Birkbeck, University of London, United Kingdom (Winter 2014)
Paul Broca, c. 1860
In 1861 the French surgeon and anthropologist Paul Broca published the first of a series of seminal papers linking loss of language function to damage to a specific region of the brain.1 Interest in what became known as ‘aphasia’ saw the publication of numerous articles on the continent, in the UK, and in America. Child cases were published alongside adult ones with age at onset rarely considered to be a relevant factor. At the same time, the first pediatric hospitals started to appear across Britain as medical pioneers sought to provide specialist facilities for children. Charles West, the founder of the first such establishment, Great Ormond Street in London (f.1852), insisted the child should be neither seen nor treated as a ‘miniature adult’. West, who described speech as ‘the highest endowment of man’ chose speech and language disorders in children as the topic of his prestigious Lumleian lecture given in 1871.2 He was aware that speech difficulties could affect the emotional and mental development of the child:
The complete inability to keep up intercourse with other children, or the great difficulty in the attempt, had cast a shadow over the mind; and the little ones were dull, suspicious, unchildlike (289).3
It was a far from easy task for a physician to accurately assess the speech produced and understood by his patients, whether adult or child. Descriptions of linguistic impairments in the medical literature of the time are idiosyncratic with very little, if any, grammatical analysis. Given that no standard investigative procedure was yet in use, each physician had to rely on his own, and his colleagues’, clinical judgement and experience when presented with cases of impaired language function. In addition, there was little or no long-term follow-up of patients. The English neurologist John Hughlings Jackson complained about the non-standardized nature of clinical language assessments:
To describe speech defects, is however, one of the greatest difficulties in clinical investigation. It is comparatively easy to set down on paper an account of the phenomena of a case of complete speechlessness, but it is very difficult to give a faithful picture of slighter defects. We usually observe in the difficulties of speech which follows a convulsion beginning unilaterally, that the patient hesitates, and slurs words; his talk is mumbling. We hear ourselves that he talks badly, but when we attempt to put down on paper what the nature of the defect is, it seems to melt into nothing. For of the above statement the reader may well say that hesitation, slurring, and mumbling are very common things. Even such a description is better than the use of such terms as “he was manifestly suffering from great impairment of speech” or “his speech was of an aphasic character” (25). 4
Despite Hughlings Jackson’s plea and the increased scientific interest in the aphasic condition, many cases published in English during the couple of decades following Broca’s papers were described in no more informative manner than “speech affected”, or “embarrassment of speech”. The medical attention focused on the nature of the condition, lesion site, etiology, and prognosis. As the century progressed though, sporadic mention was made of some (very rarely all) of the following: hearing, vocalization, use of repetition as an assessment tool, units of measurement (i.e., syllable, single words), word meaning, and the patient’s use of gesture.
In the latter decades of the century, physicians provided their own guidance on how to assess child patients. In his textbook for medical students, Francis Warner offers the following advice on conducting “the medical examination of a child”:
It is convenient to commence with some general conversation on simple subjects—e.g., his life at school or at home, in play and at work; what he reads, his companions and amusements. The faculty of speech is thus ascertained and some idea of the extent of his vocabulary. Various defects of speech may be found; there may be ill-regulated intonation, the voice at times almost dying away; there may be thickness of utterance, often in part due to nasal-pharyngeal obstruction; a few words may be spoken in reply to a question without affording an answer; the question may simply be repeated without any reply. In many other particulars speech or utterance may be defective
Warner then turns to the complex issue of language and mental capacity:
Particularly notice in conversation whether the child makes comparisons or exercises the faculty of judgement …The behavior of the child with common objects may show much as to his modes of dealing with his surroundings … In children with little or no speech it is more difficult to ascertain whether a judgement is formed (1311).6
Mental function was to a large degree determined by an appropriate response to questioning. When the patient either couldn’t speak or answered inappropriately, it was difficult to come to a decision regarding their mental state. Instead, a subjective judgement of intelligence was frequently based on facial expression and the perceived understanding of speech. The terms “seems bright” and “appears intelligent” are frequently found in published cases of the time. This linking of mental competence with assumed understanding of spoken language raised diagnostic difficulties as work on classifying the aphasic syndrome continued apace. In 1874, a decade after the first cases of impairment in language production were published, the German physician Carl Wernicke provided a model of how language may be represented in the brain.7 He demonstrated the existence of fluent aphasia (with poor comprehension skills) associated with a lesion in the auditory centre of the brain and postulated further types of language loss. This led to considerable discussion as to whether aphasia was purely a language disorder or symptomatic of a more general cognitive disorder and linked to the on-going debate on the relation between language and thought in general.8
Cases of adults presenting with Wernicke-type aphasia were soon cropping up in the literature, but it seemed to be a different story when it came to children. In 1998, Paquier and Van Dongen looked at the history of research into aphasia in childhood.9 They summarize what has become known as the ‘traditional concept’ of the condition. Among other markers, aphasia in childhood was considered transient with recovery being rapid and complete. It was believed to affect expressive language with comprehension remaining relatively preserved. Paquier and Van Dongen point out that late 20th century research has shown aphasia in children to be more complicated than this traditional concept suggests with Wernicke type aphasia occasionally observed.
