RE-EDUCATION IN APHASIA: A REVIEW OF 70 CASES

THE problem of re-education in aphasia and kindred disorders has attracted the interest and challenged the skill of both neurologists and psychologists for the past fifty years. Among the earlier discussions of the subject, those of Mills (1904) and Froeschels (1914) are worthy of special mention. But it was only with the war of 1914-18 that the problem took on real practical urgency and large-scale explorations of the possibilities for re-education in aphasia were undertaken. This work was developed above all in Germany and is especially associated with the names of Poppelreuter, Isserlin, and Goldstein. Poppelreuter's work (1917) is, unfortunately, not available, but Isserlin (1941) has reported briefly on the work undertaken by Feuchtwanger at the Brain Injuries Institute in Munich. Of 178 cases of aphasia given re-educational treatment at this centre, complete recovery was reported in 10-1 per cent. , marked improvement in 25 3 per cent. , some improvement (partial recovery) in 55 6 per cent. , and no significant change in 9 per cent. The great majority of the cases were traumatic, and these gave consistently better results than the few cases in which the aphasia was due to cerebral disease. Thus, all the cases who recovered completely or showed marked improvement were traumatic, and the group of cases who recovered partially included only 8 cases whose aphasia was due to disease. On the other hand, 50 per cent. of the patients who showed no improvement were cases of aphasia due to cerebral disease. The outcome of the re-educational work undertaken by Goldstein and his colleagues has not been presented in quantitative form, but valuable records of the technique, course, and outcome of re-education in individual cases are available (Goldstein, 1919). Goldstein (1942) has more recently summed up his experience of the problems and methods of reeducation in a useful review. Other contributions to the German literature of this period worthy of mention are those of Froeschels (1915), Gutzmann (1916), and Reichmann and Reichau (1919). Retraining work with cases of aphasia in civil life has been described by a number of authors, but all this work has been on a very limited scale (Franz, 1924; Singer and Low, 1933; Weisenburg and McBride, 1935). Weisenburg and McBride, who stress the need for more extensive studies, have presented a useful review and discussion of the whole field in their book on Aphasia (1935, pp. 92100 ; 385-412). An objective appraisal of the outcome and value of re-education in aphasia is far from easy in view of the lack of controlled studies. We are seldom able to compare in a controlled manner the course and outcome of the disorder in two equated groups of patients of which only one group has been given formal re-education. In consequence, we possess no definite standards whereby to assess spontaneous recovery of cerebral function as opposed to the effects of re-education. This is a particular disadvantage in the study of traumatic cases in which, as is well-known, spontaneous recovery is to be expected much more frequently than in cases of cerebral disease. Nevertheless, there is a certain amount of indirect evidence in favour of re-education of the traumatic case. Thus Frazier and Ingham (1920), in a review of the effects of gunshot wounds of the head, mention 16 cases of residual aphasia in which re-educational treatment had been given. They conclude that " although we have seen no evidence of the development of new language centres on the normal side of the brain, improvement has been marked in every patient of this group, the aphasic symptoms of some of which had previously remained stationary for several months" (1920, pp. 31-2). We may also mention that one of Goldstein's war cases made little progress for 31 months after his injury, but considerable progress in the first two weeks of training which was then begun. In addition, there is evidence that re-education may appreciably hasten the natural course of recovery. Thus Weisenburg and McBride, in reviewing the outcome of re-training in their own cases, conclude that " re-education increases the rate of improvement and aids in overcoming specific disabilities and also in helping the patient to find new ways of achieving the results he is unable to achieve in a normal manner" (1935, p. 412). Lastly, all workers with practical experience agree as to the value of re-educational work for the aphasic patient's adjustment and morale. We shall present in this paper the principal 75 by coright.