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CRITICAL NOTICE

Aphasia and Kindred Disorders of Speech. By HENRY HEAD, M.D., LL.D. (Edin.), F.R.S. Cambridge University Press. 2 vols. Pp. xiv + 549,

xxxiii + 439. Price £3. 3s.

There is no topic in the whole range of medical science which brings neurology and psychology into such close contact as does the study of aphasia. It may indeed be due to this inescapable connection that the nature of the mental disturbances accompanying disorders of speech has not been accurately determined long ago; for the neurologists have often neglected their opportunities of making psychological observations in favour of premature attempts to correlate particular defects of speech with the cerebral lesions revealed after death. But the problem in disorders of speech is essentially a psychological one, and we are, even to-day, too far short of adequate knowledge of the cerebral correlates of mental activity to locate with precision the lesion producing any particular aphasic defect. Moreover, "before we can determine anatomically what parts of the brain are responsible for these manifestations, it is essential to discover the nature of the disorder itself" (1, p. 166).

This is the main lesson to be learnt from Sir Henry Head's great work on Aphasia and Kindred Disorders of Speech. Putting aside all a priori classifications of aphasia, based upon what he believes to be false notions about the nature of speech and its relation to thought, Head sets himself to find out what exactly are the psychological phenomena that may be observed when cerebral lesion is accompanied by disorder of speech. In this investigation he introduces new tests, unthought of by earlier observers, some of which embody certain principles derived from his experimental work in other departments of neurology. His researches on sensation had emphasized the want of constancy in response produced by injuries of the sensory cortex, and the need for graduating the tests employed if the finer shades of defective functioning are to be detected. When tests based upon these principles were applied systematically in suitable examples of aphasia and amnesia, Head found that "the results did not correspond with any known classification and showed that these affections of speech belonged to an order different from any previously described" (1, p. 385). He maintains that defects in the use of language cannot be classed under such physiological categories as motor and sensory, or under such headings as visual and auditory; "for the use of language is based on integrated functions, standing higher in the neural hierarchy than motion or sensation" (1, p. 203).

From this point of view speech is a complex mode of behaviour and aphasic disturbances are manifestations of the ways in which a progressive act may be interfered with. Head groups the functions affected in disorders of language under the general heading "Symbolic formulation and expression"; and by this he means a mode of behaviour "in which some verbal or other symbol plays a part between the initiation and execution of the act" (1, p. 211). Words are the most common symbols used in thinking, and defects of symbolic formulation and expression are chiefly shown in disorders of speech; but Head thinks his observations show that an organic lesion can disturb the power of formulating, without words, the general aim or intention of an act.

Defects of symbolic formulation and expression are not rightly designated by terms which imply that speech disorder reveals the elements out of which speech processes are built up. The old division of aphasic disorders into motor and sensory forms-aphemia and agraphia, word-deafness and wordblindness are abandoned. We are now offered terms which express the aspects of symbolic formulation and expression most prominently affected: verbal aphasia, syntactical aphasia, nominal aphasia and semantic aphasia. Yet in their main features the forms of aphasia described by Head under these designations, with the exception of the last, correspond very closely to the classical forms. Verbal aphasia resembles 'motor' aphasia; syntactical aphasia is a form of 'sensory' aphasia-jargon aphasia or the 'agrammatism of Pick; nominal aphasia is characterized chiefly by amnesia verbalis'; semantic aphasia must be regarded as a nev. variety of aphasia, if indeed it is rightly classed in this category at all. It consists in a disturbance or failure of comprehension of the significance of words and phrases as a whole: "Semantic defects are manifested mainly in want of ability to appreciate and retain the ultimate significance or intention of words and phrases combined in normal sequence" (1, p. 261).

Only when we bear in mind the history of the growth of our knowledge of aphasia, and recall the changes that have come over our notions of cerebral localization, are we able to appreciate fully the importance of the studies set forth in these two volumes, and the novelty and significance of the conclusions arrived at. An excellent historical back-ground is provided in part 1, vol. I, which, though admittedly not unprejudiced, leaves out nothing of importance in the light of Head's own observations. Yet for those who do not accept Head's views there are certain aspects of the subject and several matters of dispute which receive but scant attention both in the historical section and in the body of the work.

The older views on aphasia, in so far as they were influenced by the older views on localization of function, come in for somewhat severe treatment at Head's hands; and to some it may seem that an undue amount of scorn is cast upon those writers who tried to simplify the exposition of their views on aphasia by the construction of diagrams. It seems to be implied throughout that those who believed in cortical "centres" for speech regarded them as consisting of dispositions of cells, restricted to definite, circumscribed, positions in the cortex and having fixed and invariable functions. But the term 'centre' has often been applied to diffuse arrangements of cells, so long as they are functionally associated in the initiation of movements and sensations or in the revival of mental images. Bastian, for example, declared that he was not a believer in the complete topographical distinctness of the several sensory centres in the cerebral cortex. Nevertheless he considered it clear that there must be certain sets of structurally related cell and fibre mechanisms in the cortex whose activity is associated with one or with another of the several kinds of sensory endowment. "Such diffuse, but functionally unified nervous networks," he said, "may differ altogether from the common conception of a neatly defined 'centre,' and yet for the sake of brevity it is convenient to retain this word and refer to such networks as so many centres1."

But it is in the supposed determinateness of the response elicited from a centre, rather than in the restriction of the centre to a definite spot or area of the brain, that the older views of cerebral localization, and the views of the 1 Bastian, Aphasia and other Speech Defects, p. 14.