Journal of the History of the Neurosciences

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Patient Tan Revisited: A Case of Atypical Global

Aphasia?

Ola A. Selnes & Argye Hillis

To cite this article: Ola A. Selnes & Argye Hillis (2000) Patient Tan Revisited: A Case of
Atypical Global Aphasia?, Journal of the History of the Neurosciences, 9:3, 233-237, DOI:
10.1076/0964-704X(200012)9:3;1-A;FT233

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Journal of the History of the Neurosciences 0964-704X/00/0903-233$15.00
2000, Vol. 9, No. 3, pp. 233–237 © Swets & Zeitlinger

Patient Tan Revisited:

A Case of Atypical Global Aphasia?*
Ola A. Selnes and Argye Hillis
Department of Neurology, Division of Cognitive Neurology, Johns Hopkins University School of Medicine

ABSTRACT

Broca’s first patient presented in support of a relationship between a lesion of the frontal lobe and aphasia
was patient Tan. Although Pierre Marie refers to this case as ‘‘indisputably aphasia of Broca,’’ the clinical
diagnosis of Tan’s aphasia has not been re-examined in light of current clinical criteria. Superficially, the
patient’s extremely limited verbal output and intact comprehension appear to fit with the diagnosis of
Broca’s aphasia, but a more thorough examination of the onset, evolution and nature of the patient’s speech
symptoms suggests alternate interpretations. Contemporary evidence in support of a robust relationship
between stereotypical utterances and Global aphasia suggests that patient Tan may have suffered from a
Global rather than Broca’s aphasia.

INTRODUCTION have combined to make this a pivotal case

There is very little question that Broca’s 1861
paper entitled ‘‘Remarks on the seat of the fac-
ulty of articulate language’’ (Broca, 1861) in
which he describes a patient with aphasia sec-
ondary to a frontal lobe lesion, represents a turn-
ing point in the history of the neurosciences.
Finger states that this may be ‘‘the most impor-
tant clinical paper in the history of cortical lo-
calization’’(Finger, 1994). He also suggests sev-
eral reasons why Broca’s initial case made such
an impact, considering the less successful previ-
ous arguments in favor of cortical localization of
speech by distinguished scientists such as Ernest
Auburtin and Jean-Baptiste Bouillaud. The im-
pact of Broca’s case is perhaps even more sur-
prising in light of its numerous shortcomings
from a clinico-pathological point of view. None-
theless, the richness of the clinical description of
the case, the detailed anatomical description of
the lesion, together with Broca’s highly re-
spected status as a clinician and scientist may
(Sondhaus and Finger, 1988).
Although there has been considerable discus-
sion concerning the nature, size and location of
the lesion in patient Tan (Marie, 1906; Moutier
1908; Signoret et al., 1984), there is some agree-
ment that CT scans of the brain show a lesion
consistent with the clinical picture of Broca’s
aphasia (Mohr et al., 1999). Relatively little at-
tention has been paid to the actual nature of pa-
tient Tan’s aphasia. There appears to be a tacit
agreement that he, regardless of the specific eti-
ology of his speech disorder, suffered from what
has subsequently become known as Broca’s
aphasia. Even Pierre Marie, one of Broca’s
toughest critics, characterized patient Tan as a
case of ‘‘indisputably aphasia of Broca’’ (Marie,
1906). MacDonald Critchley, on the other hand,
states that ‘‘correctness of the clinical diagnosis
has since been challenged,’’ but does not pro-
vide any further details (Critchley, 1960). Le-
brun discussed the possibility that the speech
disorder described by Broca corresponds to what

