JOURNAL
OF COMMUNICATION
DISORDERS
9 (1976),
157-166
THE RECOVERY PROCESS OF A BILINGUAL TOSHIKO S. WATAMORI
APHASIC
AND SUMIKO SASANUMA
Section of Communication Research, Tokyo Metropolitan Institute of Gerontology/Speech Pathology Services, The Yoikuin Tokyo Metropolitan Hospital, 35-2 Sakaecho, Itabashiku, Tokyo 173, Japan
The recovery process during the first year poststroke in an English-Japanese bilingual aphasic is analyzed with special emphasis on the effect of language therapy. The patient initially manifested equally severe impairment in both English and Japanese involving all language modalities with moderate impairment of reading and auditory comprehension and severe impairment of oral production and writing. Language therapy was conducted in English in a community where Japanese was the only language in the environment. In the course of language therapy, auditory and reading comprehension improved almost simultaneously in both English and Japanese. In contrast, oral language production and writing abilities improved markedly only for the treated language (English). The results are discussed in terms of their implication for the effect of language therapy on aphasia.
Introduction The study of bilingual aphasics has drawn much interest among investigators and a number of articles have been published on this subject (Weisenburg and McBride, 1935; Goldstein, 1948; Lambert and Fillenbaum, 1959). It has been pointed out by these investigators that the study of bilingual aphasics may provide valuable information as to the differential effects of spontaneous recovery and the effectiveness of language therapy. In other words, one should be able to make valid inferences on the effect of therapy by comparing the recovery pattern of the two languages of bilingual aphasics who receive language therapy in a hospital where one language is stressed (Osgood and Miron, 1963). Most reports on bilingual aphasics to date, however, are anecdotal and no detailed, longitudinal study has been found in the literature. The present investigation concerns the symptoms and the changes observed in an English-Japanese bilingual aphasic who preferred the English language for his therapy while living in a community where Japanese was the only language used. Case History The patient is a 65-year-old, right-handed businessman. He was born in California in 1908 to Japanese immigrant parents, and was brought up in a bilingual environment using Japanese at home and English in the community. He graduated from the University of California at Berkeley in 1930. Six years later he came to Japan to study at a Japanese university. He graduated from the university, married a native Japanese woman, and has since been living in Japan. After World 0 American
Elsevier Publishing
Company,
Inc.,
1976
157
158
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
War II he worked for an American firm and visited the U.S. several times every year until the onset of his illness. According to his wife he spoke perfect Japanese at home and had no trouble in handling the contemporary Japanese orthography although he seemed to prefer using English in reading and writing. In March 1973, immediately after his return from his visit to the U.S., the patient complained of a visual disturbance. A couple of days later, a speech disturbance appeared, which increased gradually for the next 10 days. He was diagnosed as having suffered a cerebral thrombosis. On April 22, 1973, the patient had a second attack and became totally speechless with only the residual utterance “So, so.” Neurological examination revealed no paralysis or paresis in either of his limbs, and no abnormalities of the arteries on the CAG. In June 1973,2 months after the onset, he was referred to the Speech Pathology Services of the Yoikuin Tokyo Metropolitan Hospital. Initial Test Findings The Porch Index of Communicative Ability (PICA) and selected subtests of the Minnesota Test for Differential Diagnosis of Aphasia (MTDDA) were administered in both English and Japanese in June, 1973. l For the purpose of differential diagnosis, a test of oral apraxia, articulation tests, an extensive naming test (100 words), and an audiometric examination were also administered. The results of these tests revealed severe aphasia of Broca type, with severe oral apraxia and verbal apraxia in both English and Japanese. As can be seen in Fig. 1., the degree of the impairment of one language is almost equal to that of the other across all modalities. No parietal signs were detected. On the basis of this initial evaluation, it was provisionally decided that the language therapy would be conducted in Japanese since he lived in Japan and his wife did not speak any English. After being in therapy for 2 weeks (four sessions), however, we inferred from the patient’s gestures that he felt he could not improve in Japanese and would like to work in English. His wife supported this idea too, and thus the therapy has since been conducted exclusively in English. Therapy
Program
The patient received 1-hr language therapy sessions in English twice a week for 3 months and then the number of sessions was increased to four times a week until June, 1974. The program of language therapy included auditory comprehension tasks (i.e., pointing to the pictures by name, writing phrases and sentences from dictation, and ‘The Japanese versions of these tests were carefully ence with the original.
constructed
so as to maintain maximum
equival-
THE RECOVERY
100
PROCESS
OF A BILINGUAL
159
APHASIC
r
Aud.
Read.
Oral Prod.
Writ.