However, a detailed study of 19th century British medical literature has shown that similar cases did crop up from the very start of modern research into aphasia. The distinction between “idiocy” and aphasia was particularly difficult to determine when some medical procedures could not be carried out if the child couldn’t or wouldn’t speak. As West points out “a child’s inability to describe its sensations deprives us of … important guide” (242).10
The separation of aphasic symptoms from “intellectual faculties” was particularly difficult, not only clinically, but also theoretically. Yet how the aphasic patient was both assessed and treated was dependent upon making the distinction. In the early 1890s, John Wyllie, the Scottish physician and author of a wide ranging work on all aspects of language, suggested that Wernicke’s aphasics, of whatever age, were likely to be mistaken for cases of mental impairment.11 His colleague Ross had previously commented that Wernicke-type aphasic speech “can hardly be distinguished from the mental confusion which attends the onset of unconsciousness” (51).12 Ross believed children as well as adults might present with these speech symptoms at least during the initial stage in the history of their condition, perhaps before admission to hospital. One consequence of this delay might be that sensory-type aphasic symptoms were overlooked as the child’s condition altered over the passage of time and the all-important early history of a condition, vital for accurate diagnosis was typically acquired second-hand, the informant in most cases being the child’s mother.
However, a number of childhood aphasic patients did present with some receptive language difficulties, but instead of being seen as displaying the speech patterns associated with Wernicke’s aphasics, they were far more likely to be assessed as being mentally impaired. Aphasia in childhood became defined as affecting motor production only, and this enabled many to argue for the transience of the condition:
In case of persistent aphasia in childhood, it will generally be found, on careful investigation, that the defect of speech is part of a general mental defect and not true, pure aphasia (124).13
Long-term speech impairment, typically involving comprehension deficits, was ruled outside the definition. The occasional case of chronic language impairment affecting comprehension as well as expression in a child patient that appeared in the literature was typically claimed to be ‘unique’; the exception that proved the rule.
While children with aphasia found themselves admitted to hospital, an increasing number of diary studies of infant acquisition of language began to be disseminated to the scientific community.14, 15 Physicians started to seriously consider the problem of delayed or deviant language development. It was generally assumed, despite the fact that many were described as ‘intelligent’, that these children had some impairment in mental ability or auditory perception. They were far more likely to be placed in institutes for the deaf or asylums for imbeciles than end up on hospital wards, unless they also presented with an accompanying acute or chronic condition. Teachers of the deaf and dumb were deemed the most appropriate people to offer advice and rudimentary therapy in cases of children who could hear, but who failed to show typical patterns of language development—although sadly these children were almost universally seen as unlikely to benefit from any form of education. Even well into the 20th century some institutions for the education of the deaf would not admit or even examine children who could hear and were mute or had very little speech, as it was thought they were ineducable and their condition hopeless.16 If the children were deemed to have additional learning difficulties, they would be more likely to be referred to an asylum for the feebleminded.
Once children with delayed or impaired language acquisition started to be admitted to hospital, physicians needed to devise means of assessing and treating their difficulties. Information on language could be found in the few books published on phonetics and grammar and in the medical textbooks that started to appear in the latter decades of the century—with sections devoted to both developmental and acquired language disorders in childhood such as language delay, stammering, stuttering and aphasia. This increased interest in normal and deviant child language development made it possible for physicians to begin to compare their patient’s language (or lack of) with the perceived standard and led to attempts to devise treatment regimes, some involving intensive one-to-one remediation over long periods of time.