Address correspondence to: Ola A. Selnes, Ph.D., Meyer 222, 600 N Wolfe St., Baltimore, MD 21287, USA.
Tel.: 410-955-1696. Fax: 410-614-7472. E-mail: oselnes@jhmi.edu
* Paper presented at the 3rd Annual Meeting of the International Society for the History of the Neurosciences
Annapolis, MD June 7-9th, 1998.
234 OLA A. SELNES AND ARGYE HILLIS
we today would call anarthria. However, he con-
cludes that patient Tan ‘‘is an extreme case of
Broca’s aphasia’’ (Lebrun, 1982). Many apha-
siologists today would distinguish anarthria
from Broca’s aphasia, in that the former implies
impaired neuromuscular function in both speech
and non-speech movements. By contrast,
Broca’s aphasia implies impaired planning of
motor sequences for speech.
At the risk of adding more confusion to an
already complex case, we wish to expand on an
idea previously suggested by Poeck and col-
leagues (Poeck, De Bleser, and Keyserlingk,
1984) and also briefly mentioned by Boller
(Boller, 1978) to the effect that Broca’s first
patient may have had an atypical Global aphasia.
Although the absence of several critical pieces
of information makes it difficult to ‘‘prove’’
such a claim, we believe that several lines of
evidence are consistent with this interpretation.
TAN’S SPEECH DISORDER
The critical piece of clinical evidence that sug-
gests that patient Tan may have had a Global
aphasia is the nature of his speech output. It was
described as being limited to repetitions of the
syllables ‘‘tan,’’ repeated twice. Only limited
information is available concerning the articula-
tion of these recurrent syllables: ‘‘le timbre de
la voix était naturel, et les sons que le malade
rendait pour prononcer son monosyllabe étaient
parfaitment purs’’ (Brocca, 1861, p. 345) [the
timbre of the voice was natural, and the sounds
which the patient uttered to pronounce his
monosyllable were perfectly pure]. There is no
mention of articulatory struggle, slowness, or
imprecise articulation, as would be expected
with standard Broca’s aphasia. We do know,
however, that these repetitive utterances were
augmented by an occasional swear-word if lis-
teners did not appear to understand the point that
Tan was trying to make.
An important piece of evidence concerning
the patient’s speech difficulty is unfortunately
missing. The nature of the onset of his symp-
toms is not known. Was the onset sudden or was
there a gradual or stuttering course of onset?
Was the onset associated with other symptoms
or behavioral changes? (‘‘On n’a pu savoir si la
perte de la parole était survenue lentement ou
rapidement , ni si quelque autre symptôme avait
accompagné le début de cette affection.’’ p. 343)
[One could not find out whether this loss of
speech came on slowly or fast, nor whether
some other symptoms accompanied the begin-
ning of this affection]. Broca estimates that by
the time Tan arrived at Bicêtre, he had been un-
able to speak for approximately 2 or 3 months.
What we do know, however, is that there was no
evidence of improvement of his verbal output
over the several years that he spent at Bicêtre.
At the time when he was examined by Broca and
by Auburtin, 21 years after the onset of his
aphasia, his speech output was still limited to
‘‘tan-tan’’ and an occasional swear-word.
Although no further details are provided
about the nature of Tan’s speech, Broca does
include a more general description of the speech
characteristics of aphasia in the first part of the
article:
... leur vocabulaire, si l’on peut dire, ainsi, se
compose d’une court série de syllabes,
quelquefois d’un monosyllabe qui exprime
tout, ou plutôt qui n’exprime rien, car ce mot
unique est le plus souvent étranger à tous les
vocubulaires. Certain malades n’ont même
pas ce vestige du langage articulé; ils font de
vains efforts sans prononcer une seule
syllabe.’’ (p. 332)
[their vocabulary, if one can use that word, is
composed of a short series of syllables, some-
times of a monosyllable which expresses ev-
erything, or rather expresses nothing, for this
single word is most often than not foreign to
all vocabularies. Some patients do not even
have this vestige of articulate language; they
make vain efforts without pronouncing a sin-
gle syllable].
Thus, Broca describes several features of im-
paired speech that subsequently have become
known as stereotypical utterances.
 PATIENT TAN’S APHASIA
THE SIGNIFICANCE OF STEREOTYPICAL
UTTERANCES
Starting with Hughlings Jackson, who recog-
nized four major subtypes of recurrent stereo-
typical utterances (Hughlings-Jackson, 1880),
several authors have since considered stereotyp-
ical utterances as diagnostic of severe aphasia
(Stachowiak et al., 1977; Brunner et al., 1982).
It is only more recently, however, that system-
atic studies of patients with stereotypical utter-
ances have established an association between
this type of speech output and Global Aphasia
(Poeck, De Bleser, and Keyserlingk, 1984; Blan-
ken et al., 1988; Blanken, Wallesch, and
Papagno, 1990). Therefore, it is perhaps not sur-
prising that the speech output of Broca’s first
patient has not been re-examined in the light of
this more recent evidence.
Several studies have concluded that stereo-
typical utterances are characteristic of patients
with Global aphasia. For example, Poeck and his
colleagues (Poeck, De Bleser, and Keyserlingk,
1984) concluded that recurrent stereotypical ut-
terances are uniquely associated with Global
aphasia. Furthermore, they propose that patients
who produce exclusively stereotypical utter-
ances with some degree of preserved prosody
have a fluent subtype of Global aphasia. Others
have also concluded that stereotypical utterances
are characteristic of patients with Global aphasia
(Blanken et al., 1988).
Although stereotypical utterances of the type
produced by patient Tan may in very rare in-
stances occur in patients whose speech and lan-
guage characteristics otherwise fit the syndrome
of Broca’s aphasia, it is quite clear that this is
the exception rather than the rule. It is also
likely that whenever this does occur, it is in pa-
tients who are initially globally aphasic but
whose auditory comprehension improves to the
point where they can no longer be classified as
Global, and thus by default become classified as
having Broca’s aphasia. The only large scale