Aud.
Read.
Oral Prod.
Writ’
Fig. 1. Results of initial and final evaluations on the four modalities of language. Initial evaluation (2 months post onset) is at the left, final evaluation (14 months post onset) is at the right. ., English; q, Japanese.
following verbal commands); reading comprehension tasks (i.e., matching words to pictures, and reading sentences and paragraphs); oral production task (i.e., imitation of words and greetings, naming of pictures, imitation of short phrases and sentences, spontaneous production of phrases and sentences to picture stimuli); and writing tasks (i.e., copying single words, writing words to pictures; writing words, phrases, and sentences from dictation; and spontaneous production of phrases and sentences). The tasks were graded in terms of difficulty. The stimulus words which appear in the language tests were carefully eliminated from the therapy materials.
Results In order to assess the recovery process of his linguistic impairment, the PICA and selected subtests of the MTDDA were administered periodically. The scoring of the PICA was somewhat altered so that the percentage of correct responses in each modality was calculated and combined with the MTDDA subtest results. The combined scores thus obtained were plotted on the graphs. The results of the initial and final evaluations (2 months and 14 months post onset, respectively) are shown in Fig. 1 in terms of each language modality for both English and Japanese. Figure 2 is a graphic representation of the differences between the initial and final test scores as shown in Fig. 1. Figures 3-a through 3-d represent the results of sequential subtests of each modality.
160
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
100 90
English
F
q
80 t
Aud.
Read.
Oral
Japanese
Writ.
Fig. 2. Differences in percentage between initial (2 months post onset) and final (14 months post onset) test scores on each modality in English and Japanese.
Auditory Process The tasks for the auditory process included pointing to objects by name and function, pointing to pictures spoken serially, listening comprehension of long paragraphs, and following commands. The results plotted in Fig. 3-a reveal that the two recovery curves, one for English and the other for Japanese, are quite similar. The treated language (i.e., English) shows slightly higher scores than the nontreated language (i.e., Japanese). After the fourth evaluation, 14 months post onset, the patient’s ability to understand simple, everyday conversation was judged to have reached a functional level in English as well as in Japanese, although he still exhibited difficulty following long complex material presented verbally in either language.
Reading Process
The tests of the reading process comprised matching words to pictures, following written commands, and reading comprehension of long paragraphs. As can be seen in Fig. 3-b, the recovery curves for the two languages are parallel, with the treated language consistently higher than the nontreated language (Fig. 3-b). At
OF A BILINGUAL
IOO-
u
;
40-
2 40
20-
z : a. 20
161
(b)
100
‘; 80 0 : o 600
w 8o !i L ;; 60
! 2
APHASIC
O-
2
Months
9 Post
Ol-L--GL--L-i14 2
14
Onset
Months
(cl
100
100
9 Post
Onset
(d)
r
II
8o iii
c
c
E
o 0
:
$ 600
60
0
8o
2 Months
6 Post
9 Onset
14 Months
Post
Fig. 3. Recovery curves across time: (a) auditory process; @) reading process; process; (d) writing process. l, English; q, Japanese.
Onset
(c) oral production
this moment, 20 months post onset, the patient still has some difficulty understanding long paragraphs in English although he is able to follow simple written commands. He is totally unable to read long paragraphs in Japanese. Oral Production
Process
The tasks included in the oral production process were the repetition of words, naming pictures and objects, supplying words in sentences, and describing the
162
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
function of presented objects. Oral production was found to be the most impaired process in this patient’s language ability, partly because he had severe verbal apraxia or apraxia of speech. The recovery curve of this process, as shown in Fig. 3-c, indicates an increasing discrepancy between the treated and the nontreated language through time. The discrepancies exhibited at both 9 and 14 months post onset indicate that he could occasionally respond with single words in a conversational situation in English, but was not able to do so in Japanese. Writing Process The tasks included in the writing process were writing words from dictation, writing words to pictures, and writing sentences describing the function of the presented objects. The patient was at first able to copy only geometric forms and a few words in both English and Japanese. The recovery profile of this process shown in Fig. 3-d indicates an even greater discrepancy between the two languages than was the case with oral production. After 12 months of therapy the patient was able to write 70% to 80% of high frequency words to picture stimuli and four- to five-word sentences from dictation in