APHASIA (grech, aphasia loss of the speech) — an alalia, at Krom is partially or completely lost an opportunity to use words for expression of thoughts and communication with people around at safety of functions of the articulation device and hearing sufficient for perception of elementary speech sounds.
The term «aphasia» is offered A. Trousseau in 1864.
At And. the highest mechanisms of speech function which are carried out by the second alarm system suffer, the analysis and synthesis of conditioned speech reflexes — the words which are according to I. P. Pavlov, are violated by signals of signals.
At And. two main types of speech disturbances — touch, receptive, impressivny are allocated And. (misunderstanding of the speech of people around) and motor, expressional And. (disturbance of oral speech). Aphotic frustration are observed at defeat of the prevailing, dominant cerebral hemisphere concerning speech function.
And. it is necessary to distinguish from the speech frustration with preservation of the verbal alarm system depending on disturbances of mechanisms of the speech of more low level.
It is necessary to distinguish an anarthria, a dysarthtia from motor aphasia — loss, disorder of oral speech owing to the central or flaccid paralysis, paresis of voice and articulation muscles. At an anarthria, cannot tell dysarthtias of the patient or the speeches delivered by it sounds indistinct, greased though the general scheme of the pronounced word is kept whereas at the patient motor And. the articulation device is kept, he could speak, but «is not able», cannot find the necessary articulation. On a trope of P. Broca, at the patient memory of receptions of a pronunciation is lost; he says words which are available at its order clearly.
From touch And. it is necessary to distinguish disturbances of the speech at deafness or relative deafness by both ears; the patient does not understand the speech of people around because does not hear whereas the patient A., having sufficient auditory acuity, does not understand value of the heard words.
Etiology, classification and pathophysiology of aphasias
And. it is observed at diseases of a brain of a different etiology: vascular, inflammatory, tumoral, traumatic defeats, atrophic processes in a brain — diseases of Peak, Alzheimer, etc. There can be short-term aphotic attacks at vascular cerebral crises, migraine, an epileptic seizure (aura). It is studied by researchers of different specialties — neuropathologists, physiologists, psychologists, neurosurgeons, logopedists, etc., however in a complex problem And. there are some more obscure, controversial issues.
The first descriptions of afazichesky frustration appeared in the middle of 17 century, but, in effect, history and a classical stage of studying And. begin since publication in 1861 the Parisian surgeon and Brock's anatomist of his well-known work. On the basis of data of kliniko-anatomic comparison it showed that at motor And. the lower (third) frontal crinkle of the left hemisphere of a kpereda from the cortical centers of movements of lips, language and a throat is surprised. This site of a brain, according to Brock, is a motor word center, storage of motive images of words at which loss oral speech is broken. In 1874 there was Vernike's work (To. Wernicke), in a cut it was shown that at touch And. a back third of an upper temporal crinkle of the left hemisphere is surprised. Vernike considered that the acoustical word center (storage of acoustical images of words) having major importance in speech activity was opened for them. Then there were messages on opening of other speech centers with more bounded functions: the center of reading in an angular crinkle described by Dezherin (J.Dejerine, 1914), and the center of the letter in an average frontal crinkle of the left hemisphere described by Eksner (S. Exner, 1881).
At defeat of the first the isolated disturbance of reading — an alexia (a verbal blindness) is observed, at defeat of the second — agraphia (disturbance of the letter).
In 1884 — 1885 Vernike and L. Lichtheim offered classification of aphotic frustration, edges further gained fame under the name «classical classification». In this classification seven forms A were presented. Two main — cortical motor and cortical touch which are observed at defeat of the center of Brock and Vernike's center. Other five forms A. arise: as a result of breaks of assotsiatsionny fibers between centers Brock and Vernike with the hypothetical center of concepts — transcortical motor And. and transcortical touch And.; at a break of bonds between the main centers — conduction And.; at a break of projective fibers — subcortical motor And. and subcortical touch And. Also clinical distinctions had these forms: safety of the repeated speech at transcortical motor and touch And., safety of the internal speech (thinking about, mental pronunciation of words) at subcortical motor and touch And., preferential disturbance of the repeated speech — at conduction A.
