patient complained of no motor or sensory troubles. Walking and standing were correct. Muscular strength and tone were normal, as were the deep tendon reflexes. No Babinski sign was observed. All the following sensory modalities proved to be normal: light touch, pin pinch, hair sensation, temperature, two-point discrimination (thumb, little finger, palm of the hand, big toe), position sense (big toe, hip, thumb, little finger, shoulder), vibration, localization of touch and tests of perceptual rivalry. Visual acuity was equal to 10/10° (10/10 is normal in the French system) on the right side and 8/10° on the left side (10/10° after correction). The Goldmann test revealed a right inferior quadrantanopia which did not affect the macula. Colour perception tests were normal (Hardy Rand Ritter, Farnworth 100 Hue). The electroencephalogram showed an abnormally slow background activity in the left hemisphere. A left posterior temporo-parieto-rolandic focus of slow waves was constantly observed. Computerized tomography (CT) scans were undertaken on the October 25 1976 with the head scanner of Compagnie Generate de Radiologie. The matrix was 120x 120, and the scans were parallel to the orbito-meatal line. In the left hemisphere a low density wedge-shaped lesion, with the summit toward the ventricle, was observed on three scans.

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are much more consistent with a semantic disorder than with a spatial one (he named the knee instead of the elbow; he called the wrist 'a tibia' and the knee 'an ankle').

(7) Visual and auditory identification and naming were normal. The patient was able to name 20 different colours and 50 object pictures quickly. He easily recognized the photographs of 48 VIPs. The reading impairment was not related to letter recognition defect. The patient was able to recognize and name 15 sounds characteristic of certain objects. (8) Naming of objects factually presented to either hand was seriously disturbed, whereas the identification of these objects seemed to be correct. Summary. Two years after the removal of a left parietal angioma the patient exhibited a right inferior quadrantanopia, a mild memory and calculation deficit, a slight constructional and corporeal apraxia, a naming defect of the various parts of the body, an alexia, and a naming defect for objects placed in either hand.

SPECIAL NEUROPSYCHOLOGICAL

RESEARCH

This patient who had no expressive or receptive dysphasia and no sensory deficit could not correctly name an object placed in his hand. Experimental research was carried out in order to answer seven questions: (1) was the anomia really specific to the tactile modality? (2) was the anomia different when the object was presented to the left hand or to the right? (3) was the tactile-naming impairment really

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(6) Language. Verbal expression. Spontaneous speech was correct: articulation, intonation and fluency were correct, and sentences were correctly constructed. He repeated the 50 syllables, the 125 words and the 10 phrases of the Examen de VAphasie (Ducarne, 1976) entirely correctly, and all the sentences of the Terman Merill Intelligence Scale at the highest level. Recall of words was precise and quickly performed. He was able to name 50 object-images easily and he quickly stated the opposite of a given word 49 times out of 50. Word definitions were correct (standard score 9 on WAIS Vocabulary Subtest). The patient easily constructed sentences using two or three given words (score 7/7 on the sentences constructing test of Examen de I'Aphasie). The patient's verbal expression can therefore be stated as normal. Understanding of Oral language was fairly good. The patient was able to carry out all the tests of 'oral understanding' of Examen de I'Aphasie correctly: pointing out an object named by the examiner (35/35), performing some orders (9/10), and the Three Paper Test of Pierre Marie. The critique of irrational stories of the Terman-Merrill Intelligence Scale was correctly performed up to the highest level. A discrimination test on closely-related phonemes (Derouesne and Saillant, 1978) was correctly performed. Semantic discrimination was good (IQ, 98 for the Synonym Test of Binois and Pichot (1958), orally performed). In the orally-performed Token Test (De Renzi and Vignolo, 1962), the four first parts were perfectly performed; however, the results of the fifth part were not good (7/22): this failure seems to be due to difficulty in combining many data and is probably identical to the previously described calculation defects. Therefore, the patient's oral comprehension was correct except for sentences with too much information. Writing. The patient was able to compose and write a story, to write the names of fifty object images as easily as he could verbally and to take down dictated words and sentences. All these tests were correctly performed except for a moderate dysorthographia; he wrote the words phonetically and incorrectly. Reading. The patient exhibited a serious reading impairment that will be described in a future publication (Beauvois and Derouesne, 1978).