English. In contrast, his writing ability in Japanese stayed unchanged until 9 months post onset, but from then on the patient began to show an interesting recovery process. On the initial evaluation, his writings consisted of meaningless but legible KATAKANA (the Japanese syllabery) and it was almost 9 months after the onset that he first wrote KANJI (Chinese characters) in response to picture stimuli. KANJI characters at that time were accurate in configuration but wrong in the sense that they were not the target words themselves. On the fourth evaluation 14 months post onset, the patient for the first time could write correct words in KANJI in response to picture stimuli, which clearly indicated that he had fairly extensive knowledge of KANJI before his brain damage. Of interest was the fact that after the last evaluation (14 months post onset and 12 months in therapy) the patient started to exhibit a growing interest in the Japanese language. He began to work at home using picture and word cards written in Japanese that were given to him a year ago when the therapy was conducted in Japanese. This phenomenon might be interpreted to indicate that the patient’s general language ability per se has improved over the course of language therapy to such a level where he can now begin to take in a totally different type of language system. The therapy program was modified accordingly to incorporate Japanese as well as English after September, 1974. Discussion It appears that the present study of a bilingual aphasic patient provided an opportunity to observe some differential effects of spontaneous recovery versus
THE RECOVERY
PROCESS
OF A BILINGUAL
APHASIC
163
recovery with language therapy. The fact that the language therapy he received was consistently in English while living in an environment where Japanese was used exclusively has provided a unique setting where the extra-session linguistic stimuli in the treated language was absent. At the time of initial evaluation, the pattern as well as the degree of impairment of the two languages that he had used with equal proficiency before his brain damage were almost the same. This is in accordance with the previous findings on so-called “compound” bilingual aphasia (Lambert and Fillenbaum, 1959). A close observation of the changes in his linguistic abilities over the period of 14 months post onset, however, has demonstrated different recovery curves for English and Japanese, most possibly due to the language therapy given exclusively in English. That is to say, while the receptive processes such as auditory and reading comprehension improved similarly in both English and Japanese, the expressive processes such as speaking and writing showed a sizable recovery only in English with delayed and minor changes in Japanese. Spontaneous
Recovery
and Interaction
of Treated and Nontreated
Languages
It may not be appropriate to attribute whatever improvement was observed in the nontreated language in our patient wholly to spontaneous recovery or to environmental linguistic stimuli. There is a possibility that the treatment of one language might have facilitated the recovery of the nontreated language. If this is the case, it might by hypothesized that the stimulation of one language (English) could somehow have activated the brain, possibly the so-called speech area, which in turn has contributed to the improvement of the other language (Japanese). If this hypothesis is tenable, however, all the language modalities should have been benefited. As will be seen in Figs. 3-c and 3-d, however, this effect was not clearly observed in his expressive abilities, probably because of the very nature of his aphasic syndrome in which these expressive processes were most severely damaged. A further look into the test results on his expressive abilities, however, reveals some evidence of facilitation from one language to another. For instance, his phonological ability recovered almost simultaneously in English and in Japanese notwithstanding the wide difference between the two languages in terms of their phonological organizations. At the time of initial evaluation, the patient could not produce, or imitate, any phoneme other than /s/. According to the results of the articulation tests given periodically in English (Picture Articulation Test) as well as in Japanese (equivalent of English articulation test), however, his repertoire of phonemes increased rapidly in both languages. At the end of 6 months of therapy, the patient could produce upon imitation almost all the phonemes and syllables in isolation, although he made some inconsistent errors at word level. The percentage of phonemes correctly produced in words (the patient was allowed three trials per word) were calculated for both languages. Figure 4 illustrates the recovery
164
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
IOO90 -
c m 80
C 0 Q70 ; “, 60: = 50 0
40-
: 0
4 30c ‘, 20u, 2 IO-
3
6
Months
Post
Fig. 4. Percentage of correctly produced consonants English; q, Japanese.
9
14
Onset
that have features common to both languages.