Ryad of provisions of the classical doctrine about And. became a subject of brisk discussions. According to Mari (R. of Marie, 1906), And. it is uniform, there is only Vernike's aphasia arising owing to defeat of an upper temporal crinkle; the lower frontal crinkle has no relation neither to function of the speech, nor to its frustration. He denied independent value motor And., including its aphasia of Vernike complicated by an anarthria. He drew this conclusion on the ground that at all patients observed by it so-called motor And. disorder of understanding of the speech when more difficult phrases were shown to the patient, than those which were shown to patients A was found., described in literature. On the basis of anatomic researches of Mari considered that the anarthria arises owing to defeat of a lentikulyarny zone, both hips of the internal capsule, a part of a thalamus, a striate body, the outside capsule and a fencing are a part a cut. Theory of emergence And., the offered Mari, caused a number of objections. It was specified what can only cause damage to a lentikulyarny zone dysarthtia (see), anarthria, but not Ampere-second its characteristic manifestations. In literature there is a description of cases of development motor And. without defeat of a lentikulyarny zone; at the same time absence was sometimes observed And. and at its deep defeat (M. I. Astvatsaturov, 1908).
At motor And. the understanding of the speech can be a little broken, but frustration of the expressional speech clearly prevails. According to A. R. Luriya (1969), secondary disturbance of understanding of words in connection with deep disintegration of articulary schemes which join normal in the act of acoustical perception of the word can cause deep damage to the expressional speech.
Most of modern writers does not consider reasonable and Mari's opinion that the reason And. primary decrease in intelligence is. Behavior of patients And. correct; at them intellectual defects usually are not found and if those are available (easing of memory and attention), then they are not so sharply expressed that these could explain emergence of aphotic frustration.
Lipman (H. Liepman, 1913) considered motor And. as display of a peculiar apraxia of organs of articulation. According to Wilson (C. Wilson, 1908), touch And. it is possible to explain with agnosia of sounds. However And., apraxia (see) and agnosia (see) have essential differences and to identify these types there are no sufficient bases.
Penfild (W. Penfield, 1959) considers that And. it can be connected with defeat of a paracentral segment of a dominant hemisphere where, in his opinion, the additional word center is localized.
However aphotic frustration at defeat of this area, according to R. A. Tkachyov, can be explained with the induction braking influence on a front speech zone what has the investigation emergence transcortical And.
At And. the complex system of the speech is exposed to disintegration, at a cut one of its components are kept or a little broken whereas others sharply suffered — from here variety of clinical manifestations And. and difficulties of their classification. Afatichesky frustration classify variously on the basis of different criteria — anatomic, syndromologic, linguistic, etc. Instead of classical classification much others were offered. Ged (N. of Head, 1926) offered classification, the principles of linguistics were the basis a cut. Seeing a basis And. in frustration of the act of the formulation and use of symbols, he considered what cannot be allocated as independent forms neither motor, nor touch And., and also disorder of reading and letter. According to Ged, four forms A are had.:
1) verbal, at a cut word formation suffers and there are defects of a pronunciation, the lexicon is limited, the internal speech is upset; 2) nominative, characterized by disorder of understanding of words and uses of words; 3) syntactic, at a cut the speech becomes incoherent, cable style; 4) semantic And. — at understanding of the words taken separately the patient finds misunderstanding of sense of phrases of a difficult grammatical construction, confuses such concepts as «the father of the brother» and «the brother of the father» etc.; repetition of words is not broken, in the spontaneous speech there are unsharply expressed grammatical and syntactic defects. Clinical forms A., allocated with Ged, are very close on the symptomatology to classical forms A. Verbal And. corresponds cortical motor, syntactic — conduction, and the others represent different options touch And.
On the basis of data of studying of linguistic patterns of speech function and topics of defeat at aphotic frustration of A. R. Luriya allocates three options motor And. — afferent (kinaesthetic), efferent (kinetic) and frontal (dynamic); two options touch And. — akustiko-mnestichesky and semantic; frontal dynamic and akustiko-mnestichesky And. are close to transcortical And., described by classics.
