Ncuropsychologia,1971,Vol.9, pp. ll9 to 14O. Pcrgamon Press.

Printod in Engtancl

B E H A V I O R A LS T U D I E SO F A P H A S I A :
M E T H O D SO F I N V E S T I G A T I O NAND ANALYSIS*

M. SrolrnN, L. T. SrotnARD, J. P. MoHn and J. LEICESTER

JosephP. Kennedy,
NeurologyService,
Laboratory,
Behavior Jr. MemorialLaboratories
GeneralHospital,Boston,Massachusetts
Massachusetts 02114,U.S.A.
(Received26 October 7970)

Abstract-Methods for testingand analyzingbehavioraldeficitsin aphasiawerederivedfrom

a functionalanalysisof stimulus-response relations(the stimuluscontrol of behavior).Deficits
were classifiedas breakdownsof controlling stimulus-responserelations, and profiles of
deficientand intact performancesin a severelyaphasicpatient illustratedthe fruitfulnessof
the methods. A distinction betweenidentity and nonidentity tasks emergedfrom the data,
cutting acrossthe differentresponses, stimulusmodalities,and stimulusmaterials. Separate
examinationof thesetwo types of tasks made possiblea finer classificationof the patient's
deficitsinto input, output, or relationalcatcgories,and eachof theseinto specifictypes. The
dataalsodemonstratedthat repeatedtestingovera prolongedtime may revealchangesin deficit
classificationthat would have beenunsuspected on the basisof early testsonly.

INTRODUCTION
Apuasla, despiteits clinical prominenceand vast literature,has achievedonly rudimentary
agreementon methodsfor examiningpatientsand classifyingtheir deficits. One sourceof
confusion,stressedby JecxsoN!], has beenthe uncriticalmixing of psychologicand phsio-
logic or anatomic concepts. This distinction has, unfortunately, led some workers to advo-
cate the primacy of one or the other method of classification. BnelN [2] has provided an
excellenthistory of the controversy.
Although the psychology-physiologydistinction is valid, the problem is not to determine
which is primary. Observedaphasicdeficitsare behavioral, but they result from anatomical
lesionsand derangedphysiology. Correlations of lesionswith behavioral deficits, however,
will be exercisesin futility if either set of observationsis improperly controlled or has no
consistent classificatory schemeof its own. The behavioral examination and classification
must be at least as rigorous as the physiologic and anatomic if the correlation is to be
meaningful.
This paper describesbehavioral techniquesfor examining, analyzing and classifying
certain aphasic deficits, illustrating the methods through a relatively comprehensiveexa-
rnination of one patient. Two basic behavioral concepts,reinforcement and stimulus
control, underlie the methodology.
Reinforcement
A powerful ernpiricalprincipleis that consequences governbehavior. Behavioris likely
to recur if it producesreinforcingconsequenccs (for example,food); behavior that con-

Reprint requeststo Neurology Research,Massachusetts General Hospital, Boston, Massachusetts,

021l4 (Dr. Sidman).
+ This investigationwas supportedby researchgrant NS 03535fron-rthc National Institute of Neuro-
logicalDiseases and Stroke. Miss Martha Willson, Miss Cynthia Rose,and Mr. Richard Schneiderassisted
technically.

l19
n0 M. SrrvrtN.[,. T. Srrrr>r>arrn..l.
P. Morrn ancl.1.l-r,rcr,slrrr

s i s t c n t lpy r o d u c e ns o r c i n f o l o c l n c nwt i l l n o t c h a u g c( n o l c a r n i n g )o, r w i l l d c c l i n e .T y p i c a l l y .

a r e s p o n s oi s c o n t r o l l e db y s e v e r a cl o n s e q u e u c e e s ,i l c h w i t h i t s o w n n t o t l u l a t i r r gf a c t o r s
( d e p r i v a t i o nI,e s i o n se, t c . ) .
H u m a n b e h a v i o ro f t e n p r o d u c e si n t e r m e d i a t ec o n s e q u e n c el isk e n l o n e y . T h e i n t e r -
nrediatecollsequenceis a common element in bel.ravioralpathways to many different
reinforcers.A personmay be satiatedwith food, drink, and sex, yet nloney will remain a
controlling consequencebecauseit can still lead to various comforts, amuseillents,etc.
Because their reinforcingeffectiveness doesnot dependcompletelyon any singlemodulating
factor, behavioral consequenceslike money are called generalizedreinlbrcers [3, 4].
One may reasonablyquestion the validity of teststhat fail to provide reinforcersfor
the patient. Personalsatisfactionor the examiner'sapprovalmay suffice,but many patients
merelygo through the motions or even react to testswith disdain. To avoid this problem.
we provided immediategeneralizedreinforcement,money, for eachof the patient'scorrect
responses.
CrscuwrNo [5] relateddisturbancesof higher function in animalsto lesionswhich des-
troy the controlling relation betweenstimuli and reinforcement. He noted, however,that,
". . . the types of sensory-rhinencephalic linkages seen in subhuman primates are less
common in man . . ." ([5], p. 269). A reasonmay be the pervasiveness of generalizedrein-
forcersin the control of human behavior. [f a lesiondestroysthe relationbetweenbehavior
and a particular reinforcer,generalizedreinforcerswill remain effectiveand behavior may
seem undisturbed. The breakdown of relations between behavior and generalizedre-
inforcersis a separatecategoryofdeficit [6], and although not involved in the presentstudy
must have a place in any comprehensiveclassification.

Stimulus control
A responseusuallyproducesreinforcementonly when a particular stimulus is present.
Receptororientation and the lessclearly definedprocessesof selectiveattention determine
which elementsof complex stimuli exert behavioralcontrol. The role of selectiveattention
in behavioral deficit will be clarified in this report.
The patient's experiencewith the stimulus-responserelations being studied, physical
and social featuresof the test environment,and the instructionshe receiveswill influence
his performancethroughout the examination. Such factors modulate stimulus control [7].
Automated test proceduresand immediatereinforcementof the patient's correct responses
give him reliable nonverbal instruction about the adequacyof his performance,and help
circumventhis particular social and educationalbackground.
Since a modulating factor controls many stimulus-responserelations, a diseasethat
changesthe influenceof such factors will causewidespreaddeficits in stimulus control.
Similarly,if reinforcementis no longer effective,deficitswill be widespread.To distinguish
a generalstimulus-cor.rtrol deficitfrorn a breakdownof the response-reinforcementrelation,
the examinermust demonstratethat the reinforcer he is using is still effective. Also, the
generalstimulus*controldeficit must be classifiedseparatelyfrom breakdownsconfined to
restricted stimulus-responserelations.
Stimulus-responserelations have arrother critical characteristic: a single stimulus
controls many responses;a single responseis controlled by many stimuli. Diseaseneed
not break down all relationsin which a particular stimulus or responseparticipates. For
example, S may be a printed word that controls oral reading (S-Rr), copying (S-Rz),
and pointing to a picture (S-Rt. A cerebrallesionthat destroysS-Rr but leavesthe other
 AND ANALYSIS lzl
IIEIIAVTORAL SfUl)tES OI APHASIA: Mt'l'tlODS OF INVIS-TIGATION

word without knowing

S*R relationsintact rs often said to leavethe patient able to read the
its significance.If the lesion leavesS-R3 intact but destroys the other S-R relations,we
of stimuli and responses:
have Broca's aphasia. The cleficitmay involve broader classes
he hears them' or his only
the patient may respondnormally to printed words but fail when
deficiencymay be oral speechin responseto all stimuli'
define aphasias
Not all classificationsmake the same distinctions, but they inevitably
are deficient
and agnosiasby sensemodalities, stimuli, and responses;the basic observations
stimulus-resPonse relations.
by different
Different stimuli, responses,and stimulus-responserelations may be affected
To clarify the factors
variables, and in quantitatively different ways by the samevariables'
constant' maintain
responsible for such variabiliiy, tests must hold modulating variables
patient, and response
stimulus constancy while varying the responsesrequired of the
that differ in their
constancywhile varying stimuli. To compare stimulus-responserelations
ls contrary to elementary scientific good sense' It is meaningful
stimuli and responses
only under rp""iul circumstances to compare S1-R1 with S2-R2; rather, the comparison
should be S,_p, vs' S1-R2 or S2_R1. This principle will be elaborated.

METHODS
roomandfaceda squarematrix-ofninetranslucent windows'each
Thepatientsatin a sound-resistant matching'
Jquur.. H" performedfour typesof tasks: simultineous delayed
matching-to-sample,
Z in"t es . named in writing
naming. The to
stimuli be named
matched, or
orally,
oJ na-lng, andwritien<oip.Lt"Ol
werepresented throughvision,hearing,or touch'
Si multaneousmatt hi ng-to-sample
was projected onto the
visual-visualmatching (visual sampleantl visual choices). A sample stimulus
window, stimuli (choices)
center window of tt" mui.i* 1Flg. r-A). When the patient pressedthe center
correspondedto
ttre outer windows (-pig.t-n). He was then to pressthe outer window that
"pp."..J." lf he chose correctly,'chimes rang.and a nickel was automatically delivered. Incorrectresponses
ifiir".pf
darkened; 1.5 sec
p.oOu..O".neither chimesno. niik.l. Immediatelyafter each choicethe windows were
later a new sampleaPPeared'
Auditory-visualmatching(auditorysantpleandvisualchoices). Auditorysampleswerewords:thespoken
used as visual stimuli'
equivalentsof the pictures,'.irf"it, nurnbers,objects,letters,and words that were
onceevery2 seconds',-The
A mastertape read ttre woid onto a tape loop wirich repeatedit approximately.
patien-t'stask was: pressthe blank
centerwindow, although illuminated,containedno visual sample' The
center window to producevisual choices; then, press the outer window that had a visual stimulus corres-
choicesneither'
ponding to the auditory sample. Correct choicesproducedchimesand nickel; incorrect
1'5 sec later a new auditory
After a choice,repetitionoi the auditory sampleceaied,windowsdarkened,and
samplebeganthe next trial.
small common objects,
Tactile-visualmatching(tactile sampleantl visual choices).Tactile sampleswere
in. t'ign; upper-case, 2 in. hieh), or plasticdigits (2 in' high)' By placing his
plasticlettersllower-case,i.)l
being able to seethem.
tand into a box belowtt *inao* --utii*iir. patientcould feelthe sampleswithout
The centerwindow was dark, " but visualchoicls wereexposedwhile thapatient palpatedthe sample. After
withdrawn and a new one
he presseda visualchoice,pilducing chimesand nickelif correct,the samplewas
inserted.
D eIayed matching'to-samPIc
the sample (Figs'
The sample disappearedbefore choicesappeared;the patient had to remember
e). li tne sa.ple *u, visual, the center-window darkened when the patient pressedit' Auditory
l-C, rt,
pressedthe blank center window
sampleshad to occur at least once and then ceasedwhen the patient
and pressedthe blank
Tactile sampleswereremovedas soonas the patientcompletedhis tactileexploration
centerwindow.
Choicesat first appearedimmediatelyupon disappearance of the-sample(zero-delay)'Each time the
patie;t chosecorrectly,a ionger delay was inierposedbetweenremoval of the next sampleand appearance
patient'saccuracyadjusted
ofchoices. Ifhe madeun..rJ., a shorterdelayintervenedon the next trial. The
 122 M < l t t t ra n d . 1 .l , , rt c l s r r , H