Early pioneers such as Walter Baugh Hadden, physician at Great Ormond Street hospital, used the alphabet to systematically test the pronunciation of individual sounds made by his child patients with the same task used on subsequent occasions to monitor any improvements in speech.17 In addition, he typically noted the child’s ability to copy or write to dictation with both the left and right hand. Although other physicians also started to provide a transcription of their patient’s speech (these rudimentary attempts to standardize assessments enabled physicians to make comparisons between patients), Hadden went further than most in investigating the relation between his patient’s articulatory difficulties in speech production and how that impacted on speech perception, the ability to read aloud and reading comprehension. The remediation of speech difficulties in children focused exclusively on the phonetic analysis of speech as the clinical examination of grammatical aspects of language was very rudimentary even in adult aphasia until after the First World War. Hadden believed that in cases where the speech defect was minor the condition typically disappeared without the need for special treatment. In more serious cases he thought therapy both possible and necessary. The work started by these physicians led to improvements in diagnosis, assessment, and treatment and marks the beginning of modern practices in both acquired and developmental language disorders.
- Paul Broca, Remarques sur le siège de la faculté du langage articule, suivies d’une observation d’aphémie. Bulletin de la Société d’Anthropologie 6 (1861): 330-357. Paul Broca, Du siège de la faculté du langage articule dans l’hémisphère gauche du cerveau. Bulletin de la Société d’Anthropologie tome V1 (1865): 377-393 translated by Berker EA, Berker AH and Smith A, Localisation of speech in the third left frontal convolution. Archives of Neurology 43 (1986): 1065-1072.
- Charles West. On Some Disorders of the Nervous System in Childhood, London: Longmans, Green and Co. 1871
- Charles West. Lectures on the diseases of infancy and childhood. London: Longman, Brown, Green and Longmans.1884.
- John Hughlings Jackson. A Study of Convulsions. London: Odell & Ives. 1870
- Francis Warner, Neural and Mental Disorder in Children. In W. Edwards (Ed.) Cyclopedia of the Diseases of Children. London. 1899
- Carl Wernicke. Der aphasische Symptomencomplex. Breslau: Cohn und Weigert 1874
- Conolly Norman. Considerations on the mental state in aphasia. Journal of Mental Science. 45: (1899), 326-37.
- Philippe Paquier, and Hugo Van Dongen. Acquired aphasia in children. In P. Coppens., Y. Lebrun and A. Basso. (Eds.) Aphasia in Atypical Populations NJ: Lawrence Erlbaum. 1998.
- West Lectures on the diseases of infancy and childhood. 1884.
- John Wyllie, The Disorders of Speech. Edinburgh Medical Journal, (1892), 1 & 2, 289-314, 401-421, 501-523, 585-604, 681-693, 777-793, 897-907, 977-992.
- James Ross, On Aphasia: being a contribution to the subject of the dissolution of speech from cerebral disease. London: J&A Churchill. 1887.
- William Gowers. A Manual of Diseases of the Nervous System. London: Churchill 1893.
- Hippolyte Taine. On the acquisition of language by children. Mind, 2, (1877), 252-259.
- Charles Darwin. Biographical sketch of an infant. Mind, 2(7) (1877), 285-294.
- Cecil Worster-Drought, & Allen, I. M. Congenital auditory imperception (congenital word-deafness): and its relation to idioglossia and other speech defects. Journal of Neurology and Psychopathology, 10(39), (1930), 193–236.
- Walter, B, Hadden,. On certain defects of articulation in children, with cases illustrating the results of education on the oral system. Journal of Mental Science, (1891), 96-105.
PAULA HELLAL, PhD is an honorary research fellow at Birkbeck, London, with interests in the history of research into acquired and developmental disorders in language, child language acquisition, communication difficulties in people with profound and multiple learning disabilities (PMLD) and the relation between language and thought. She holds a degree in Linguistics and Spanish, and an MA and PhD in applied linguistics. Hellal has published articles and book chapters on 19th-century investigations into language impairment in children and adults and on the use of various communication aids for adults with PMLD.
Highlighted in Frontispiece Winter 2014 – Volume 6, Issue 1