Kleyst (K. Kleist, 1962) considered, as touch, and motor And. have four independent options. At touch And. it: 1) deafness on sounds of the speech; 2) deafness on words; 3) deafness on names; 4) deafness on offers. At motor And. there are respectively same types of frustration concerning expressional functions of the speech.
Only two basic groups of aphotic frustration — motor and touch are presented to Kleyst's classifications, in effect. In its division on separate forms A. not qualitative, but quantitative distinctions between them were considered, edges during the different periods of a disease the same patient can have various intensity of speech frustration.
Goldstein (To. Goldstein, 1948) put forward a trace, situation: at all forms A. complete work of a brain, all activity of hemispheres in general suffers. In his opinion, there are four aphotic syndromes: 1) verbal deafness and verbal dumbness; 2) touch and motor Ampere-second preferential disturbance of the expressional or impressivny speech; 3) transcortical motor and touch And.; 4) the central A.
Afaticheskiye syndromes in Goldstein's classification correspond classical, at the same time the term «conduction aphasia» is replaced with the term «central aphasia», in to-ruyu also cases touch were included And. Its first group — total A.
Veyzenburg and Bride (T. H. Weisenburg, M. of Braid, 1935), Kreyndler and Fradis (A. Kreindler, A. Fradis, 1968) consider that in view of exclusive variety of aphotic frustration classification can be only purely empirical and there has to be perhaps simpler. According to these authors, it is necessary to be limited to division of aphotic frustration into four groups: 1) And. preferential expressional; 2) And. preferential receptive; 3) And. expressional and receptive; 4) And. anamnestic.
In this classification the mixed character of basic groups motor and touch is emphasized And., that correctly hl. obr. concerning cortical options. Besides, in it there is no division of basic groups And. on separate forms.
Both in the given classifications, and in works of certain authors independence of these or those classical forms A is denied., hl. obr. conduction, transcortical and subcortical. Any of the offered classifications And. did not gain the general recognition since in everyone there are shortcomings, but, from the syndromologic point of view, classical classification is more suitable for clinical practice. Classical forms A. exist and have independent value of syndromes, but are not stages of involution of more general disturbance of speech function as considers a number of authors. Transition of one form A. in another it is in certain cases possible, hl. obr. at total And., but in many cases from the very beginning of pathological process in a brain this or that form A is established., keeping the characteristic features and at considerable recovery of the speech. The interpretation of the speech and its pathology from positions of a narrow lokalizatsionizm and psychological associationism is absolutely unacceptable. The terminology offered by classics for designation of forms A., it is not adequate to reality and therefore it is impossible to understand this classification in literal anatomic sense. For designation of clinical forms A. many names were offered that creates difficulty in practical work and studying of literature. Therefore before development of more rational classification of aphotic frustration it is reasonable to use classical terminology.
To a crust, time a symptomatology And. in comparison with the classical description it is added with new clinical observations and data of special researches. Expressiveness of aphotic frustration at different forms is various — from lungs, the erased manifestations before full loss of the speech.
In the doctrine about aphasia the questions of localization of the center of defeat which are closely connected with questions of classification of aphotic frustration figure prominently. Criticizing ideas of classics of a word center, Jackson (J. N of Jackson, 1884) fairly pointed that localization of aphotic frustration is not identical to localization of the speech. The theory about the static «engramma», «images» of the speech which are in receptacles what the speech centers are is metaphysical, in particular. The speech is dynamic, and aphotic frustration as Jackson specified, can change in the intensity depending on a situation, an emotional condition of patients.