S I M U L T A N E O U SM A T C H I N G

C ( D EL A Y ) E
D E L A Y E DM A T C H I N G

Ftc. l. Examplesof the windowmatrix duringsucccssive

stagesof simulteanous
and clelaycd
matching-to-sample.Sectext.

the time over which he had to rememberthe samplc,the dclay increasingor decreasingin 4-secsteps (ad-
justing delay).
No stimuli were testedin delayedmatchingunlessthe patient achievedat least?5 per cent correct on
simultaneousmatching. A delay test endedwhen he chosecorrectly after a 40-secdelay or completedthc
test set without passing40 seconds.
Oral nanting
The patient had simply to say aloud the name of the sample. Free to say as many namesas he wished,
he had to indicatewhen he wasfinished. The final namewastakenas his response.lfthe patientnamed the
samplecorrectly,the examinerpresseda button which soundedthe chimesand delivereda nickel. After
incorrectresponses,the only consequence was presentationof the next sample.
Written narning
The patient had to write or print the name of the sample. He had a new pieceof paperfor each trial;
previously-writtennameswerenevervisibleto him. If he wrote more than one, the first wasrecordedas his
responseunlesshe crossedit out. When the patient handecthe paper to the examiner,reinforcementand
samplechangingproceededas in oral naming.
Stimulus materials
Sampleand choicestimuliappearin Appcndix1. With rcpeatcdtcsts,a systen"ratic rotation through
f o t l r t o s i x e q u i v a l c n t s e t s o f e a c h t y p c p r c v e n t e d t h e p a t i c n t f r o m l e a r n i n g d i s p l a y c o n f i gi rur real et ivoannst,
displayfcaturcs,and sequences of choiccsor window positions,all of which would havepermiltedhim to
achievehigh scoreswithout observingthc samples.
Most setshad 20 trials;somchad 18. To conserve timc, a testendedaftertcn trialsif morc than scvcn
or lessthan three were correct. Number and sequenceof testsper session,examiner, ancl time betwcer.r
sessionsvaried. The final task of a sessionwas usuallyone which the patient normally did well, providing
a control for fatigue,bordeom,discouragement, or satiation. A poor scorewasreportedonly if a good per-
formancewas obtainedon a differenttask later in the session,or if the poor performancerecurredduring an
adequatelycontrolledsession.
Summaryof procedures
ln Fig. 2, items in boxesare observable,controllable,and measurable.Unboxed items are intervening
events,to be consideredlater. Samples,at the left, provideciinitial input to the patient in any of three mo-
dalities; vision, hearing,or touch; he processedsamplesaccordingto the demandsof eachtask. In simul-
taneousmatching(top line), pressingthe samplewindow exposeda secondset of input stimuli, the choices;
the final responsein the sequencewas to pressa choicewindow. Delayedmatching (secondline) had the
sameinitial inpr.rtand final output as simultaneousrnatching,but the delayintervenedbetweensamplepress
and appearanceof choices;choicesappearedwithout the sample. Naming and writing (lines3 and 4) had
 AND ANALYSIS
OF INVI]STICA'TION
OF APTIASIA:METHODS
STUDII]S I23
I]F,IIAVIORAL

paticnt prodtrcctlauditory or visual

t l r c s a m c i n i t i i t l i t r p u t a s r l l a t c l r i n g ; t h c n a r . r r cs p o k c n o r w r i t t c n b y t h c
Itctlbrtck .
fclt all tactilc stirnuli with
l l c c a u s c o l ' o u r p a t l c p t ' s r i g h t h c n r i p a r c s i s ,h c w r o t c , p r c s s c r lw i n d o w s , a r r d
his lcft hand.

lq!;a7yg - . - . .S 7 s l 1 Y q 6 l ,
romplc atPCfr ol
to6ptc &
\\ romple

S 1q l6yq6l
95;s1y g-...--.-..*
choiccs orpccl ol

5vir. -T

Frc. 2. Summaryof tcst procedures.Seetext.

RESULTS AND ANALYTIC METHODS

'fhe
patient'sclinical descriptionis in Appenclix2' Tcst scoresfronl a 3l-week series
simplicity
will be exanined first rvith responsesconstant ancl sanple stimtrli varying. The
(normal nicldlc-classchildren perfornr nearly perfectly after the first grade)'
ol the tasks
ancl probabilities based ou the nunlber of choice stimuli availableon each matching-to-
scores:
sampletrial led to the following conservativescalefor quick evaluationof the
performance'
Lessthan 30 per cenr correct: Definitely deficient. In the range of chance
30 to 70 per (ent corre(:t: Definitely deficient, but better-than-chanceperformance'
75 to 100per cent correct: Satisfactory performance'
Delayed matclting: Failure to pass 40-secis a deficit'

Sample input raricd: resPottseoulpul constant

demonstrate
Initiot delicits and subsequentlime course. Different recovery courseswill
performances on different materials' Even
the need for caution in comparing a patient's
invalidate comparisons of tests given at
wjth stimuli held constant,temporal changemay
in tertns of relative rates of change'
cliffercnttimes. Therefore, we evaluated the test results
showsthe
F-igure3 is a prototype of those which follow' Each frame on the left side
patienfs scoresfor o giu.n response: matching, naming, or writing single letters' Tasks
presentation on each Gurve'
are iclentifieclwithil each frame, rnoclalityof sarnple-letter
delayed
Scorcsfor simultaneousmatching, naming, and writing are per cent Gorrect;for
No test was gi'v'enevery week: a
matching, the longestclclaythe patient passedcorrectly.
the test was only given once'
rnodality label for a singleunconnectedpoint rneans
and
Early clcficitsintproved gradually but unevenly,as in simultaneoustactile-visual
letters (visual-naming and tactile-
auclitory-visualrnatching, naming visual and tactile
(repeating
naniing),ancldelayedvisual-visualanil tactile-visualmatching' Auditory-naming
6 and7, were nearly perfect'
the aurlitory sample)and all writing, first testedin weeks
deficits,
Cl' the right sicleof Fig. 3 are tlre patient'sscoresfor testswith trigrams. Initial
sinrilarto singleletters,werc more severeand longer lasting'
t24 L. T. SroonrnD. J. P. MoHR and J. Lucrsrrn
M. STDMAN.

IRTGRAMS
SINGLEI,EIIERS

..:
(, 2

oud

WRIIING
(,
z
'- .at{
t, ' 'i t \ -- l)
-/\+ J'--:'.- ---=l
a r. - - - --- arA --'--
NAMINE
A , | 7-----'-
,,-}-'(,.. t"''y-*--'-.-----..
'v ---'----:
z i ---';;:rr
o NAMING ,, --.-.A(.'---
o

iJ

G
E
o
I V oud
5lM.
MAICHING

| 3 5 . 7 9 t 1 1 3 1 5 1 7 1 9 2 1 2 3 2 5 2 7 2 9 3 31 . 5t 7 9 1 1 1 3 1 5 t ? 1 9 2 1 2253 27 29 3'l
WEXS WEEKS

Frc. 3. Test scores as a function of time; singleJetter and trigram materials. Week I was
actually the third week post stroke.

"Identity" and"nonidentity" tasks. Simultaneousvisual-visualmatching of letters is an

"identity" task; sanple letter and correct choice are exactly the same. The patient can
match a letter without recognizing it as a letter, even without having seen it before. The
same considerationsapply to numbers, words, colors, and objects.
So long as the patient can discriminate and match any physical stimulus aspect, for
example, shape,area, or angularity, he need have no behavior uniquely common to a parti-
cular sample and choice. He cannot, however, match a letter seento a letter heard without
having learned names or other responsesthat are uniquely common to a particular visual
letter and its auditory counterpart; auditory-visual matching is "nonidentity."
Tactile-visual matching may be a second type of identity task. Having learned that
tactile and visual stimuli, although physically different, may be equivalent, the patient can
match a tactile to a visual letter without having experiencedthe letter before in either
modality.
Certain naning and writing tasksconstituteadditional identity classes.For example,
auditory-naming may involve only repetition. A patient who can imitate sounds will be
able to name a dictated letter he has neither heard nor spoken before. He may also copy
 MI'THODS OF INVES'II(;AI'ION ANI) ANALYSIS 125
AIlIIAVIORAL SI'UDI!,S OI. APHASIA:

an
a visual letter without having seeuor written it before. Tactile-writingmay also be
identity task; a patient who can draw tactilesamples1nayGopy a tactile letter he has never
felt or written before.
B y c o n t r a s t ,t h e p a t i e n tc o u l d n o t d o n o n i d c n t i t yt a s k sb y i m i l a t i o n ,c o p y i n g ,o r f o r m
in this
equivalen"e,but only by virtue of learnednediating responses'Nonidentity tasks
study were: all auditory-visual matching, visual-naming,tactile-naming' and auditory-
writing; visual matching of words with pictures,words with colors, words with numbers,
a n d n u m b e r sw i t h d o t s .
We believethat delayed matching. even of identity tnaterials,is a nonidentity task'
In delayedmatching, sampleand choice are neveravailablefor simultaneousGomparison;
the
the patient nrust respondto the samplewith sorre behaviorthat permits him to bridge
delay. Two observationswould be consistentwith the interpretation of delayedmatching
task is
as a nonidentity task: a breakclownin the patient'sperformancewhen an identity
of improvenlent in
changedfrom simultaneous to delayedmatch ing ; different relative rates
simultaueousarrd delayednratching.
We shall now documentthe validity of the identity-nonidentitydistinctionby showing
that:
A. Within eachresponsecategoryidentity tasksimprovednrore rapidly than, or along
with nonidentity tasks, but never nore slowly. All materials but one demonstratedthis
sequence.
to
B. The patient's performatrceoften broke down upon a changefront simultaneous
delayedmatching,in identity as well as nonidentity tasks'
b. Oelayed-matching tasks did not always improve in the sarne temporal sequenc
as the correspondingsimultaneousidentity-matchingtasks'
In Fig. 3, identity tasks have larger data points and solid lines. Within each response
category, identity performances inrproved n-rostrapidly, although all single-letterwriting
taski *Lre approximately the same when first tested. In simultaneousmatching, the trends
third,
of improvement were: first, visual-visualidentity; second,tactile-visualidentity;
naming (repeating) came. first'
auditory-visualnonidentity. In naming, auditory identity
then tactile and visual nonidentity. Differentialwriting trends appeared only in the trigram
data; the order was like simultaneousmatching.
Although the patient scored 75 per cent or better on simultaneousmatching, delays
single
causedall his good performances to break down, exceptauditory-visual matching of
matching was the reverse of
letters. The order of improvenrentin delayed single-letter
also lagged behind delayed
simultaneousmatching. Delayedvisual-visualtrigram matching
tactile-visualmatching; delayedauditory-visualmatchingwas not tested,sincesimultaneous
rnatchingwas nevergood.
The left side of Fig. 4 shows the trends when the patient matched, named, or wrote
and
3-letter words. There ivere two types of visual samples,3-letter words and pictures,
patient (aud. sp.), or pronounced
two types of auclitory samples,3Jetter words spelledto the
(' a u d .p r . ) .
Alain, identity tasks improved first. In matching and writing, the patient improved
rnostrapidly in responseto visual and tactileword samples;next, to pronouncedor spelled
was
samples;and last, to pictures. The identity naming task, repeatingpronouncedwords,
(testedrelatively late)'
.head of all nonidentity naming exceptpronouncing spelledwords
All rnatchingbroke clown during the early delay tests' Delayed matching did not clearly
prescrvethe identityon-nidentityrecoverysequence.
t26 M. SrnveN,L. T Stooo,rno J. P. Mosn and J. Lncrsrrn

WoRDs
3-[ErlER cotol NAMES
tr'
fl
-: l.
U t \ :
, \.L
Ylr , / \
t l / ) ''\oud(pr.)
1--.-,i-\-J.
o DEI-M
. ATCHING

W RI I I N G

.-. -:_._.
(, WRIIING

z
, oud
I ('f)
1,1i'{ / - .
E
B Prct. a r I

-!-.-.-, +..!' "t ,i'-::'- ..//,.'

_l ,./'-.-.-1.\.\
"r, .---_... . ..-t.'
z vir. i ,; -'t/'
j'
o
A
color,'
t'-'!
i.t xAMTNG
g
SI^'I.MAICHING
(J

a
B /-6 \ -rY', r"
o
,ilt ; ;u's.l

r 3 5 7 e 1 1B J i r r * f 2 1 2 3 2 5 2 7 2 e 3 111 3
3 5
5 7 9 t1 l1 1
7 e 13t5
5 11 771s9129122 1t 22 5t 2 5
7 22 97t21 e t 1
WEEKS

Ftc. 4. Testscores
asa functionof time;responses
involving3-letterwordsandcolornames.

Performancesin the right side of Fig. 4 involved color names in the responses. Colors
or color names provided the input. The only identity tasks administered,auditory-naming
and visual-writing of color-name samples,improved earlier than or along with nonidentity
naming and writing. The matching tasks,both nonidentity, broke down when delay was
introduced.
'On
the left side of Fig. 5 are trends for word-pictureand picture-picturematching.
Sampleswere the samepicturesand visual,tactile,spelled,or pronounced3letter words as
in Fig. 4. The only identity task, simultaneouspicture-picturematching,was ahead of trll
the others,but did not break down in delayedmatching.
Colors were choicesin the matohingtasks on the right side of Fig. 5. Sampleswere
colors and visual or auditory color names. Simultaneouscolor-color identity matching,
perfect in the first test, broke down when delay was introduced. Ratesof improvementin
delayedand simultaneousmatchingfollowed a similar sequence.
The patient'sscoreson sayingand writing the namesof picturesand colors, not sho\4'r1
in Fig. 5, were included in Fig. 4.
Figure 6 summarizestests in which sampleswere visual or tactile digits, visual or
auditory digit names,and visual or tactile dots. The dots varied in pattern but corresponded
 tsEHAVIORAL STUDIES()F' APHASIA: MF,THODSOF INVES'I'IGAI'ION ANI) ANAI,YSIS t27

,:
L'

asd.v.z,'\-----',/
(P'. ) oud.w. {
(rP.)
o D E T .M A I C H I N G

vir Picl. 5tM.MATC}.IING vir. col

. . -.t
z - '' \'.
';/r,''
oud
t t
l: ! lx .,'
. z
. . B
d._ col. no.
5IM. MATCHING
6 v
e
.t 3 5 7 9 11 13151719212325272931 1 3 5 7 9 1r 13151719212t25272931
WEEKS WEEKS

Frc. 5. Test scores as a function of time; matching-to-sample with pictttres and color choices.

DOTS
DIGII NAMTS
o"d
" "
d '
---.:.,' dis :
f:
i=-::*_------_-_ -. :-;i-;:t't- aig;-]ti'
. i
roc.di9.- j
j . . i\ /' D E ! .M A T c H I N G

ais
i "),,',.
Dt. MATcHTNG

(,
7

o
NAMING

vir.dolr
/loc.di9
rr.or9.\.r!-+.+

o
'r'i;
/rl, :7
\to..dis SIM. MAICIIING

SIM. MATCI{IXG MAICHING

| 3 5 ? 9 1 11 3 1 5 1 7 1 9 2 1 2 3 2 5 7 7 2 9 3 11 3 5 7 9 Itt3't517 t9 1 3 5 t 9 fi 't3151719
WTIKS WEEXS WEE(S

Frc. (r. Test scores as a fLtnction of time; responses involving digit names, digits, and dots
l2tt M . S t t > u r w , L . T . S r o l r t > a n t r ,J . l ' . M o H t l a n d J . L E l c F . s l T R

i n q u a n t i t y t o t h c a l t p r o p r i a t cd i g i t . l n t c s t si n v o l v i l t gd i g i t t t a n r c si t s r c s p ( ) l l s c(sl e l i s i t l c
o f F i g . 6 ) , t h c o n l y i d e n t i t y t a s k g i v c n w a s a u d i t o l y - n a n r i n g( r e p c t i l i o no l ' c l i c l a t c dd i g i t
n a m e s ) .W l r e nt e s t e d t, h i s w a sa b o v eo r e q u a lt o n o n i d e n t i t yn a n i n g . S i m u l l a n e o um s atch-
ing tasks,all nonidentity, were perfornled well in their first tests and all broke down when
delay was introduced.
In the center column, responsesinvolved digits rather than digit natlles. All writing
was performedwell when first tested. Identity matching of visual digits, perfectin the first
week,broke down in delay. Tactile-visualmatchingwas considerablyweakerthan auditory-
visual in the secondweek, the only instancein which an identity task fell behind a non-
identity task involving the samechoicestimuli.
The third column shows trends for nonidentity rnatchingof digit samplesto the ap-
propriate numbersof visual dots.
Samplesin Figs.7 and 8 werecomnlon objects,seenor palpated,or their spokennalnes.
The only identity task in Fig. 7, auditory-naming(repeating),ranked ahead of nonidentity
namins.

O B J E C IN A M E S

z
U
E

u
e
t
o
U
| 3 5 7 9 1113151719212321272931
WEKS

involvingobjectnames'
Frr;.7. Testscoresasa functionof time; responses

In Fig. 8, visual and tactile object and spoken object-namesampleswere nlatched to

pictures of the actual objects, projected in color and shadowed to give 3-dimensional
effects. Simultaneousvisual-visualand tactile-visualidentity matching inrproved beforc
a u d i t o r y - v i s u anl o n i d e n t i t ym a t c h i n g . O n l y t h e n o n i d e n l i l yt a s k b r o k e c l o w ni n c l e l a y a, n d
relativetrends within delayedand simultaneousmatchingwere similar.
Additionql fndings ronsistent v,ilh the identity-nonidentity distint'Iittn. Single-letter
matching in Fig. 3 had lower-casesamplesand choices. Tactile-visualtests in which the
patient had to match upper-casesample letters to lower-casechoicesreturned to normal
4 to 6 weekslater than the correspondingperformancesof Fig. 3.
Although many upper-caseletters have essentiallythe same shapeas their lower-case
counterparts,some pairs are quite dissirnilar,the most obviousbeing: A-a, B-b, D-d, E-e,
G-g, H-h, N-n, Q-q, ancl R-r. Table I combines all tests in which the patient made at
least one error: when upper-casesampleswerc nrembersof dissimilarpairs the error rate
 I]F]HAVIoRALSTUDIESoFAPHASIA:ME.|.HoDsoFiNvEsTtcAT|oNANDANALYSIS
129

OBJECIS

,:
U

o
D E L .M A I C H I N G

o l
z =
o U
B <

c i
F ( ,
r r E MAICHING
c 3
E

? 9 1 1 1 3 1 5 1 7 1 9
WEEKS

Frc.8. Testscoresasafunctionoftime;matching-to-samplewithobjects(pictures)aschoices.
(errors per opportunity) was 40 per cent, compared with 2l per cent when upper-case
samples-wermembers of similar pairs. Error rates showed no such differencebetweenthe
two sets of letters when samplesand choices both were lower case. Hence, within tactile-
visual matching of single letters, identity tasks were performed more accuratelythan non-
identity.
Table 1. Error ratesin matchingUpper-case
and Lower-casesampleletters with Lower-casechoices

Samples
Upper-case (%) Lower-case ('/')

Dissimilarpairs 40 27
1l
Similarpairs 2l

Samplelettersfor writing were lower case,but the patient was reinforced lbr correct
writing or printing in either rlpper-or lower-casestyles. Lower-caseprinting predominated
in his iesponsesto visual or tactile 3-letterwords. He preferred to print upper-caseletters,
however, when sampleswere auditory and their form unspecified. The difference supports
the view that this patient'sletter-writing fron visual or tactile sampleswas an identity, or
copying, task. writing trigrams,color names,and digit nameswere similarlyconsistent'
posNnRand Mrrcspr-l [8], using upper- and lower-caselettersas well as other stimuli.
found that normal adr.rltsmatched physically identical stimuli more rapidly than physically
different stimuli which had the same class names. Their analysis suggestedstrongly that
different levels of stimulus processingwere involved in the identity and nonidentity tasks.
Defcits classified ss input, output, or relationql
One can rule out input deficit as an explanation for a subnormal performance by show-
ing that the patient can, under some circumstance,respond normally to the same stimuli.
For example, even while our patient had trouble naming visual letters, he wrote and
matched those same letters (Fig. 3). Therefore, his problems with visual letters could not
be classifiedas input deficits. [n the early rveeks,however,no test with tactileletter samples
 130 M . S r o p r r N , L . T . S r o l ) D A R n ,J . P . M o H n a n d J . L a t c r s r r , r r

