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distinguishing this syndrome from pure word mutism (see above) Transcortical motor aphasia occurs in two clinical contexts: (1) in a mild or partially recovered Broca s aphasia in which repetition remains superior to conversational speech (repeating and reading aloud are generally easier than self-generated speech) and (2) in states of abulia and akinetic mutism with frontal lobe damage, for the same reason Several of our cases have resulted from infarctions in the watershed zone between the anterior and middle cerebral arteries, after cardiac arrest or shock These transcortical syndromes are of great theoretical interest and are probably more common than is currently appreciated Foreign Accent Syndrome This rare but peculiar (and somewhat amusing) condition de es classi cation but is worthy of comment because it may be mistaken for hysteria or psychosis An accent that is vague but distinctly foreign replaces the patient s native language The syndrome arises after a left-sided lesion, most often a stroke; and a mild Broca s aphasia is usually associated Although the accent may be interpreted by the listener as compatible with German, Spanish, French, Asian, or another nationality, authoritative analysis of the speech pattern indicates that the alterations are not speci c to any genuine language and are simply attributed by the listener to a known foreign accent Usually this aberration is encountered as a transient phenomenon during recovery from stroke The relation to disorders of prosody is unclear An extensive analysis of one case and references can be found in the article by Kurowski and colleagues

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Writing is, of course, an integral part of language function, but a less essential and universal component, for a considerable segment of the world s population speaks but does not read or write It might be supposed that all the rules of language derived from the study of aphasia would be applicable to agraphia In large part this is true One must be able to formulate ideas in words and phrases in order to have something to write as well as to say; hence disorders of writing, like disorders of speaking, re ect all the basic defects of language But there is an obvious difference between these two expressive modes In speech, only one nal motor pathway coordinating the movements of lips, tongue, larynx, and respiratory muscles is available, whereas if the right hand is paralyzed, one can still write with the left one, or with a foot, and even with the mouth by holding a pencil between the teeth The writing of a word can be accomplished either by the direct lexical method of recalling its spelling or by sounding out its phonemes and transforming them into learned graphemes (motor images) ie, the phonologic method Some authors state that in agraphia there is a speci c dif culty in transforming phonologic information, acquired through the auditory sense, into orthographic forms; others see it as a block between the visual form of phonemes and the cursive movements of the hand (Basso et al) In support of the latter idea is the fact that reading and writing usually develop together and are long preceded by the development and elaboration of auditory-articular mechanisms Pure agraphia as the initial and sole disturbance of language function is a great rarity, but such cases have been described, as summarized in the review of Rosati and de Bastiani Pathologically veri ed cases are virtually nonexistent, but CT examination of this case disclosed a lesion of the posterior perisylvian area This is in keeping with the observation that a lesion in or near the angular.

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gyrus will occasionally cause a disproportionate disorder of writing as part of the Gerstmann syndrome As mentioned earlier, the notion of a speci c center for writing in the posterior part of the second frontal convolution ( Exner s writing area ) has been questioned by some aphasiologists (see Leischner) However, Croisile and associates do cite cases of pure dysgraphia in which a lesion (in the case they reported, a hematoma) was located in the centrum semiovale beneath the motor parts of the frontal cortex Quite apart from these aphasic agraphias, in which spelling and grammatical errors abound, there are special forms of agraphia caused by abnormalities of spatial perception and praxis Disturbances in the perception of spatial relationships appear to underlie constructional agraphia In this circumstance, letters and words are formed clearly enough but are wrongly arranged on the page Words may be superimposed, reversed, written diagonally or in haphazard arrangement, or from right to left; in the form associated with right parietal lesions, only the right half of the page is used Usually one nds other constructional dif culties as well, such as inability to copy geometric gures or to make drawings of clocks, owers, and maps, etc A third group may be called the apraxic agraphias Here language formulation is correct and the spatial arrangements of words are respected, but the hand has lost its skill in forming letters and words Handwriting becomes a scrawl, losing all personal character There may be an uncertainty as to how the pen should be held and applied to paper; apraxias (ideomotor and ideational) are present in the right-hander As a rule, other learned manual skills are simultaneously disordered Speculations as to the basic fault here are discussed in Chap 3, under Apraxia and Other Nonparalytic Disorders of Motor Functions, and in Chap 22, in relation to the functions of the frontal and parietal lobes In addition to the neurologic forms of agraphia, described above, psychologists have de ned a group of linguistic agraphias, subdivided into phonologic, lexical, and semantic types (Roeltgen) These linguistic models are based on loss of the ability to write (and to spell) particular classes of words For example, the patient may be unable to spell pronounceable nonsense words, with preserved ability to spell real words (phonologic agraphia); or there may be preserved ability to write nonsense words but not irregular words, such as island (lexical agraphia); patients with semantic agraphia have dif culty incorporating meaning into the written word, eg, the moon comes out at knight For the most part these linguistic agraphias have no well-established cerebral localization and only tenuous associations with the classic aphasias, for which reason this subject is of greater interest to linguists and psychologists than to neurologists.