Concerning localization of aphotic frustration in literature there are various opinions. One authors (Goldstein, etc.) deny existence of special areas of brain bark which defeat leads to speech disturbances. According to extensive anatomoklinichesky researches of modern writers [Akhuryagerra and Hekan (J. Ajuriaguerra, N. Hecaen), 1960, etc.] it is possible to consider established that motor and touch And. there corresponds defeat in the speech zones described by classics — in Brock's centers (fields 44 and 45 of Brodmann — see Very tectonics of a cerebral cortex) and Vernike (the field 22 Brodmanna), but bigger extent, with distribution of defeat to depth of adjacent white matter. A role of cortical speech zones of a dominant hemisphere, more extensive, than it was considered by classics, was shown as well by Penfild with sotr. during neurosurgical operations. They observed elements of aphotic frustration at an extirpation or irritation electric current of a lobby (Brock's center, lower parts of the central crinkle, the additional motor field) and back (Vernike's center, angular and supramarginal crinkles) speech areas of a brain. For an explanation of emergence of aphotic frustration Monakov (K. Monakow, 1914) attached great value not so much to defeat of the speech centers how many to a diaschisis (see). Existence of aphotic frustration in a clinical picture of a disease facilitates establishment of the topical diagnosis that is especially important at volume processes. So, e.g., the first symptom of abscess of a temporal share of a dominant hemisphere of an otogenic etiology is touch anamnestic And.
I. P. Pavlov's doctrine about the second alarm system created premises for dynamic localization of speech function and for understanding of a pathophysiology And.
Differentiation between alarm systems, according to I. P. Pavlov, is not so much anatomic how many functional.
The second alarm system inseparably linked with the first shall be widely localized in brain bark. To it there correspond data of morphological studying of evolution of brain bark. Emergence of the second alarm system, by data And. N. Filimonova, finds the reflection in decrease in specific weight of analyzers of the first alarm system that value for the second alarm system is explained by powerful development of the areas having especially big though not exclusive. From this point of view A. R. Luriya's data received during the studying traumatic are of interest And., according to the Crimea focal lesion of any site of the main and border speech areas leads to elimination of any private premises necessary for implementation of the speech act, and at the same time inevitably leads to disturbance of all functional system in general.
For activity of the second alarm system, are of very great importance for speech function a lower part frontal and an upper part of a temporal share of the left hemisphere (at right-handed persons); damage of these departments causes disturbance of the speech. At the same time by analogy with analyzers of the first alarm system the front speech zone can be considered as rechekinestetichesky synthesis analyzer, and back — as reche-acoustical synthesis analyzer.
The physiological role of these analyzers consists in implementation of the highest analysis and synthesis of rechekinestetichesky and reche-acoustical irritants, in formation of speech reflexes and their diverse bonds with all analyzers of bark. According to A. A. Ukhtomsky, the word center is drawn not in the form of locally outlined site, but in the form of the constellation of the sites located, maybe, is quite wide and combined not so much in the ways, how many unity of working action.
Use of a speech motor technique of A. G. Ivanov-Smolensk, and also the technique developed by E. V. Schmidt and N. A is important for clarification of cortical neurodynamics at aphotic frustration along with clinical trial. Sukhovskoy (use as the indicator of conditional reaction of change of a functional condition of the visual analyzer). For objective assessment of a condition of the internal speech at And. apply an elektromiografichesky research of muscles of the articulation device (Yu. S. Yusevich, F. V. Bassin, E. S. Beyn). The research of the electroencephalogram with aphasia finds mezhpolusharny asymmetry, change of an alpha rhythm, dominance of a delta rhythm in patients. These data have limited topiko-diagnostic value. Speech dissociation, making the main maintenance of an aphotic syndrome, receive the explanation in the light of the experimental data established by I. P. Pavlov's school during the studying of brake process — locality of braking, its extreme divisibility, various degree of a tormozimost of different functional systems depending on their uprochennost, etc. At transcortical And. cases of very fractional speech dissociation as, e.g., dissociation between parts of speech — the patient calls objects (nouns) are observed, but is not able to call actions (verbs). At some patients only the designations relating to a certain circle of representations drop out. Alarm value of the heard word is in some cases lost, but this value concerning the written word remains. Clearly dissociation at polyglots concerning separate languages acts, to-rymi they owned. Studying of speech dissotsiation in the light of the physiological doctrine of I. P. Pavlov matters also from the point of view of further development of the doctrine about the second alarm system. I. P. Pavlov emphasized more than once that in the conditions of pathology physiological mechanisms act especially clearly.
On features of pathophysiological structure of a form motor and touch And. it is possible to divide into two groups (R. A. Tkachyov, 1961).