\ v a sn o n r l a l ; l a c t i l c i n p u t d e f i c i tf o r s i n g l el e t t e r sc o u l d n o t b e r u l e d o u t u n t i l l a t c r .
To exclude output deficit, otle must show that thc patient can exccutethe responsc
s a t i s f a c t o r i l tyt n c l e rs o m ec i r c u m s t a n c eF. o r e x a n r p l c c, v e n w h i l e o u r p a t i e n t h a d t r o u b l c
n a n r i r r gv i s u a la n d t a c t i l el e t t e r s( w e c k6 a n d l a t e r ' I)r cw a s a b l c t o n a n t ea u d i t o r yl c t t e r s :h i s
s u b n o r t n a l e t t e r - n a n r i nw g i r sn o t a n o u t p u t d e l i c i t . O u t p u t d e f i c i tc o u l d n o t b e r u l c d o u t ,
however,bel'oreintact rcpetition had beendemonstrated.
If input and output are intact, a subnornralpcrforrnancethat involvesthe intact ele-
ttlentsmust, by exclusion,fall into the relationalcategory. It indicatesa deficient stinrulus-
r c s p o n s er e l a t i o n .
This patient's early deficits werc difficult to classify becausehe ctid not havc all the
t l e c e s s a rtye s t s ,b u t s t a r t i n gw i t h w c e k s( r - 7 ,a c o m p l e t ea n a l y s i sw a s p o s s i b l e .[ . i k c s i r r g l e
l et t c r s ,v i s u a lt r i g r a ms a m p l c s( F i g . 3 , w c e k s6 a n d 7 ) l e d t o s a t i s f a c t o r sy i n r u l t a r r e o unsr a t c h -
i n g a n d w r i t i n g ; a u d i t o r y s a n r p l c sw e r c n a n c d a d e q u a t e l yt;a c t i l es a t n p l e sp r o d u c e csl a l i s -
factory sitnultaneousmatching. Each modality was involved in at least one satisfactory
performance,demonstratingthat each trigram input was intact.
On the output side,identity matching, naming, and writing were satisfactoryin weeks
6-7, demonstratingthat cach output was intact. Subnormal performanceswith trigrams
were neither input nor output deficits.
Similar analysisof Figs. 4-8 revealsat least one satisfactoryperfbrmancewith each
input, and at leastone instancein which eachfornl of responsewas good. With input and
output deficitsruled out, all dcficitsafter rveek5 nrust be classifiedas relational.
An examination that fails to combine each output with each input may lead to mis-
taken identificationof the cleficit; in weeks l-5, before identity narning had been tested,
one might have concludedthat the patient suffereda narning ontput deficit. Also, if the
patient is testedearly, before various input-output combinationshave revealeddifferent
recoverycourses,one may fail to observeinput or output deficitsresolvinginto relational
deficits.

Cal egories of' rela t ional dcfi ci t

T h c r c l a t i o n a lc a t c g o r yo f ' d c l q c i ti s n o t a u n i t a r y c r r t i t y . D i f l e r e n t n o n i d e n t i t . yp c r -
l b r m a n c et r e t r d sa n t o n gs t i n r u l u sr n a t e r i a l si n
, p u Lr n o d a l i t i e sa, n d o u t p u t r e s p o n s ei sl l u s t r a t c
i t s t n u l t i f a c e t c dn a t u r c
Modality-specifcrelationaldeJtt'it.s.Separationof'tlre Lwo types ol stimulus-responsc
relation, identity and nonidentity, even when they share a comnton output, is required
before one can accuratelydelineatenrodality-specific deficits.
For example,if the sequenceof improvementin r,r'ritingor simultaneousrnatchingwere
exatnined without separatingidentity from nonidentity tasks, it would appear that the
patient'sresponsesimproved first to visual, then to tactile,and finally to auditory samples.
Would a classificationof deficitsaccordingto input rnodality be preferableto the identity-
nonidentity distinction? In support of the greater generality of the identity-nonidentity
distinction,we offer the following:
First, in naming, the identity task improved most rapidly even though its input was
always auditory. Thus, the identity-nonidentity distinction generalizedfrom matching
a n d w r i t i n g t o n a m i n g ; i n p u t m o d a l i t i e sd i d n o t .
Second,delayed natching to auditory samplessontetimesimproved belbre delayed
m a t c h i n g t o v i s u a l o r l a c t i l e s a m p l e s . T h e p a t i e n t ' si m p r o v e m e n ti n t h e s e n o n i d e n t i t y
t a s k s d i d n o t c o n s i s t e n t l yf o l l o w t h e s a n - r se e q u e n c co f i n p u t m o c l a l i t i e sa s s i n r u l t a n e o u s
matching.
 I ] E I I A V I O I { A I ,S I U D I T . SO F A P I I A S I A : M E T H O D S0 F I N V I S T I ( i A I ' I O N A N D A N A I . - Y S I S I.II

Third,iclentityrnatciringandwritinw g oofr d s i n r e s p o n s c t o v i s t t a l - w o r d s a m l w l l cesr c

supcrior t o n o n i c l c n t i t n
y r a t c h i n g a n t l w r i t i n g o l ' t h e s a r t r eu ' o r c l si t r r e s p o l l s t
e o p i c turcs
( t : i g . 4 ) , e v e nt h o u g ht h e s et r s k s s l l r r e dt h e s a u r ci n p u t m o d a l i t y . S i n r i l a rd i s t i n c t i o n s - h c l d
h c t u , c c nc l i l l c r c n tv i s u a li r r l t u t sf o r c o l o i ' n a r r c u ' r i t i n g( l b r c x i r l r l p l cc, : o l o rv s . c o l o r n a n t c
s a n r p l c sF, i g . 4 ) , a n d n r a t c l r i n g o l - c o l o ro r p i c t u f cc l t o i c c s( l t i g . 5 ) . l ) i g i t n a r n c s d . igits.
t r r c ld o t s ( F ' i g . 6 )d i d n o t c l c a r l y t l i l T e r c n t i a t v
c a r i o u sv i s u a li n p t r t s .
When nolidentity tasks were oonsidcredscparatelya cliflcrent type ol- ordcrliness
e m e r g e cal c c o r c l i n gt o i n p u t m o d a l i t i e s . W h e n c v e rc l i f f e r e n c ecsx i s t c dw i t h i n n o n i d c n t i t y
writing, llaming, or simultaneousmatchirrg,rcsponsesto auditory samplesirnprovedfirst.
Trends distinguishingvisiolr and touch for the santesanples were not evidentexcept lbr
digits. The anlysisof idcntity tasksrvasincomplcte,for tactile-tactileand auditory-auditory
matchingwerenot tested. Delayedrrratching,inconsistentwith respectto input modalities,
will be examinedseparately.
Confuinej motlality- and material-spet'dicrelational det'icits. Although visual sanrpies
gelerally proclucecl nlorc severenoniclentitydeficitstl.ranauditory samples,we have noted
variationsan-iong tasks tlrat clifferedonly in the type of visual input. For exanlple,oral
picture naniring was less impaired than sayingthe samenalnesin responseto visual-words,
writing or rnatching thc sanre nrrmcs in responseto pictures(Fig. a), and matching picture
choicesto visual-words (Fig. 5). Critical to thesedifferenceswas the involvementof visual
w o r d sa s i l i t i a l s a n r p l i
c n p u t ( v i s u a l
w o r d n a r l i n g a n d w o r c l - p i c t u rm e a t c l t i n g )c, h o i c ei n p u t
( p i c t u r e - w o r cnl r l r t c h i r r go, r r c s p o i l s e - p r o d u c e i ndp u t ( p i c t u r e - w l i t i r r g )O . nly oral picturc
n a m i n gi 6 v o l v c d 1 c lv i s u a w
l o r c l s .A l s o , t h e p a t i c n t ' s
n a r n i u go l ' p i c t u r e sa n d s p e l l i n go f p r o -
n o u n c e dw o r d s a m p l e w
s e r e t h e o n l y i n s t a n c e i
s n w h i c h n o n i < l e n t i t n
y 'i r m i n gw a s s u p c r l o r
to comparablematching tasks with visual word choiccs.
Visual-digit naming was also lessimpaired than sayingthe nauresin responseto visual
words or writing the nanresin responseto visual digits (Fig. 6). Matching digit-nanrc
choicesto visual-digitsamples,horvever,showedno deficit.
Visual color namesdicl not sharethe specialstatusof digit namesand picture nattlesin
producing relational cleficits.The palient'snarningof visual colol-srvasimpaired and was
1ot superior to naming visual color words, or 1o writing and matching color names to
visual color samples(Fig. a). The combined modality-materialspecificityof visual-word
deficitsdid not extendto color-name deficits.
() ulput-spet'ifi c r elat ionoI deJic: i Is
Up to now we }rave considere<ithe effectsof different input stimuli while keeping
outputs constant. Thls type of analysisexposedthe need to separateidentity from non-
identity tasks, lecl to the classificationof this patient's deficits as relational rather than
input or outpllt, and pcrtlittccl the iclcntificationof rnodality- and nraterial-specific rela-
w
t i o n a l d e { i c i t s .N o r v , i n o r d c r t o i c l c n t i f yo u t p u t - s p c c i f irce l a t i o n a dl e f i c i t s , e s h a l lr e v crsc
t h e n r c t h c l do f a n a l y s i sa n d e x a n r i n ed i f l c r c n tr e s p o l t s crsv h i l ek c c p i n g t h c i n p u t c o n s t ant.
Nanting v,s.v,riting. Thc lcl't sidc ol' [rig. 9 showsthe paticnt's nonidcntity nalrring ancl
w r i t i n g s c o r c si n r e s p o n s ct o v i s u a ls a n r p l e st;h c r i g l r t s i d e ,t o a u c l i t o r ya n d t a c t i l es a m p l c s
Narning was superior to writing in rcsltonscto visual pictures,digits, ancl objects; spcllecl
and pronouncedwords; tactile cligitsancl objects. Only with color sanrpleswerenarnitlg
a n d w r i t i n g n o t e a s i l yd i s t i n g u i s h a b l e .
Our analysisdiffers frorn the custonlaryevaluationof dyslexiaand clysgraphiain trvt>
important ways. First, the nost often reportedcomparison,writing-from-dictation(audi-
tory-writing) with reacling-from-text(visual-naming),violates the principle that different
t32 M . S r o r q , l N ,L . T . S r o u t x n n , J . P . M o t r n a n d J . L l t c s s r s n

A U D I I O R YS A M P L E S
VI SUAI' SAMPI.ES nodrn9
I (Pronounctn9l
a
nonirg ,/t--- -t--. I
[ -r. ,'
i-----."i

wtiling-." prcluREs S P E T T T DW O R D S

9'

z
u
4 i{rili^9
G WORDS
PRONOUNCED

IACIILESAMPTES
o ---r--\1,.t
-." :-
4 t . a
aodrng 1".-
-'l '."
t
Ir
4
vriling -* noming wriling
no6Ct n omcl
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E
DIGIIS
4
o
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nomrn9
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,..^----*-- - ------'-'-"
'{---.
'zt-r- -'--'--'--
rr^-, OBJECIS
w.iling
nomct \.