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independent of recognition-impairment (astereognosia)? (4) did the defect appear in the verbo-tactile sense as well as the tacto-verbal sense? (5) was the defect restricted to the naming of objects? (6) was the tacto-verbal impairment dependent on a tacto-visual impairment? (7) could tactile identification be transferred from one hand to the other? (1) Was the Anomia Specific to the Tactile Modality! In order to test the specificity of the tactile-naming impairment statistically, the performances of this patient in tactile, visual and auditory object-naming were compared. Three comparisons were made: percentages of correct responses, response-naming time, and kind of misnamings. Downloaded from http://brain.oxfordjournals.org/ by guest on March 23, 2016

Naming Tests. The subject was asked to name objects presented to him either tactually (tactile naming), visually (visual naming) or auditorily (auditory naming). For the three kinds of tests the procedure was the same. Stimuli were successively presented during the same testing period. From the time the stimulus was presented to the subject he had one minute to give a response; yet when he named (wrong or right) the object before the end of this period, the next stimulus was immediately presented. We taped the verbal responses and recorded the response times. Tactile naming. The subject was blindfolded. Fifty objects were placed first in his right hand, then fifty different objects were placed in the other hand, and he was asked to name the objects. One month later the fifty objects which were previously presented to his right hand were presented to his left hand and conversely. The stimuli were everyday objects, for example, tools, food, clothing, etc. Visual naming. Two kinds of objects were presented. First, in order to allow a direct comparison with tactile naming, the same one-hundred objects previously used for tactile presentation were visually presented. This visual naming test was performed between the two tactile-naming tests, about fifteen days after the first tactile naming. Yet, it might be thought that the difficulty was possibly not equivalent in the visual and tactile naming of the same objects, that is, it was more difficult to name some objects when they were presented to the hand than when presented for visual naming. This is why in a second test, fifty pictures of objects, visually difficult to recognize, were presented to the subject for naming. They were pictures normally used in the neuropsychological laboratory to reveal minor degrees of visual agnosia. For the most part, the objects drawn on the pictures could not be manipulated as they were landscapes, animals and so on. Auditory naming. Eighty very familiar tape-recorded sounds of objects (telephone bell, cat mewing, bells, etc.) were presented to the patient in a sound-proof room. The patient had to name the object from the sound he heard. It was not possible to find sounds related to the tactually-presented objects, nor to use objects related to recorded sounds for tactile naming. Indeed, objects which can be easily recognized tactually seldom emit a characteristic sound, and many objects which emit a well-known sound cannot be put in the hand (a dog, a bell,

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an ambulance, a baby crying, etc.). This is why two precautions were taken; first, words corresponding to the sounds used were not more frequent than words corresponding to the tactually-presented objects; secondly, the frequency with which these sounds are heard does not seem higher than the frequency with which the tactually-presented objects are used.

TABLE 1. SAMPLES OF TACTILE MISNAMINGS

Stimulus a cork a box of matches a ladle a glove a knife a tea-cup a doll an old tube of tooth-paste

Response a bottle some cigarettes a soup-tureen slippers a fork a plate . . . a spoon a ball a worn-out toothbrush

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Results. Percentage of correct responses. The sensory modality in which the stimulus was presented (tactile, visual or auditory) had an important effect on the percentage of correct naming responses (tactile-visual comparison: x2 = 48-20, P

Bilateral tactile aphasia: a tacto-verbal dysfunction.

Brain (1978), 101, 381-401 BILATERAL TACTILE APHASIA: A TACTO-VERBAL DYSFUNCTION by MARIE-FRANCE BEAUVOIS, BRIGITTE SAILLANT, VINCENT MEININGER and F...
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