Treat the first group cortical and subcortical motor and touch And., which cornerstone structural damage of the corresponding speech analyzers or their conduction paths is.
The second group is made transcortical motor and touch And., which defining pathogenetic factor is not structural damage of speech analyzers, and their deep braking induced by the center of the defeat which is out of a kernel of the analyzer is preferential in front departments of a brain at motor And. and in back departments at touch.
The first group of aphotic frustration has in the basis a-ism of a neniye of the mechanism of speech analyzers. At defeat of the cortical end of the speech analyzer its analitiko-synthetic function suffers that is clinically expressed in difficulty of word formation, the articulation falls apart, the ekforiya (reproduction) of words is complicated. The correct repetition by the patient of the heard words is complicated or it is impossible, except for those which he says. Rechekinestetichesky temporary bonds are lost, but not slowed down, as at transcortical motor And. Since rechekinesteticheskiya and recheslukhovy analyzers are in close interrelation, at damage of one analyzer is broken to a certain extent and function of another therefore at cortical motor And. the phenomena touch are observed And. and vice versa; at patients the letter and reading which are also connected with these analyzers suffer.
At subcortical motor And. not the rechekinestetichesky analyzer, but its conduction paths is struck. At this form as well as at cortical, word formation, and usually in such sharp degree is broken that the patient is able to pronounce only a few words. But, unlike cortical motor And., touch speech temporary bonds are kept. The understanding, sometimes preservation of ability to read silently and to write is explained by patients of the speech it.
Motor cortical aphasia it is described also under the names «expressional aphasia», «verbal aphasia of Brock». Disturbance of all components of the expressional speech is characteristic, the spontaneous speech is especially complicated. The speech is deprived of expressiveness, obscure, slowed down, with searches of proper words, the pronounced words are distorted, paraphasias literal (replacement, shift of syllables) and verbal are noted (replacement, shift of words). Grammatical creation of the speech wrong, there are no inducement and conjugations (agrammatism), so-called cable style prevails — the speech consists hl. obr. from nouns in the Nominative case, verbs in an uncertain form sometimes meet, it is a lot of exclamations. At easy forms of motor aphasia only the correct creation of phrases is broken. In hard cases of the patient can pronounce only the remained single words, syllables (a speech embolus). The internal speech is violated. The understanding of separate words, short phrases is kept, the understanding of long phrases can be difficult. Reading, the letter, the account are broken, the amusia (loss of ability to reproduce musical rhythms, melodies, etc.) is possible.
Motor subcortical aphasia, pure motor aphasia of Dezherin. This form was described Brock under the name «aphemia».
At motor subcortical aphasia the expressional speech is sharply upset, the patient can pronounce only monosyllables, more often "yes", "no" or a combination of separate sounds; the repeated speech is impossible. The understanding of the speech, the internal speech are kept what lack of any touch speech disturbances testifies to. According to the offer investigating the patient can show of how many letters the word consists, a cut he cannot say, specifies mistakes in incorrectly constructed phrases. At communication with people around of the patient pronounces the word which is available at his order with the intonation adequate to what he wants to express, .chto is followed by an expressive mimicry and gesticulation. There can be safe a possibility of independent reading about itself.
Motor transcortical aphasia, studied generally at vascular damages of a brain, it is characterized by sharp dissociation between the repeated and spontaneous speech. In the absence of the last or its sharp difficulty patients freely repeat pronounced investigating words, can read aloud and take dictation. A pronunciation of words clear, only at some patients insignificant disturbances of an articulation which they notice are sometimes noted and try to correct. The independent letter is violated in the same degree, as well as the spontaneous speech, understanding of the speech (oral, written) kept. Repetition by the patient of the heard words is not ekholalichesky reaction. He can answer the question asked it, reproducing in the answer the heard words, at the same time, that especially important, it makes grammatical correct phrase, enters the necessary pretexts. So, in the Nominative case and verbs in an uncertain form of the patient easily builds the phrase with grammatical correct approvals of the offered nouns. At transcortical And. one of the main properties of cortical activity — systemacity is kept. I. P. Pavlov considered that the monotony of grammatical forms absolutely matches earlier established fact of systemacity in nervous processes of the working hemispheres. The dialogical form of the speech already soon after a stroke becomes possible; the patient uses the words which are available in questions in the answer. The narrative speech is sharply upset. Further at patients the active vocabulary extends more and more, it is preferential at the expense of nouns, recovery of verbs considerably lags behind. Unlike anamnestic And., the subnarration, naming of the first syllable do not help with reproduction of the forgotten word.