1 3 5 7 9 1 1 1 3 1 5 1 7 1 9 2 1 2 3 22 57 2 9 J 1 I 3 5 7 911 13151?1921232527
WEEKS

naming
Frc.9. Nonidentity andwritingin response to thesamesamples. Visualsamplesleft
column;auditorysamples,upperright; tactilesan'rples, (pic-
lowerright. Samplematerials
tures,colors,etc.)areidentifiedon eachframe.

responses are conparable only when the input remainsconstant. A consequence of failure
to observethis restrictionis illustratedby Fig. 10, in which a comparisonof our patient's
auditory-writing with visual-namingfails to reveal the differencebetween naming and
writing.
A secondfeature is our avoidanceof the term "reading" as a responseclassification.
Readingis a term appropriate both to sayingand writing the namesof visual (or tactile)
stimuli, but not auditory stimuli. The operationalresponseclassifications,(oral) naming
and writing, encompassreading as expressedin speechand writing, yet pernit separate
examinationof both responsesto visual and auditory stimuli, whether or not the perfor-
mancecan be labelled"reading".
Combinedmodality-materialspecificityand naming vs.writing. The role of visual words
in this patient'sdeficitshelpsexplain the unusualsuperiorityof naming over writing (Fig. 9).
Naming and writing werecomparedonly as responses to the sanresamples,and visual word
sampleswere eliminatedbecausethey permitted identity writing, or copying. Becauseof
theseconstraintsvisual words were never inputs in naming tasks that could legitimatelybe
comparedwith writing. All writing, however, had visual words as response-producedinput
from the writing itself (Fig. 2).
 Bt ilAVl()RAl.Sl(Jt)lls ()l At'll,'\slA: Ml;lll()t)s ()l: tNVtsll(ilAll{)N ANI) AI NAYSS I .1.1

-_-,\*+2-''
!'

SINGTE
LEITERS OBJECIS
z
U
e

'tRIGRAMS

z COLOR
o NAMES

(, AUOltotY sAXPlt
...-.wriling
c
e
o V I S U A IS A M P L T :
U ----nomrn9

W E T K S

to auditorysamples,
Frc. 10. Nonidentitywriting responses to visual
and namingresponscs
samDles.

As noted before,visual color namesdid not produce the same unique relational deficit
as visual picture or digit llames. Consistentwith this, rvriting color names was the sole
exceptionto the rule that writing was inferior to oral narning (Fig. 9).
This patient'srelationalwriting deficitwas at leastin part secondaryto the more general
visual-wordrelationaldeficit.
Matching vs. naning and y,riting. Nonidentity matching of names to various input
stimuli usually improved rnore rapidly than or along with saying or writing the names.
However,this generalizationwas weakenedby certainexceptionswhich reflectedthe visual-
word relationaldeficitsdescribedabove; the patient'sdata are not conclusiveon this point.
Delayed matching-to-sample.Did the delayed-matchingdeficits fall into the same cate-
gory as other relationaldeficits,or is a memory categoryrequired? Someevidencesuggests
that the delaydeficitswerea secondaryconsequence of relational deficitsother than memory
The change from simultaneousto delayed matching introduced two new factors
First, the sample was no longer available when the patient made his choice. If sample
disappearancecausedthe clelayed-matchingdeficit, length of the delay would be immaterial.
Delay clurationwas the secondfactor. If the time interval werecritical, mere disappear-
anceof the satnplewould causethe patient little difficulty,but longer delayswould produce
more errors.
The adjusting-clelay proceduredoesnot easilylend itself to the differentiationof sample
disappearance and delay duration. The longestdelay the patient can attain in 20 trials may
be influencedby the extent to which absenceof the sample,by itself, causeserrors. The fol-
lowing considerationssuggestthat this patient'sdelayed-matchingdeficitswere a function
of sampledisappearance per se.
First, even in the early weeks the patient did not show clinical signs of the global
amnesiathat would be expectedif his severedelayed-matchingdeficits reflected a memory
loss.
134 M. StoulN,[-. T. Srouorno,J. P. MonnandJ. Lntcpsrsn

Second,more than 50 per cerrt of'thc patient'sresponseshad to be correct if he was to

a d v a n c et o t h c 4 0 - s e cd e l a y . l f s a n r p l cd i s a p p c a r a n crcc d u c e dh i s a c c u r a c yt o j u s t a b o v e
5 0 p e r c e n t ,h e m i g h t f a i l t o p a s s4 0 s e cw i t h i n 2 0 t r i a l s b u t n r i g h t s u c c e e di f h e h a d m o l e .
This was, indeed,observedon a few occasionswhen 1hc patient was given rnore lhan 20
t r i a l s ,a n d i n c l i c a t etsh a t e r r o r sc a u s e db y s a m p l ed i s a p p e a r a n crea, t h e rt h a n t l e l a yd u r a t i o n ,
limited his perforrnance.
Third, a few testswith fixed clelaysgave sin.rilarerror scoresat short and long delays.
This was to be expectedif sampledisappearancerather than delay duration were critical.
With san-rple disappearance implicated as alcaLlseof the breakdownsin delayedmatch-
ing, we may speculateon connectionsbetweendelay deficitsand relational deficitsother
than mernory. The input lnust generatesome processthat "carries" the sample after it
disappears. Naming is the usual bridge betweensample and delayed choice. A patient
who is unable to name sarnples,choices,or both is likely to perform poorly when first
exposedto delayedmatching. Although this patient's initial breakdownsin delayedrnatching
were aacompaniedby deficitsin naming the samplesor choices,there were two exceptions.
Delayedvisual-visualmatching of digits was poor (Fig. 6, center)even though the patient
could name visual digits; delayedmatching of visual digit sampleswith digit-name choices
was poor even after the patient hacl recoveredhis ability to name visual digits and digit
names(Fig.6, left). Theseexceptions,along with ttre failure to observeany instancesin
which good naning accompaniedgood initial delayedmatching, cast some doubt on the
relation betweennaming and delayedmatching deficits. There is also the problem of the
patient'simprovementin somedelayed-matching tasksevenwhile nalningwas still deficient.
Although naming is the nornral way to bridge delays,however,the patient need not apply
n a m e sn o r m a l l y . H e m a y i n v e n tn a n t e so l ' n a n l eo n l y c e r t a i ns t i m u l u sa s p e c t s :l o n g , s h o r t .
large, snrall, bright, dull, straight, crooked. Then, samplc disappearancewill no longer
block delayed matching. As in identity tasks, inrprovement in delayed nutching may
reflectattentional shifts rather than recovervfrom the relationaldeficit.
DISCUSSION
Analytic methods
In the analysisof behavioraldeficit we have chosenthe traditional stimulusmaterials
and responses of the aphasiabattery. Clearly they are complex,varying along more dimen-
sions than we have delineated. Just as clearly, however,thesevery stinruli and responses
havetraditionally revealedthe rich and varied phenomenaof aphasiaand agnosia. Rather
than refine thern, and risk refining their associateddisorders out of existence,we have
taken them as they are, adding only the laboratory refinementsof procedural automation
and consistencywhile observingthe elementaryprinciple of controlled stimulus and res-
ponsevariation.
Becausedifferentfactors influenceresponsesto the various stimulusmaterials,we have
avoideddirect comparisonsof the patient'sscoreseven on similar testsdone with different
materials. For example,we have not atternptedto delineateseparateletter and number
"centers" by comparing auditory-visualrnatchingof singleletterswith singledigits;there
are 26 letters,but only l0 digits. We have not tried to conrpareword and trigram writing
on the basisof "meaningfulness",three-letterwords usually have one of five vowelsas the
n r i d d l el e t t e r , b u t c o n s o n a n t r i g r a m sh a v eo n e o f 2 l c o n s o n a n t si n t h e m i d d l e . W e h a v e
not attenpted to delineateseparateagnosiasby comparing scoresfor picture, color, and
number naming; 3-letterpicture namescontain fewer lettersthan most color and number
names.
 :.^;.;;".;.;;;J"""':,:"^:;"n"*
,ns,cac,, .",,*lli
r e f e r e n c teo t h e t e s tp r o f i l e sw i t h i n e a c hm u t e r i a l . l j o r e x a n r p l en, a m i n gp i c t u r c sw a s s u p e r -
i o r t o s a y i n g t h es a m en a n l e si n r e s p o n s teo p r i n t e dt e x t , b u t n a m i n g c o l o r sw a sn o t s u p e r i o r
to natning printed color words. Thcsc and other profile differencesrvithin color-naming
a1d picture-naming t a s k s ,n o t t h e a b s o l u t et e s ts c o r e sd, i s t i n g u i s h e d the two materials.
Comparisonsof absolutetest scoresacrossnaterials are justified only when the more
deficient performanceis also the sinrpler'. For example, rvords are longer than letters,
coltain severallettersaselenrents, and comefrom a largerstimuluspopulation. lf a patient's
auditory-visual matching of words is intact while he is deficientwith letters[9], the difference
is meaningful, particularly if other patientsshow the opposite'
Perhapsrrore important than revealingdifferences,comparison of test profiles per-
mitted the clemonstrationof uniformitiesacrossmaterialswhertabsolutescorescould only
have beenconfusing. For exarnple,trigrarnsproducedmore profound deficitsthan single
lettersor 3-letlerwords,but the trenclrelationsfor correspondingtaskswithin eachof these
lraterials were similar. In spite of wide variations in absolutetest scoresacrossmaterials
and over time, we were able to delineatelarge areasof orderliness'
Comparisonsof input or outpllt sufficiencyacrossmaterialsare also of limited value,
and may even be misleading. Although a good performancewith, for example, visual
letter samplestells r.rsthat the paticnt is not blind, he nr.aystill have an input deficit for
colors or evcn visual words. Similarly one cannot rule out u priori the possibilitythat a
patient ntay be able to say words but not letter namesor even color names. Although all
theseare speech,they are not the sarueoutput.
By evaluatingdifferentresponses to the samestimulus,and the sameresponseto differ-
ent stimuli, one can identify a subnormal performanceas an input, output, or relational
deficit. Standardterminologydoesnot easilyadapt itselfto thesedistinctions.A reasonably
good aphasiaexaminationmight wrongly classifythe presentpatient as "mixed expressive-
receptive". His widespreaddeficitsin naning anclwriting, hovrever,were not "expressive,"
or "1noto1." All were relationaldeficits. His difficultieswith certaintypes of visual words
rverealso relalional, not "receptive," "sensory," or "agnosic." Inputs were deficientonly
when related to certain types of output, and outputs only when relatedto certain inputs.
O n l y b y r i g o r o u s l ya p p l y i n g t h e m e t h o c l o l o g i c aplr a c t i c : eo f t c s t i n ga l l c o m b i n a t i o n so f
e a o ha v a i l a b l ei n p u t a n d o u t p u t c a n r e l a t i o n a lc i c l i c i t sb e i c l e n t i { i eadn d a n a l y z e d .
The existcnceol orderly but clillcrentrecovcrycoursesIbr varior,rsstinrttlus-response
r e l a t i o n s ,w h i l e n o t s u r p r i s i n g ,r a i s e sc e r t a i n p r o b l e n t sr c l e v a n tt o c l i r r i c a le x a t n i n a t i o n
rnctIodology. Trcnd patternsin our patient'stestscoresfrom one peliod oftinle, considered
alone, would lead to cliffercntconclusionsthan the sanretestsfrom another period. Also,
trend pattcrns for identity and nonidentity tasks lvere dilTerent. Biased selectionor in-
cornpletetestingwould per,nit one to bolstera nunrberof contradictoryconclusionsabout
the functional significanceof lesions,dependingon one's theoretical predelictions. T'he
problems are complicatedby variability in the recoverycourseeven under relatively well-
controlledlaboratoryconditions,and by the likelihoodthat someapparentrecoveries lnerely
reflect the patient's new approach to a task.
Deficit categories
If response-reinforcement relations are deficient,the patient may be behaviorless;if
stimuluscontrol is generallydeficient,he will be unableto respondappropriatelyto the test
stimuli; if the sample,changingon each trial, does not "instruct" the patient, he will be
unable to do the tests. Such deficitsset an upper limit on the severityof the disorders to
 136 M. Slorvlr.r,
L. T. Slonn,rtru.
J. P. MorrRandJ. Ltrcrsrsn