l,
curves for consonants that have features common to both English and Japanese 0 .e., lpl, lbl, /ml, Id, Itl, Id/, Id, III, ItsI, Id z I, hd, Igl, ihl, and Ijl). It can be seen from the figure that the recovery for these phonemes occurred almost simultaneously in both languages. Types of phonemes, however, seemed to have had differential effect upon the recovery rate. It was noted that those phonemes that recovered comparatively well were ones that are unique to one or the other of the languages but are considered to be relatively easy for apraxics, i.e., lfl, Iwl, lrl, and lr$ for English (Johns and Darley, 1970); Ip I and lc#dfor Japanese. On the other hand, those phonemes that are considered to be “difficult” for apraxics, i.e., consonant blends in English (Shankweiler and Harris, 1966; Johns and Darley, 1970) and palatalized consonants in Japanese remained difficult for the patient to the end. Recovery
as a Function
of Language
Therapy
Previous investigators who studied the effect of language therapy versus spontaneous recovery in aphasia have reported the tendency of differential recoveries
THE RECOVERY
PROCESS
OF A BILINGUAL
APHASIC
165
according to the modalities of language. Vignolo (1964) studied 69 aphasic patients of whom 43 received and 27 did not receive speech therapy. He tested oral expression and auditory comprehension twice, with the minimal interval of 40 days, and pointed out that auditory comprehension improved more than oral expression during spontaneous evolution for the nontreated patients. Vignolo indicated that anarthria (verbal apraxia) had a negative influence on the recovery of expressive speech. This was in accordance with our patient who exhibited severe verbal apraxia. Reading and writing processes were not included in Vignolo’s study. Hagen (1973) studied the effect of treatment versus nontreatment with a group of 20 aphasics who had group III type of aphasia in Schuell’s classification, i.e., a diagnostic category that is essentially equivalent to Broca’s aphasia as is exhibited by the present patient. The results indicated that while both groups exhibited spontaneous recovery during the first 3 months of the program, only the treated group continued to progress beyond the point of spontaneous recovery to attain functional communication ability. The author further indicated that auditory comprehension and simple visual comprehension spontaneously recovered to a functional level for both treated and nontreated groups within 9 months post onset, while language formulation, speech production, reading, and spelling improved in a different fashion. That is, slight spontaneous improvement was observed for the nontreated group in the latter abilities up to 9 months post onset but did not recover to a functional level. Our findings in the present study are consistent with these results in that the expressive processes in the nontreated language (Japanese) did not show marked improvement. The reasons why the receptive aspect of language tends to spontaneously recover more have not been completely clarified. Hagen tried to explain the results from the standpoint of hemispheric dominance for each modality. According to the author’s interpretation, auditory comprehension and simple visual comprehension improved spontaneously since they are bilaterally represented processes in the brain. Thus the abilities that require exclusive mediation of the left hemisphere such as sentence comprehension, language formulation, speech production, and spelling improved only through proper treatment. However, the very nature of the patients’ aphasia should not be overlooked in this connection. Our patient as well as Hagen’s exhibited Broca type aphasia in which expressive abilities are severely limited with a fair preservation of comprehension. Thus the inherent difficulty in the patients’ expressive abilities has prevented spontaneous recovery in these modalities and improvement was possible only through treatment. Further investigation concerning the recovery process for different types of aphasia should follow. Another variable to be considered here might be the inherent differences in modalities themselves. Receptive processes such as auditory comprehension and simple visual comprehension can be stimulated unconsciously in the patient’s
166
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
daily living, while the recovery of expressive processes, i.e., speaking and writing, might require active and conscious effort on the part of the patient. These speculations need to be investigated further.
Conclusion The case presented in this study would seem to support the previous hypothesis on compound bilingual aphasia, i.e., the two languages the patient used were disturbed in the same way corresponding to the type of his aphasia. In addition, the results of the present study seem to offer the following conclusions as to the effect of language therapy in aphasia. 1. Auditory and reading comprehension improved similarly in the treated and the nontreated languages (English and Japanese, respectively). 2. Oral production and writing abilities revealed an increasing discrepancy between the treated and the nontreated languages, with the greater recovery rate for the treated than the nontreated language. 3. Although English and Japanese are linguistically quite different languages, certain aspects of both languages, such as phonology, recovered almost simultaneously. 4. The results of this study suggest that for this type of patient, certain language abilities such as oral production and writing may benefit proportionately more from appropriate treatment than auditory and reading comprehension. The authors are grateful to Mrs. Martha T. Sarno for her valuable comments and suggestions.
References Goldstein, K. Language and language disturbances. Hagen, C. Communication abilities in hemiplegia: Rehabil.,
1973,
New York: Grune & Stratton, 1948. effect of speech therapy. Arch. Phys.
Med.
54, 454-463.
Johns, D., Darley, F. Phonemic
variability
in apraxia of speech. J. Speech Hearing Res.,
1970, 13,
556583.
Lambert, W. E., Fillenbaum,
S. A pilot study of aphasia among bilinguals.
Can. J. Psychol.
1959,13,
28-34.
Osgood, C. E. , Miron, M. S. (Eds.). Approaches to the study of aphasia. Chicago: University of Illinois Press, 1963. Shankweiler, D., Harris, K. S. An experimental approach to the problem of articulation in aphasia. Cortex, 1966, 2, 277-292. Vignolo, L. A. Evolution of aphasia and language rehabilitation: a retrospective exploratory study. Cortex, 1964, 1,344-367. Weisenburg, T., McBride, K. E. Aphasia: a clinical and psychological study. New York: Hafner Press. 1935.