Conduction aphasia treats group motor afaticheskikh frustration. The narrative speech is sharply upset, words are distorted, many literal and verbal paraphasias are noted, at the same time the separate correctly pronounced words and phrases can meet. The understanding of the speech of people around is kept. Main symptom conduction And. — disturbance of the repeated speech — has the features. Unlike similar disturbance at other forms A., the words which are correctly said spontaneously in a context are sharply distorted when patients try to repeat them according to the offer of investigating. At cortical motor And. too repetition of words is complicated, but patients correctly repeat those words which they manage to be told spontaneously. Besides, it should be noted also that at cortical motor And. patients, trying to repeat the offered word, though reproduce it incorrectly, but to some extent keep the scheme of the word whereas at conduction And. patients at repetition say the sound combinations deprived of sense which do not have the slightest similarity to the word, a cut they were offered to repeat.
Touch cortical aphasia it is characterized by disturbance of understanding of the speech of people around. The patient perceives the speech as noise or a conversation on the unknown for it language. Elementary hearing is kept, phonemic is broken. Owing to absence or insufficiency of acoustical control the expressional speech for the second time falls apart. The patient speaks much and quickly (a logorrhea — a speech incontience). Perseverations — frequent repetition by patients of the same designations of a subject used in various phrases or separate syllables in the pronounced words are observed. His speech is unclear for people around, many paraphasias, literal and especially verbal are noted. Sometimes it represents a flow of senseless, inarticulate sound combinations («slang aphasia», «verbal salad»). Often there is no awareness of the defect. The repeated speech, reading, the letter are violated. In more mild cases of the patient catches in someone else's speech sense of separate words, short phrases, especially most often used. Quite often the acalculia — disturbance of ability to make arithmetic operations meets. The patient confuses figures, categories (e.g., 36 and 63; IV and VI), signs (+ and —). The acalculia usually meets at touch And., combined with semantic. At an acalculia the centers of defeat in the left hemisphere are found (in right-handed persons), it is preferential in parietooccipital area.
At touch subcortical aphasia ability to speak, write, read at impossibility of repetition of the words told the patient and letters from dictation is kept.
Distinctiveness touch transcortical aphasia the possibility of the correct repetition of the offered words and small phrases at disturbance of understanding of someone else's speech is. In the spontaneous speech of patients grammatical constructions remain. Also lengthening of stage of latency for understanding of the words offered investigating is noted. Reading aloud and the letter from dictation without understanding written is possible.
Quite often the combination touch and motor transcortical meets And. From speech functions in these cases only the repeated speech is kept.
Anamnestic aphasia (see. Amnesia ) it is characterized by a zabyvaniye of the name of objects, names. The forgotten name of the word is replaced with its description. The patient remembers the proper word at the hint of an initial syllable, its letter at once. The understanding of the speech is not broken. Reading is aloud possible. The spontaneous letter is upset because of the main defect, the letter is from dictation possible.
Total aphasia. The speech, receptive and expressional, in all its manifestations is lost. Trying to speak, the patient can sometimes say this or that sound. Emergence total And. it is observed most often at acute disorders of cerebral circulation, ischemic and hemorrhagic, in a zone of vascularization of deep and superficial branches of an average brain artery. In cases with a lethal outcome on section the extensive defeat of a dominant hemisphere including speech zones is found. In many cases total And. is exposed in a varying degree to involution (reduction of vascular and neurodynamic frustration); usually at first the receptive speech is recovered.
Alalias are often combined with other neurologic symptoms: a hemiplegia or a hemiparesis, a hemianaesthesia, a hemianopsia (at touch And.).