w h i c h o u r m c t h o d s a r e a p p l i o a b l e .A t t h e o t h c r c x t r e n r e p , a t i c n t sw i t h s r - r b t l car p h a s i c
disorderswill do all our tests pcrfcctly. Theref'ore,tlrc rrrcthodswc havc prcscntedafc
a p p l i c a b l et o p a t i e n t sw h o s ec l e f i c i t ls- a l li n t o a n r i c k l l cr a n g eo f s c v c r i t y . W i t l r i n t h i s r a n g e
s o m e p a t l e n t sm a y s h o w o n l y a f c w d e l j c i t so r e v c no n l y o n e , r e s t r i c t c dp c r h a p s1 o a s i n g l e
stimulus-response relation, while othcrs nray show widcsprcadproblcnts of sevelaltypes.
The presentpatient fits into the latter category. I'lis paltcrn of dcficiencyand nornral pcr-
formance provides a basis for comparison with other classificationsystclljsand patients.
and for testingcertain theoriesof higher nervousfunction.
DeJicient nonidentity and intact identity perJbrinances. Consistently intact identity
performancesautomatically rule out input ancl output clcficits. HEln [10] has also noted
the importanceof intact identity perfornranceas a control for the patient's understanding
of the task. In our patient, the identity-nonidentity distinction took precedenceover sti-
mulus modalities,materials,and responses;onlv after classifyingthe identity tasks sepa-
rately was it possibleto analyzethe relational deficits into specificmoclalities,materials,
and responses.
The identity classificationrecognizesthat patients may do some rratching, naming,
and writing tasks as identities,but normal adr.rltsubjectsare likely to do them as non-
identity languagetasks,via naming. It is of interestto note the finding of Brncs and IJonr-
Nrn [1] that first-gradeand older children are lnore likely to rnatch objectson the basis
ofclass or functional attributes(nonidentity) than contnronstinrulusproperties(i<tentity),
while youngerchildrendo the opposite. A pal.ient'streatnent of letteisor rvordsas identities
s u g g e s t tsh a t t h e c o n t r o l l i n g s i i n i u l i a r c l c t t c r sa s s h a p c s ,n o t l e t t e r sa s l a n g u a g e ;l n e r e l ) '
sounds,not soundsof a word. Becausehe cannot processlettersand rvordsinto language.
he learns to attend to asp;cts of those stimuli rvhich would not normally exert exclusive
control over his responses.Our paticnt's early iniproverncntsin idcntity tasks probably
reflect his learning substitute behavior rather than his recovery frorn cleficit. Since the
stimulus aspectsto which the patient reactsmay clifferfrom those the examiner specifies,
comparisonsof identity lvith nonidentity tasks in tests of language,of specificagnosias,
or of inter- vs. intra-modalityintegration,are likcly to be invalid. TruaER| 2] has provided
an excellentdiscussionof this and relatednratters.
Failure to attend to stimuli as languagemay seernan input deficit. I-anguage,however,
unlike shapeor color, is not a physicalstimulusproperty, nor is it speechor any other single
output. Languageis a relational processthat includesinput and output. A general dc-
ficiency in this relation will, if a patient can discrin-rinate physical stimulus diinensions,
cause an attentional shift, reflectedin good identity and concurrently poor nonidentity
performances.Thus, the faster improvementsin identity than nonidentity tasks were pro-
bably secondaryto, and actually dernonstrativeof, continr-ring relationaldcficits.
The identity-nonidentitydistinction assumesadditional inrportancewhen one recog-
nizesthat not all patientsshow the same patterrr. Patientsrvith morc rcstrictecllanguage
deficienciesmay show impairment prcdonrinantlyf<lr 1;alticularstiliuli and responsesin
nonidentity-tasks,for examplecolor naming ! 3], matohingspoken lcttcr natnesto printect
l e t t e r s[ 9 ] , o r n o n r e p c t i t i v eo r a l n a l r i n g f l 4 ] . P a t i e n t sw i t h r i g h t - h c m i s p h c rlce s i o n sm a y
even be rnore delicicnt in certain iclcntity thun norridentity tasks, fbr er.amplein tactile-
visual vs. auclitory-visualmatching of letters! 51.
Relatbnal noming deficits. Our patient was able to repeat words when he could not
say them in responseto appropriatc visual and tactile stimuli. He was able to match and
write visualand tactileword samplesthat he could not name. His namingdeficits,therefore,
 BEHAVIORAL STUDII]S OTI APIIASIA: METHODS oT INVF]STIGATIONAND ANALYSIS '3'7

were not simply an amalgam of receptrveand expressivcelements;they were a distinctly

separatecategory. Relational narning deficits are crucial elerrcnts in BnalN's [2] central
a p h a s i a( b u t n o t G o r - n s r E r N '[s6 ] c e n t r a la p h a s i a ) i,r r N t r t . s p t t ' s[ 1 7 ] d e s c r i p t i o no f W e r -
n i c k e ' sa p 6 a s i a a, n d i n a m n e s t i ca p h a s i a .O u r o p c r a t i o r r adl e { i n i l i o r ro l ' r c l a t i o n a ld e f i c i t s
n-rayhclp clarify such conceptsas Ilr<,tttr's"ccrttral worcl attci nreaning schcmas," and
N r s l s r N ' s " l a n g u a g ef o u n u l a t i o n a r c a . " I n t h c a b s e n c eo f p a t h o l o g i cc o n t i r n r a t i o nw e
are not in a positior-r to specifythc anatonricalcorrclittc'sof suchprocesses,anclrveventure
no tnore than the behavioraldescliption of a particular kincl oi'breakdown in stimulus-
responserelations. That such behavioralclescription,independentlyelaborated,doesmake
contact with anatomical obscrvationsnray cncourageattenpts to classifyrrroreprecisely
t h e p s y c h o l o g i c adl i s t u r b a n c c isn a p h l s i a .
GEscswrNp[18] and Terrsrn ! 2] have stresseilthe importanceof distinguishingfailures
of naming fronr failures of recognition. Or.rrpractice of comparing naming, writing, and
matchiug, in both the identity and nonidentity n-,ocles, as responsesto the same input
stimuli, perrnitsus to identifl, naniing clefioits which exist in isolation and those which,as
in our patient.form only one clenrent of a Iarger deficit contplex. Differentialclassification
is also possible r.r,ithin strictl.v nan'iing dehcits. Plrtients nlay range from severeoutput
deficitswith no oral speech, through nlore or less sevcre relational deficits in which only
identity namingis intact, to more isolatecl deficits such as inaccurate naming of visualcolors'
Our exantinationtechniques pcnnit tlre is<llation of thesc and other more subtle deficit
categories.
Modality and intermoclality deficit spetifiritl'. Although visual, tactile, and auditory
inputs were associatedwith sornc deficieutpcrfc,rtttanccs, our patient's nonidentity tasks
weregenerallynrorecleficientin responscto visual and tactile than to auditory inputs. This
differenceprobably reflectsthe conrbined modality-materialspecificitydiscussedbelou'.
At present,our examination<loc-s not pernrit complcteevaluationof intermodality deficit
specificiry. In our malclriug-to-sanrpletests, all choiccs are visual stinruli. Therefore,
a poor tactile-visualmatching score,lor exanrple,lacks the necessary controls that would
be provicledby tactile-tactilc,tactile-auditoryand visual-tactilen-ratchingtests.
CombinerJmoclality anrl material de/icit spet'dicity. Nonidentity tasks that involved
pictures and spoken picture nantesexclusivclyas stimuli and responseswere somewhat
impaired, but correspondingtasks that had the same namesin the visual and tactile mo-
dalitieswereevenrnore impailecl. Perfomr.ance profilesin number and number-nametasks
showecla similar pattern, but colors ancl color nantes did not. The definingcharacteristics
of words that prodtrcethis type of deficit have yet to be identified.
This patient'sinability to respond oorrectly to visual words led to poor scoresin audi-
tory-visual word-word matching, aud in visual-visual word-picture and picture-word
matching. These deficits, in conjunction with his irnpaired auclitory-visualmatching of
words with pictures,raisea puzzling theoretical issue. A previous review of the literature
[9], particularlyof thc patientswith corpus callosunr sections reportetl by Cazz,rNtce et al.
tl9-21], suggeste{that rvorcl-wordand word-picture tnatchitrg could be accomplishedby the
6ondonrinanthen.risphere. Thc present patient's tlcficits suggest that either: (a) somepart
6f the clomilant hcrnisphereis requircd for urrdisturhctl u,ord-picture nlatclring, even in
a
p a t i c n t s w i t h c o r p u s c a l l o s u n rs e c l i o r r s , n c l t l r a t t l t c irrcsent p a t i c n t ' s l c f L - h e tnisphere
lesionsinterfere.cl with this funotiorr; or (b) untlctc'ctccl lcsions wcl'c prcscllt in this patient's
riglrt lrenrisphcre also
'fhe
p r o b l c m i s f u r t h e r c o r n p l i c a t e rbl y t h i s p a t i c n t ' sd i f l i c u l t i e si n a u d i t o r y - v i s u a l
138 M . S r l n r a x , L . T . S ' t t t n u r r n r > . . 1P. . M < t u n a n ( ' l. 1 .L t , t ( . f s r [ R