OF COMMUNICATION
DISORDERS
9 (1976),
157-166
THE RECOVERY PROCESS OF A BILINGUAL TOSHIKO S. WATAMORI
APHASIC
AND SUMIKO SASANUMA
Section of Communication Research, Tokyo Metropolitan Institute of Gerontology/Speech Pathology Services, The Yoikuin Tokyo Metropolitan Hospital, 35-2 Sakaecho, Itabashiku, Tokyo 173, Japan
The recovery process during the first year poststroke in an English-Japanese bilingual aphasic is analyzed with special emphasis on the effect of language therapy. The patient initially manifested equally severe impairment in both English and Japanese involving all language modalities with moderate impairment of reading and auditory comprehension and severe impairment of oral production and writing. Language therapy was conducted in English in a community where Japanese was the only language in the environment. In the course of language therapy, auditory and reading comprehension improved almost simultaneously in both English and Japanese. In contrast, oral language production and writing abilities improved markedly only for the treated language (English). The results are discussed in terms of their implication for the effect of language therapy on aphasia.
Introduction The study of bilingual aphasics has drawn much interest among investigators and a number of articles have been published on this subject (Weisenburg and McBride, 1935; Goldstein, 1948; Lambert and Fillenbaum, 1959). It has been pointed out by these investigators that the study of bilingual aphasics may provide valuable information as to the differential effects of spontaneous recovery and the effectiveness of language therapy. In other words, one should be able to make valid inferences on the effect of therapy by comparing the recovery pattern of the two languages of bilingual aphasics who receive language therapy in a hospital where one language is stressed (Osgood and Miron, 1963). Most reports on bilingual aphasics to date, however, are anecdotal and no detailed, longitudinal study has been found in the literature. The present investigation concerns the symptoms and the changes observed in an English-Japanese bilingual aphasic who preferred the English language for his therapy while living in a community where Japanese was the only language used. Case History The patient is a 65-year-old, right-handed businessman. He was born in California in 1908 to Japanese immigrant parents, and was brought up in a bilingual environment using Japanese at home and English in the community. He graduated from the University of California at Berkeley in 1930. Six years later he came to Japan to study at a Japanese university. He graduated from the university, married a native Japanese woman, and has since been living in Japan. After World 0 American
Elsevier Publishing
Company,
Inc.,
1976
157
158
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
War II he worked for an American firm and visited the U.S. several times every year until the onset of his illness. According to his wife he spoke perfect Japanese at home and had no trouble in handling the contemporary Japanese orthography although he seemed to prefer using English in reading and writing. In March 1973, immediately after his return from his visit to the U.S., the patient complained of a visual disturbance. A couple of days later, a speech disturbance appeared, which increased gradually for the next 10 days. He was diagnosed as having suffered a cerebral thrombosis. On April 22, 1973, the patient had a second attack and became totally speechless with only the residual utterance “So, so.” Neurological examination revealed no paralysis or paresis in either of his limbs, and no abnormalities of the arteries on the CAG. In June 1973,2 months after the onset, he was referred to the Speech Pathology Services of the Yoikuin Tokyo Metropolitan Hospital. Initial Test Findings The Porch Index of Communicative Ability (PICA) and selected subtests of the Minnesota Test for Differential Diagnosis of Aphasia (MTDDA) were administered in both English and Japanese in June, 1973. l For the purpose of differential diagnosis, a test of oral apraxia, articulation tests, an extensive naming test (100 words), and an audiometric examination were also administered. The results of these tests revealed severe aphasia of Broca type, with severe oral apraxia and verbal apraxia in both English and Japanese. As can be seen in Fig. 1., the degree of the impairment of one language is almost equal to that of the other across all modalities. No parietal signs were detected. On the basis of this initial evaluation, it was provisionally decided that the language therapy would be conducted in Japanese since he lived in Japan and his wife did not speak any English. After being in therapy for 2 weeks (four sessions), however, we inferred from the patient’s gestures that he felt he could not improve in Japanese and would like to work in English. His wife supported this idea too, and thus the therapy has since been conducted exclusively in English. Therapy
Program
The patient received 1-hr language therapy sessions in English twice a week for 3 months and then the number of sessions was increased to four times a week until June, 1974. The program of language therapy included auditory comprehension tasks (i.e., pointing to the pictures by name, writing phrases and sentences from dictation, and ‘The Japanese versions of these tests were carefully ence with the original.
constructed
so as to maintain maximum
equival-
THE RECOVERY
100
PROCESS
OF A BILINGUAL
159
APHASIC
r
Aud.
Read.
Oral Prod.
Writ.
Aud.
Read.
Oral Prod.