The research of aphotic frustration
the Research of aphotic frustration is made according to a certain scheme with studying whenever possible of all parties of speech activity.
Research of expressional function of the speech. At a research of the spontaneous speech of the patient ask to tell a story to the disease, contents of the shown pictures, to retell just listened story, etc. The dialogical speech is investigated, suggesting the patient to answer questions of different complexity. In the course of the research of the repeated speech of the patient repeats for investigating separate letters, syllables, short and long phrases, difficult pronounced words. The automated speech is investigated, suggesting the patient to count from 1 to 20 and upside-down, to retell the alphabet, to end begun investigating a proverb, the familiar song.
Research of receptive function of the speech. At a research of understanding of the speech of the patient shall show called investigating objects, parts of a body, to follow simple and difficult verbal instructions (to thumb a nose, to narrow eyes etc.), to correct incorrectly made grammatical and on sense of the offer, to explain sense of metaphors («clever fingers», «iron health» etc.).
Research of reading. Check whether the patient understands the handwritten and printing text read silently, suggest to carry out written instructions, check reading aloud.
Research of the letter. Check the spontaneous letter, ability to write dictations, to write off.
Research of the account. Check the written account and oral: various arithmetic actions, written and oral problems of different complexity. It is necessary to find out what hemisphere is dominant at this patient. It is necessary to exclude a possibility of the hidden left-handedness on the basis of poll, on it can specify also cases of left-handedness in a family of the patient. For detection of the hidden left-handedness several tests are offered: crossing of hands on a breast, at the same time the right hand (at right-handed persons) is from above; to put fingers of hands — the thumb of the right hand will be also from above.
In order to avoid the wrong conclusions it is not necessary to make a research of the speech at the patients who are in a condition of an oglushennost, confusion. It must be kept in mind the raised tormozimost and an exhaustion of patients with And. At exhaustion, in unfamiliar society their speech can worsen.
the Diagnosis does not represent difficulties. It is necessary to exclude an anarthria, a dysarthtia, to be convinced of safety of hearing. It must be kept in mind that at deep decrease in intelligence gross violation of oral speech and its understanding can be observed. At a speech akineziya (lack of motivation to the speech) a different etiology of the patient, unlike the patient A., does not do attempts to speak.
the Question of the forecast of aphotic frustration in literature is taken a little up. Undoubtedly, it in many respects depends on the nature of a disease of a brain, at Krom there were aphotic frustration. At the favorable course of a disease speech frustration can regress considerably or disappear completely. In particular, by data A. R. Luriya, in big percent of cases is observed recovery of the speech at traumatic A. Ukazyvalos that at a hematencephalon the speech is recovered better, than at fibrinferment of brain vessels. Under equal conditions of subjects there are more chances of recovery or improvement of the speech, than the patient is younger. About dependence of the forecast on a form of aphotic frustration literary data are especially limited. Some authors consider that the forecast is generally better at motor, than at touch A.
Vydelennye classics clinical forms A. the currents substantially depending on their pathophysiological features have the features; predictively is optimum transcortical And., both motor, and touch. In cases when there was a combination touch and motor transcortical And., at first the understanding of the speech is recovered. At many patients the speech is practically recovered in the previous form, but patients note that at sharp exhaustion or at contagious excitation they suddenly forget separate words. Speed with which the speech is recovered is various at different patients. At a number of patients recovery of the speech happens spontaneously in short terms (in several days, weeks), but there pass months more often. Recovery of the speech at transcortical And. is result of a disinhibition of the corresponding speech analyzer. At conduction And. also perhaps in some cases considerable improvement of the speech that, apparently, it is necessary to carry hl. obr. at the expense of the mechanism of a disinhibition. At the aphotic frustration referred to the first group, the forecast is worse, than at And. the second group, the forecast at subcortical A. Odnako at special training at a number of the patients suffering from cortical forms A is especially adverse., perhaps certain improvement owing to compensation of speech defect and possible participation of a subdominant hemisphere.
Patients with And. need treatment of a basic disease and at indications in recovery logopedic training.
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P. A. Tkachyov.