matchingof letternanreswith letters. Other patientstestedin lhe sanrcway have had no or

lesserproblemswith picture nanrssand picturcs but werc nrarkedlyimpaireclin auditoly-
v i s u a l m a t c h i n go f l e l t c r s[ 9 , l 4 ] . R c s o l u t i o no l t h c s e p r o b l c n t sr t r u s ta w a i t p a t h a l o g i c a l
[ i n d i n g s ,b u t i t i s c l c a r t h a t t h c r n c t h o col l ' b c h l v i o l a l c l a s s i f i c a t i oyni c l d sc l a t ar c l c v e n t o
diil'crcnlial rleurologicclassiiicalion.

REF'ERENCES
1 . J r c x s o N , J . H u c H t - t N < ; s . O n a f l e c t i o n s o f s p e c c h f r o m d i s e a s eo f t h e b r a i n . B r o i n 1 , 3 0 4 - 3 3 0 , 1 8 7 U .
Reprintcd in J. Trvt-on (Ecl.), Selat'tul Writirrgs oJ'John Hughlitrg,rJrtckson. Vol. 2, pp. t-55-170. Basic
Books, New York, 1958.
2. Bn,ttN, I\. Spccch Disordars. Burtcrwortlr, Washington, 1961.
3 . S x t u t t t . H , B . F . S c r a l c c ,u n t l I l u m a n l ) , , h a v i o r . M a c M i l l a n . N e w Y o r - k . 1 9 5 4
4 . S x t x x r , n , l ] . F . V e r b a l B t ' l t u r , i o r .A p p l e t o n - ( c n t u r y - C r o f t s , N c w Y o r k , 1 9 5 7 .
5. GrsctrwtNo, N. Disconnexion syndromesin animals and man: Partl. Broin 88.237-293. 1965.
6. LINosrev, O. R. Characlcristics of the behavior of chronic psychotics as revealcd by free-operant
conditioning n-rethods. Dis. nerv. Systcm,Monogr. Supp!.27,66-78, 1960.
7. Golotruoro, L Perception. In Exparitntntol Foundations oj Cliniru! Psychology, A. J. BrcHn,c,cu
(Editor), pp.28O-340. Ilasic Books, New York, 1962.
8. PosNrn,M. I.andMIrcnrll,R.F. C h r o n o m e t r i c a n a l y s i s o f c l a s s i { i c a t i o nP.s y r h o ! . R c v . 7 4 , 3 9 2 4 0 9 ,
1961.
9 . R o s t , N t r n t ; t , n ,P . t ] . , M o u t t , . l . P . , S r o t > o r t l o , 1 . . T . a n d S r o u a N , M . l n t e r a n d i n t r a m o d a l i t y m a t c h i n g
deficits in a dysphasic yotrth. Arths. Neurol. 18, 549-562, I 968.
I0. Hnao, H. Aphasia and Kindred Disonl<'rs oJ Spaech. Cambridgc Univ., l.ondon, 1926.
l l . B I u c t t , H . C . a n d B o n r r l n , M . S t i m u l u s c o u r p o t i t i ( ) na n d c a t e g o r y u s a g e i n n o r m a l c h i l d r e n . - / .
Genct, Psychol. 109, 195-104, 1966.
12. Trulr.n, l"l-L. Perception. ln Mtr-xt,t, B. and l'r-r-rnr,R H,. - L . A l t c r - a t i o n o f p e r c e p t i o n a n d n t e m o r y i n
m a n : r c l ' l c c t i o n so n m e t h o d s . h ' r A t n l y s i s o J B e h a v i o r u l C h a n g c , L . W r r s r u n r z , (Editor),pp. 268-
375. Harper & Row, New York, 1968.
1 3 . C r s c H w l N t > , N . a n d F u s t t - to , M . C o l o r - n a n r i n g d c f e c t s i n a s s o c i a t i o n w i t h a l e x i a . A r c h s . N e u r o l .
15, 137-146, 1966.
-f.
1 4 . M o n n , J . P . , I . t t c l s l l R , J . , S r ( ) r ) r ) A R nL ,. a n t l S r u v n N , M . l l c h a v i o r a l s t u c l i e so f a p h a s i a : e v o l u t i o n
of the dellcit in total aplrasia. ln prcparation.
1 5 . L t t t - l s r r n , J . , S t o t v t ' t t r tM
, . , S t o u u n n u , I - . T . a n d M o r r n , J . P . S o m e d e t e r r n i n a n t so f v i s u a l n e g l c c l .
J. Ncurcl. Neurosurg. l>:sy1111u,.32, 5u0*5t17, l9(r9.
I 6 . G o t - u s l t t N , K . L u n g u u g t ' u t t r lL u t t g u u g eI ) i s t u r l r u n t c s . C l u n e a n t l S t r a t t o n . N c w Y o r k , l 9 4 t l .
1 7 . N t r t - s t ' r . tJ, . M . A g n o s i u , , l p r u - r i u , A p l u s i u , 2 n d e c l i t i o n . H a f i r e r , N e w Y o r k , 1 9 6 2 .
I t j . G r s c r t w t N u , N . l ) i s c o n n e x i o n s y n d r o r n c si n a n i n r a l s a n d n r a n : l > ' a r tl l . B r u i n 8 8 . - 5 8 5 - 6 4 4 ,1 9 6 5 .
. 1 9 . C a z z r n l c ; , r , M . S . , B o c ; l r r , - 1 .[ : . a n d S p r r n n v ,I { . W . S o m e f u n c t i o n a l c l l e c t s o f s e c t i o n i n gt h e c e r e b r a l
c o m m i s s t r r e si n n a n . P r o c . N a t . , 4 c a d . S r i . 4 8 , 1 7 6 5 - 1 7 6 9 ,1 9 6 2 .
2 0 . G n z z r N t c . , r , M . S . , B o c l N , J . I l . a n d S p l , n n v , R . W . O b s e r v a t i o n so n v i s u a l p e r c e p t i o l l a f t e r d i s c o n -
nexion of the cerebral hemispheres in man. Brain 88, (pt 2),221-236, 1965.
21. (irrzznNrcA, M. S. and Slrnnv, R. W. Language aftcr section of the celebral comnrissures. Brarir
9 0 , ( P t r ) , 1 3 1 - 1 4 8 ,t 9 6 7 .

APPENDIX I. S]'IMULUS MATERIALS

Exampleof one trial

I\'[aterials Sarnple Choices

Letteror Letter Letters:

Name:
b, c, d, f, h, j, k, I, m, n, p, q, r, s, t, v, w, b b,j,x,z,l,m
x,y,z

Trigram or Trigrams:
[.etterNames:
p f x , k v h , n p t , r j t , r n b c l ,s x c l ,l q s , t h k , k f i ' , pfx pfx, fxp, xpf, fpx, pxf, xfp
v l m , j t q , w s x , l . r v p ,x b f , d k b , w p j , b f . i . c t d ,
ckl, nqs
 llItlAVl()RAl. SItil)lllS Ol; APIIASIA: Ml,flloi)S ()li lNVLSll(;AtlON ANI) ANAI'YStS lt9

Stimulus Matelials (continr.rcd)

Word or Wordsor Pictures:

Picture:
cat, bed, man, cow, hat, pig, box, hen, cat cat, cow, hat, pie, dog, ear,
saw, bug, axe, boy, Pie, hut, bee,dog, ear, bug, bee
zoo. car. hoe

Color or Colors or Color Names:

Color Name:
red, orange,yellow, green,blue, white orange orange,blue, green,red,
white, yellow

Digit, Dots, Digits, Dots, or Digit

or Digit Name: Names:
'1,
1,2,3,4,5,6,7.8,9 5 5 , 9 , 6 , 8 , 2 , 3 ,4

Object ox Object Pictures:

Object Name:
cork, bottle opener,screrv,marble,coin, cork cork, ball, nail, marble,
lock, caster,hairpin, block, matchbook, hairpin, screw,key, caster
clothespin,plug, key, washer,nail, chain,
lighter,bolt and nut, rubberband,button