Writ’
Fig. 1. Results of initial and final evaluations on the four modalities of language. Initial evaluation (2 months post onset) is at the left, final evaluation (14 months post onset) is at the right. ., English; q, Japanese.
following verbal commands); reading comprehension tasks (i.e., matching words to pictures, and reading sentences and paragraphs); oral production task (i.e., imitation of words and greetings, naming of pictures, imitation of short phrases and sentences, spontaneous production of phrases and sentences to picture stimuli); and writing tasks (i.e., copying single words, writing words to pictures; writing words, phrases, and sentences from dictation; and spontaneous production of phrases and sentences). The tasks were graded in terms of difficulty. The stimulus words which appear in the language tests were carefully eliminated from the therapy materials.
Results In order to assess the recovery process of his linguistic impairment, the PICA and selected subtests of the MTDDA were administered periodically. The scoring of the PICA was somewhat altered so that the percentage of correct responses in each modality was calculated and combined with the MTDDA subtest results. The combined scores thus obtained were plotted on the graphs. The results of the initial and final evaluations (2 months and 14 months post onset, respectively) are shown in Fig. 1 in terms of each language modality for both English and Japanese. Figure 2 is a graphic representation of the differences between the initial and final test scores as shown in Fig. 1. Figures 3-a through 3-d represent the results of sequential subtests of each modality.
160
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
100 90
English
F
q
80 t
Aud.
Read.
Oral
Japanese
Writ.
Fig. 2. Differences in percentage between initial (2 months post onset) and final (14 months post onset) test scores on each modality in English and Japanese.
Auditory Process The tasks for the auditory process included pointing to objects by name and function, pointing to pictures spoken serially, listening comprehension of long paragraphs, and following commands. The results plotted in Fig. 3-a reveal that the two recovery curves, one for English and the other for Japanese, are quite similar. The treated language (i.e., English) shows slightly higher scores than the nontreated language (i.e., Japanese). After the fourth evaluation, 14 months post onset, the patient’s ability to understand simple, everyday conversation was judged to have reached a functional level in English as well as in Japanese, although he still exhibited difficulty following long complex material presented verbally in either language.
Reading Process
The tests of the reading process comprised matching words to pictures, following written commands, and reading comprehension of long paragraphs. As can be seen in Fig. 3-b, the recovery curves for the two languages are parallel, with the treated language consistently higher than the nontreated language (Fig. 3-b). At
OF A BILINGUAL
IOO-
u
;
40-
2 40
20-
z : a. 20
161
(b)
100
‘; 80 0 : o 600
w 8o !i L ;; 60
! 2
APHASIC
O-
2
Months
9 Post
Ol-L--GL--L-i14 2
14
Onset
Months
(cl
100
100
9 Post
Onset
(d)
r
II
8o iii
c
c
E
o 0
:
$ 600
60
0
8o
2 Months
6 Post
9 Onset
14 Months
Post
Fig. 3. Recovery curves across time: (a) auditory process; @) reading process; process; (d) writing process. l, English; q, Japanese.
Onset
(c) oral production
this moment, 20 months post onset, the patient still has some difficulty understanding long paragraphs in English although he is able to follow simple written commands. He is totally unable to read long paragraphs in Japanese. Oral Production
Process
The tasks included in the oral production process were the repetition of words, naming pictures and objects, supplying words in sentences, and describing the
162
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
function of presented objects. Oral production was found to be the most impaired process in this patient’s language ability, partly because he had severe verbal apraxia or apraxia of speech. The recovery curve of this process, as shown in Fig. 3-c, indicates an increasing discrepancy between the treated and the nontreated language through time. The discrepancies exhibited at both 9 and 14 months post onset indicate that he could occasionally respond with single words in a conversational situation in English, but was not able to do so in Japanese. Writing Process The tasks included in the writing process were writing words from dictation, writing words to pictures, and writing sentences describing the function of the presented objects. The patient was at first able to copy only geometric forms and a few words in both English and Japanese. The recovery profile of this process shown in Fig. 3-d indicates an even greater discrepancy between the two languages than was the case with oral production. After 12 months of therapy the patient was able to write 70% to 80% of high frequency words to picture stimuli and four- to five-word sentences from dictation in English. In