study of stereotypical utterances is retrospective
(Code, 1982). It concluded that 26% of patients
with non-word recurrent utterances were classi-
fied as Broca’s aphasia; however, the number of
these patients who were recovered Global apha-
235
sics was not indicated. Moreover, information
was collected through questionnaires, and no
definition of what constituted a stereotypical
utterance was provided, which makes it difficult
to interpret the significance of these data.
In addition to the less well known association
of stereotypical utterances with Global aphasia,
there are other reasons why contemporary apha-
siologists may not have questioned the clinical
diagnosis of Broca’s first patient. For example,
patient Tan’s ability to comprehend speech was
judged to be relatively intact, which would
clearly be less consistent with Global aphasia.
Because patient Tan could neither speak nor
write, however, the assessment of his auditory
comprehension was obviously a challenge. He
would indicate his responses by gestures with
his left hand. Thus, Broca states, ‘‘notre
moribond ne pouvait pas se faire comprendre
aussi bien qu’il comprenait les autres.’’ (p. 345-
6) [...our moribund patient could not make him-
self understood as well as he could understand
others].
TAN’S COMPREHENSION
Since early reports of aphasia generally did not
comment in much detail on the patient’s ability
to comprehend speech, Broca’s description of
Tan’s comprehension is surprisingly detailed
(Boller, 1978). Before Wernicke, language was
generally thought of as verbal expression or
speech, whereas language comprehension was
thought to relate more to general cognitive abili-
ties or intelligence (Whitaker and Etlinger,
1993). Broca mentions in his paper that articu-
late language is probably more important and
more complex than comprehension (‘‘le plus
important et probablement les plus complexe’’ ,
p. 332). Broca introduces the paragraph in which
he describes Tan’s level of comprehension with
the following sentence: ’’L’état de l’intelligence
n’a peu être exactement déterminé.’’ [The state
of his intelligence could not be determined very
precisely].
He then goes on to explain that Tan appeared
to understand most questions asked of him, de-
spite being limited to the use of his left hand to
236 OLA A. SELNES AND ARGYE HILLIS
indicate his responses. He did particularly well
with numerical responses, and could indicate,
for example, how many days he had been sick.
He sometimes answered 5 days, sometimes 6
days. He could indicate the correct hour when
Broca showed him his watch. Broca concludes
from this: ‘‘Il est donc incontestable que cet
homme était intelligent, qu’il pouvait ré-
fléchir...’’ (p. 346) [It is therefore indisputable
that this man was intelligent, that he could
think...].
Nonetheless, Broca expresses concern that
Tan’s comprehension may not have been en-
tirely normal. He states that Tan gave no re-
sponse to several questions that ‘‘a man of aver-
age intelligence should have been able to re-
spond to.’’ In addition, he notes that Tan would
express great irritation if the listener did not
fully understand his responses. In some cases,
Tan’s responses were unambiguous, yet incor-
rect. For example, he had no children, but none-
theless responded affirmatively when asked if he
had children. Broca concludes that there is little
doubt that there has been a profound decline in
Tan’s intelligence, but despite of this, Tan ap-
peared to have more than enough intelligence to
carry on a conversation (p. 346).
In discussing patient Tan’s level of compre-
hension, Poeck and his colleagues conclude that
his comprehension may not have been ade-
quately challenged by virtue of the ‘‘limited de-
mands on comprehension in a patient institution-
alized for twenty-one years in an asylum of the
mid-19th century.’’ In his review of the history
of comprehension disorders in aphasia, Boller
(1978) also raises the possibility that patient
Tan, based on his comprehension, may fit the
clinical category of Global rather than Broca’s
aphasia, but does not elaborate further.
There is also another consideration. Level of
comprehension in patients with Global aphasia
depends on how it is tested. As noted by
Goodglass and Kaplan (1983), patients with
Global aphasia may perform surprisingly well if
asked questions of immediate personal rele-
vance. They also note that many patients with
Global Aphasia often understand geographic
place names quite well and can locate them on
an outline map. Other authors have demon-
strated that patients with Global aphasia perform
significantly above chance on tasks such as sort-
ing out the odd item from a list of semantically
related items (Deloche, Andreewsky, and Desi,
1981).
There is another feature of Broca’s initial
case that would have made the contemporary
diagnosis of global aphasia somewhat unlikely.
As Pierre Marie pointed out, Global aphasia un-
accompanied by hemiparesis is sometimes seen,
but it is not common. It is known that by the
time patient Tan arrived at Bicêtre, approxi-
mately 2-3 months after the onset of his speech
symptoms, he was not hemiplegic. Today,
Global aphasia without hemiplegia is still un-
common, but certainly well-recognized as a
clinical entity (Damasio, 1992; Legatt et al.,
1987). The time course of Tan’s neurological
symptoms, with slowly progressive hemiplegia
first involving his right arm and subsequently
his right leg after the onset of his aphasia, has
added further enigma to the etiology of this un-
fortunate patient’s brain injury.
Patient Tan’s language disorder clearly fit
with Broca’s concept of aphemia, as defined by
him in his 1861 paper. The clinical concept of
Broca’s aphasia has evolved considerably over
time, however. As a consequence, this review of
the clinical evidence supports the somewhat par-
adoxical conclusion that although patient Tan is
generally thought of as being a prototypical ex-
ample of Broca’s aphasia, his clinical presenta-
tion may have been more consistent with what
we today would think of as Global aphasia.
ACKNOWLEDGEMENT
The authors thank Dr. Harry A. Whitaker for helpful
comments and Dr. Pamela Tallay for her editorial
assistance.
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