APPENDIX 2. CLINICAL NOTES

Initial evaluation
The patient, J. L. P., a 62-year-oldright-handedsheetmetal worker, and sole sourceof information
concerninghis illness,claimedgoodhealthuntil 5 daysprior to admission,whenhe notedmoderateweakness
of the right upper extremity and slight weaknessof the right side of the face. The weaknessworsened
over the next iwo days to involve the right leg as well. On admission,he admitted to "some trouble" with
speechbut was uncertainof its duration.
GeneralPhysicalExaminationshoweda thin, unkempt,aphasicman with blood pressure160/80,putse
48 and regular. A grade 2/6 systolicejectionmurmur was heard over the apex and radiated to the right
calotid artery. Pulsesin the carotid arterieswere214.
NeurologicExaminationshoweda denseright homonymoushemianopia. There was a moderateright
hemiparesis, iaceand arm exceedingleg with increasedtone and striking drift of the right arm, DTR's 3 plus
in the right arm and leg. Vibration and pin appearednormally appreciated,but a penny placedin the right
hand wai misnamed.His speechwas dysfluent, with frequenterrors in word finding and rare paraphasias.
Articulation was clear. He statedhis name,approximatedate,and place.At sight he nameda watch, called
a watchband"bracelet" and the stem "night hand." From dictatedcommandhe repeatedshort phrases,
recitedthe numberseriesand repcated5 digits forward and 3 reverse;simple calculationswere performed
easily.
iaboratory Data: The whits blood count was elevatedto 10,500.Normal valueswere obtained for
hematocrit,BUN, FBS,2 hour post prandialsugar,Na, K, Cl, vanDenBerg,ESR. On the fifth hospital
day a lumbar punctureshowedclear,colorlessfluid with proteinof 81.
Hospital course
Secontlhospitaltluy. A left conrnroncarotid arteriogramdemonstratedcomplctc occ'lusionof the lcft
intcrnalcarotidartery,witl-rfaint filling of t hecarotid siphon,mainlyfrom pharyngeal branches of the extcr-
nal carotidartery,slightfillingthroughthe oplrthalrnic artcry,and minimalfiltingof branches of the middlc
cerebralartery iu the 3-4 secondIilln.
It wasdecidedthat no operativeintcrventionwould be undertaken, and the remainderof the paticnt's
hospitalizationconsistedof evaluationand rehabilitationof his basicneurologicdeficits.
Fourthhospita!week. An Eisensontestfor aphasiawascarriedout by the LanguageClinic over several
days time. At sight, he failed all testsof naming, but succeecled in matching4/4 objects,3/3 pictures,5/5
simple forms, and 5/5 reducedsize pictr.rres.From dictatedcommandhe mimicked 3/3 sounds,repeated
l0/i0 digits, 6/6 words, 5/5 sentences, answeredl0/10 questionsrequiring a singleword answer,answered
4/5 questionsrequiring whole sentenccs,recitedthe digit series,the alphabet,weekdays,months, pointed
to 5/6 body parts,obeyed6/6 simplecotnmandsand l2l12 complexcommands.
S i . r t h h o s p i twacl e k . H e w a s t e s t e d a t t h e b e d s i d e b y t w o o fu s ( J . P . M . a n d J . L . ) . A t s i g h t , r e a d i n g
aloud was tesiedwith text from the Gray Oral ReadingTest, the Wexler IntelligenceScale,the Stanford-
 .[.
140 M . S r r r n r a NL, . Sloooanu, J. P. MoHn and J. Lrrcrsrtn

B i n e t , a n d t h c p o l y l i n g u a l m a g a z i t . r cQ u i n t o L i n g o . A l l t l - r e s et c x t s w e r e r e a d a l o u d a s n e o l o g i s m s
or with
s u b s t i t t l t e d s h o r t w o r d s . I n t h c S t a n f o r d - B i n c t s u b t e s t , h e a c c e p t c d a s c o r r e c t s e n t e n c e sw i t h
scrambled
w o r d o r d c r . A l t h o u g h h e r c f t r s c dt o a t t e n r p t t o r c a d a l o u d f r o m s i m u l t a n e o u s l y - t r a n s l a t e dt e x t f r o m
erinlr;
L i n g o , h e s c p a r a t e dt h e L n g l i s h t c x t f r o n l t h a t o f o t h e r l a n g u a g c s ,a n d i l e n i c d e v e r h a v i n g
seen bel'oie the
c h a r a c t c r si r l t h c R t t s s i a nt e x t . A l t h o r " r g hl r c r n i s r r a r n c r*l i r h n c o l o g i s r n s ,l r c c o r r e r : t l yp o i n G < i t h c m i s s i n g
to
i t c m s a r r d t o t h e a b s u r d i t i c s i n t h c s u b t e s t so l t h c S t a n f o l t l - u i n c t . t s r o n d i t r a r a d c , i t r r n r u w l ,h c m i m i c k e J
J / J c o n l n l o n s o u n c l sl t c l a i l e d t o n t r n c . l l c t l c l i r r c r l- 5 / 5d i c t a l c d w o r r l s f r o r n t h c w c x l c r v o c a b u l a r y
subtcst.
I ' l e ' : u ' e c l 5 / 5 r v o r d s s p c l l c c lt . h i ' r a s l c t t c r s ( i s , s i r , r i s c , s l r i r o , p l i c r s ) .

, S c v o r t t ' c t h l n s p i t uxl ' c t ' l . . I { c w a s r c e x a m i r r c t l s h o r t l y p r i o r t o d i s c h a r g e .T ' h c d e n s e r i g h t h o m g p y m o u :

h e m i a n o p i a , d c n s e r i g h t b r a c h i a l w c a k n c s s ,s l i g h t r i g h r f a c i a l a n c l l e g w e i k n e s s r e m a i n e d - u n c h u n g " j .
T11"
tongue wiis slrong allcl articulation rcntained rrormal. [{e ntanagcd a feeblegrip with the right hand
and
s h o w e d 7 / 1 0 g r a s p . T h e l e g w a s i i f t c d e a s i l y a t t h e h i p a n d t o i s < l o r s i f l e x e csl l i g t r t t y a g a i n s t r e s i s t a n c c .
J o i n t p o s i t i o n s c n s c , v i b r a t i o n , a n c l P i r . rw e r e a p p r e c i a t r - ccl q u a l l y i n t h e r i g h t u n a t " f t i n d e x f i n g e r . H i s
c o n v e r s a t i o na p p e a r e < rl c l a x c t l a n d t l n i n t c r n l p t c d b y d y s f l u c n c y a s o n a d r n i s i i o n . A t . r r g f t l h e p e r f o r m e d
no
b e t t c r w i t h t h e s i i t n c t c x l s t h a n h c h a c j a t 6 w c r : k s . H c r n i s n a n r c c ls r n g l c l c t t e r s p r c s c n t e d i n m i s o r i e n t e r l
f a s h i o n , b u t s u c c c c d c t li n n a r . n i n gt h c r n a f l c r h c r o - o r i c r r t e <tl h e n - rh i r t r i l l ' . H e s a i d , ' s t o p " w h e n
shown a
r c d c a r d a n < la s k c d w h a t t h c c o l o t m e a n t i f o n a s t r c e t l i g h t . B L r t h e m a d e e r r o r s p o i n t i n g t o c o l o r s
repre-
s e n t i n gg r a s s ,b a n a n a s ,a n d s k y . ( ) r ' rt l i t t u t c t !t o n n t u n t l l - r cr e p c a t e c l o n g , u n f a m i l i a r w o r d s ( i . e . n i c k o l a s h k a ) ,
s p e l l e d h i p p o p o t a m u s , d e f i r t e dt h c W e x l c r v o c a b u l a r y s u b t u s t w o l d s i e p a i r , c o m m c r c c , t c r n - r i n a t e ,
edifice,
and impalc, but not travesly trr plagierize. Hc statetl.'30', as thc numbcr oiinches in 2! feet.
After one year. When last scen clinically, his exanrination showetl little change. He has been living alone
in a small hotel and finds his own way to and from the laboratory.

R 6 s u m e - A p a r t i r d ' t r n e a n a l y s e f o n c t i o n n e l l e d e s r c l a t i o n s s t i m u l u s - r 6 p o n s e( l e c o n t r d l e d L l
c o m p o r t c l l l c n t p u r l c s t i r n u l L t s )o, n a t l e r i v 6 d c s m i ' t h o d e s d ' e x r m e n c t d ' e n r l y s e d c s d 6 f i c i t ,
c o m p o r t e n l e n t a u x d a n s I ' a p h a s i e . L e s d i f i c i t s e t a i e n t c l a s s 6 sc o m m e d e s e f f o n d r e m e n t s d e s
t ' c l a t i o n sd t r c o n t r 6 l c s t i r r u l u s - r c p o n s c ;d e s p r o f i l s d e p c r f o r m a n c e s ,d i f i c i t a i r e s e t i n t a c t e s ,c h e z
t t n s u j e t a t t e i n t d ' a p h a s i es t v i r e i l l u s t r c n t I ' i n t a r e t d e l a m 6 t h o d e . L a d i s t i n c t i o n e n t r e p r e u v e s
d ' i d e n t i t i e t d p r e u v e sd e n o n - i d e n t i 1 6r e s s o r tc l a i r e m c n i c l e sd o n n d e sr e c e u i l l i e s .C e t t e d i s i i n c t i o n
p a s s e a t r a v e r s l e s d i l l 0 r e n t e s r e p o r r s e s ,l e s m o d a l i t 6 s e t l e s m a t 6 r i e l s d e s t i m u l u s .
En
examinant scparement ces deux types d'6preuve, on obtient une classifcatigrr plus precise des
dcficritsdu rraladc selon lcs catdgorics d'cntree, de sortie ou de relation, chacune de celle-ci i
son tour pouvant 0tre classce selon un type specifique. Les donnes recueillies demontrent
que des examens r6pftcs sur une pdriode prolongde dc temps peuvent r-ep3rerdes changements
d e c l a s s i f i c a t i o nd u d , : f i c i t , r ' t - t o t l i f i c a t i o nqsu i n ' a u r a i e n t p a s 6 t 6 n o t 6 e si n u t i l i s a n t s e u l e m e n t
l c s t c s t sh a b i t u c l s .

Z u s a t n m c n f i t s s u n g - T c s t n r e t h o t l c nu n t l V c r l r a l t c n s a r . r a l y s cbnc i A p f u a s i k c r nw u r d e l a u s e i n e r
f u n k t i o n a l c n l ) r i . i f u n gt l c l l { c i z r c a k t i o n s b c z i c h u n g c rar b g c l e i t c t . t j i c M e n g c l r v u r c l e na l s K o n -
t r o l l v c r s a g e n d i c s e r B o z i e h u n g c nk l a s s i f i z i e r t . A n . r B e i s p i e tc i n e s s c l r w e r a p h a s i s c h g c s t i i r t e n
K r a n k c n m i t c i n c m M a n g e l p r o f i l u n d t e i l w e i s ei n t a k t e ; L e i s t u n g c n w u r . d e d i e F r u c h t b a r k e i t
d i e s e rU n t c r s t t c h u n g s m c t h o t l c nd c r l o n s t r i c r t . A u s d e n l ) a t e n k o n n t e i - n a ne i n e U n t e r s c h e i d u n g
zwischcn identisclren und nicht identischen Aulgabcn trelTen und so einen kiirzeren Weg bei dei
C)rdnung verschiedener Reaktionen, Reizmodalitiiten und dem Priifungsmaterial cinsChlagen.
Die getrenn te Priifun g dcr genanntcn beiden A ufgabentypen erlaubte eini feinere Klassitjkation
d e r M i i n g e l n a c h I n p u t , C ) u t p u t o d e r n a c h R e l a t i o n s k a t e g o r i eu n d s p e z i f i s c h e nU n t e r t y p e n .
Die Ergebnisselicllen dariib.e'rltinaus erkenncn, dat! die Wiedcrholungvon Testuntersuchungen
t-iber lzingere Zeit zv einer Anderung der Stdrungseinteilung fiihren kann, was auf der Bisis
fr0herer Testpriifungen rricht moglich war.