contrast, his writing ability in Japanese stayed unchanged until 9 months post onset, but from then on the patient began to show an interesting recovery process. On the initial evaluation, his writings consisted of meaningless but legible KATAKANA (the Japanese syllabery) and it was almost 9 months after the onset that he first wrote KANJI (Chinese characters) in response to picture stimuli. KANJI characters at that time were accurate in configuration but wrong in the sense that they were not the target words themselves. On the fourth evaluation 14 months post onset, the patient for the first time could write correct words in KANJI in response to picture stimuli, which clearly indicated that he had fairly extensive knowledge of KANJI before his brain damage. Of interest was the fact that after the last evaluation (14 months post onset and 12 months in therapy) the patient started to exhibit a growing interest in the Japanese language. He began to work at home using picture and word cards written in Japanese that were given to him a year ago when the therapy was conducted in Japanese. This phenomenon might be interpreted to indicate that the patient’s general language ability per se has improved over the course of language therapy to such a level where he can now begin to take in a totally different type of language system. The therapy program was modified accordingly to incorporate Japanese as well as English after September, 1974. Discussion It appears that the present study of a bilingual aphasic patient provided an opportunity to observe some differential effects of spontaneous recovery versus
THE RECOVERY
PROCESS
OF A BILINGUAL
APHASIC
163
recovery with language therapy. The fact that the language therapy he received was consistently in English while living in an environment where Japanese was used exclusively has provided a unique setting where the extra-session linguistic stimuli in the treated language was absent. At the time of initial evaluation, the pattern as well as the degree of impairment of the two languages that he had used with equal proficiency before his brain damage were almost the same. This is in accordance with the previous findings on so-called “compound” bilingual aphasia (Lambert and Fillenbaum, 1959). A close observation of the changes in his linguistic abilities over the period of 14 months post onset, however, has demonstrated different recovery curves for English and Japanese, most possibly due to the language therapy given exclusively in English. That is to say, while the receptive processes such as auditory and reading comprehension improved similarly in both English and Japanese, the expressive processes such as speaking and writing showed a sizable recovery only in English with delayed and minor changes in Japanese. Spontaneous
Recovery
and Interaction
of Treated and Nontreated
Languages
It may not be appropriate to attribute whatever improvement was observed in the nontreated language in our patient wholly to spontaneous recovery or to environmental linguistic stimuli. There is a possibility that the treatment of one language might have facilitated the recovery of the nontreated language. If this is the case, it might by hypothesized that the stimulation of one language (English) could somehow have activated the brain, possibly the so-called speech area, which in turn has contributed to the improvement of the other language (Japanese). If this hypothesis is tenable, however, all the language modalities should have been benefited. As will be seen in Figs. 3-c and 3-d, however, this effect was not clearly observed in his expressive abilities, probably because of the very nature of his aphasic syndrome in which these expressive processes were most severely damaged. A further look into the test results on his expressive abilities, however, reveals some evidence of facilitation from one language to another. For instance, his phonological ability recovered almost simultaneously in English and in Japanese notwithstanding the wide difference between the two languages in terms of their phonological organizations. At the time of initial evaluation, the patient could not produce, or imitate, any phoneme other than /s/. According to the results of the articulation tests given periodically in English (Picture Articulation Test) as well as in Japanese (equivalent of English articulation test), however, his repertoire of phonemes increased rapidly in both languages. At the end of 6 months of therapy, the patient could produce upon imitation almost all the phonemes and syllables in isolation, although he made some inconsistent errors at word level. The percentage of phonemes correctly produced in words (the patient was allowed three trials per word) were calculated for both languages. Figure 4 illustrates the recovery
164
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
IOO90 -
c m 80
C 0 Q70 ; “, 60: = 50 0
40-
: 0
4 30c ‘, 20u, 2 IO-
3
6
Months
Post
Fig. 4. Percentage of correctly produced consonants English; q, Japanese.
9
14
Onset
that have features common to both languages.
l,
curves for consonants that have features common to both English and Japanese 0 .e., lpl, lbl, /ml, Id, Itl, Id/, Id, III, ItsI, Id z I, hd, Igl, ihl, and Ijl). It can be seen from the figure that the recovery for these phonemes occurred almost simultaneously in both languages. Types of phonemes, however, seemed to have had differential effect upon the recovery rate. It was noted that those phonemes that recovered comparatively well were ones that are unique to one or the other of the languages but are considered to be relatively easy for apraxics, i.e., lfl, Iwl, lrl, and lr$ for English (Johns and Darley, 1970); Ip I and lc#dfor Japanese. On the other hand, those phonemes that are considered to be “difficult” for apraxics, i.e., consonant blends in English (Shankweiler and Harris, 1966; Johns and Darley, 1970) and palatalized consonants in Japanese remained difficult for the patient to the end. Recovery
as a Function
of Language
Therapy
Previous investigators who studied the effect of language therapy versus spontaneous recovery in aphasia have reported the tendency of differential recoveries
THE RECOVERY
PROCESS
OF A BILINGUAL
APHASIC
165
according to the modalities of language. Vignolo (1964) studied 69 aphasic patients of whom 43 received and 27 did not receive speech therapy. He tested oral expression and auditory comprehension twice, with the minimal interval of 40 days, and pointed out that auditory comprehension improved more than oral expression during spontaneous evolution for the nontreated patients. Vignolo indicated that anarthria (verbal apraxia) had a negative influence on the recovery of expressive speech. This was in accordance with our patient who exhibited severe verbal apraxia. Reading and writing processes were not included in Vignolo’s study. Hagen (1973) studied the effect of treatment versus nontreatment with a group of 20 aphasics who had group III type of aphasia in Schuell’s classification, i.e., a diagnostic category that is essentially equivalent to Broca’s aphasia as is exhibited by the present patient. The results indicated that while both groups exhibited spontaneous recovery during the first 3 months of the program, only the treated group continued to progress beyond the point of spontaneous recovery to attain functional communication ability. The author further indicated that auditory comprehension and simple visual comprehension spontaneously recovered to a functional level for both treated and nontreated groups within 9 months post onset, while language formulation, speech production, reading, and spelling improved in a different fashion. That is, slight spontaneous improvement was observed for the nontreated group in the latter abilities up to 9 months post onset but did not recover to a functional level. Our findings in the present study are consistent with these results in that the expressive processes in the nontreated language (Japanese) did not show marked improvement. The reasons why the receptive aspect of language tends to spontaneously recover more have not been completely clarified. Hagen tried to explain the results from the standpoint of hemispheric dominance for each modality. According to the author’s interpretation, auditory comprehension and simple visual comprehension improved spontaneously since they are bilaterally represented processes in the brain. Thus the abilities that require exclusive mediation of the left hemisphere such as sentence comprehension, language formulation, speech production, and spelling improved only through proper treatment. However, the very nature of the patients’ aphasia should not be overlooked in this connection. Our patient as well as Hagen’s exhibited Broca type aphasia in which expressive abilities are severely limited with a fair preservation of comprehension. Thus the inherent difficulty in the patients’ expressive abilities has prevented spontaneous recovery in these modalities and improvement was possible only through treatment. Further investigation concerning the recovery process for different types of aphasia should follow. Another variable to be considered here might be the inherent differences in modalities themselves. Receptive processes such as auditory comprehension and simple visual comprehension can be stimulated unconsciously in the patient’s
166
TOSHIKO
S. WATAMORI
and SUMIKO
SASANUMA
daily living, while the recovery of expressive processes, i.e., speaking and writing, might require active and conscious effort on the part of the patient. These speculations need to be investigated further.
Conclusion The case presented in this study would seem to support the previous hypothesis on compound bilingual aphasia, i.e., the two languages the patient used were disturbed in the same way corresponding to the type of his aphasia. In addition, the results of the present study seem to offer the following conclusions as to the effect of language therapy in aphasia. 1. Auditory and reading comprehension improved similarly in the treated and the nontreated languages (English and Japanese, respectively). 2. Oral production and writing abilities revealed an increasing discrepancy between the treated and the nontreated languages, with the greater recovery rate for the treated than the nontreated language. 3. Although English and Japanese are linguistically quite different languages, certain aspects of both languages, such as phonology, recovered almost simultaneously. 4. The results of this study suggest that for this type of patient, certain language abilities such as oral production and writing may benefit proportionately more from appropriate treatment than auditory and reading comprehension. The authors are grateful to Mrs. Martha T. Sarno for her valuable comments and suggestions.
References Goldstein, K. Language and language disturbances. Hagen, C. Communication abilities in hemiplegia: Rehabil.,
1973,
New York: Grune & Stratton, 1948. effect of speech therapy. Arch. Phys.
Med.
54, 454-463.
Johns, D., Darley, F. Phonemic
variability
in apraxia of speech. J. Speech Hearing Res.,
1970, 13,
556583.
Lambert, W. E., Fillenbaum,
S. A pilot study of aphasia among bilinguals.
Can. J. Psychol.
1959,13,
28-34.
Osgood, C. E. , Miron, M. S. (Eds.). Approaches to the study of aphasia. Chicago: University of Illinois Press, 1963. Shankweiler, D., Harris, K. S. An experimental approach to the problem of articulation in aphasia. Cortex, 1966, 2, 277-292. Vignolo, L. A. Evolution of aphasia and language rehabilitation: a retrospective exploratory study. Cortex, 1964, 1,344-367. Weisenburg, T., McBride, K. E. Aphasia: a clinical and psychological study. New York: Hafner Press. 1935.
