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substitutions, especially for consonants The most notable feature of this type of speech disorder is its transience; within a few weeks or months, language is restored to normal Bastian and more recently other authors have called this syndrome aphemia, a term that was used originally by Broca in another context to describe the severe motor aphasia that now carries his name Probably the syndrome is closely allied to the mini-Broca s aphasia described on page 417 The anatomic basis of pure word mutism has not been determined precisely In a few postmortem cases, reference is made to a lesion in Broca s area Damasio and Geschwind have stated that the lesion is anterior and superior to this area A well-studied case has been reported by Roch-LeCours and Lhermitte Their patient uttered only a few sounds for 4 weeks, after which he recovered rapidly and completely From the onset of the stroke, the patient showed no disturbance of comprehension of language or of writing Autopsy disclosed an infarct that was con ned to the cortex and subjacent white matter of the lowermost part of the precentral gyrus; Broca s area, one gyrus forward, was completely spared Other cases have involved mainly Broca s area Anomic (Amnesic, Nominal) Aphasia Some degree of word nding dif culty is probably part of every type of language disorder, including that which occurs with the confusional states and dementia In fact, without an element of anomia, a diagnosis of aphasia is usually incorrect Only when this feature is the most notable aspect of language dif culty is the term anomic aphasia employed In this latter condition, a relatively uncommon form of aphasia, the patient loses only the ability to name people and objects There are typical pauses in speech, groping for words, circumlocution, and substitution of another word or phrase that is intended to convey the meaning Perseveration may be prominent Or the patient may simply fail to name a shown object, in contrast to the usual aphasic patient, who produces a paraphasic error Less frequently used words give more trouble When shown a series of common objects, the patient may tell of their use, or demonstrate the same, instead of giving their names The dif culty applies not only to objects seen but to the names of things heard or felt (Geschwind), but this is more dif cult to demonstrate In addition to displaying normal uency of spontaneous speech and preserved comprehension and repetition, the patients we have seen with anomic aphasia have been surprisingly adept in spelling Beauvois and coworkers have described a form of bilateral tactile aphasia due to a left parieto-occipital lesion in which objects seen and verbally mentioned could be named, but not those felt with either hand Recall of the names of letters, digits, and other printed verbal material is almost invariably preserved, and immediate repetition of a spoken name is intact That the de cit is principally one of naming is shown by the patient s correct use of the object and, usually, by an ability to point to the correct object on hearing or seeing the name and to choose the correct name from a list The patient s understanding of what is heard or read is normal There is a tendency for patients to attribute their failure to forgetfulness or to give some other lame excuse for the disability, suggesting that they are not completely aware of the nature of their dif culty Of course, there are patients who fail not only to name objects but also to recognize the correct word when it is given to them In such patients, the understanding of what is heard or read is not normal, ie, the naming dif culty is but one symptom of another type of aphasic disorder.

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Anomic aphasia has been associated with lesions in different parts of the language area, classically in the left temporal lobe In these cases the lesion has been deep in the basal portion of the posterior temporal lobe or in the middle temporal convolution, in position to interrupt connections between sensory language areas and the hippocampal regions concerned with learning and memory Mass lesions such as a tumor, herpes encephalitis, or an abscess are the most frequent causes; as these lesions enlarge, a contralateral upper quadrantic visual eld defect or a Wernicke s aphasia is added Occasionally, anomia appears with lesions due to occlusion of the temporal branches of the posterior cerebral artery, and it s in these instances that we have seen the most dramatic cases, usually associated with a right hemianopia and alexia but normal writing ability Anomia may be a prominent manifestation of transcortical motor aphasia (see below) and may be associated with the Gerstmann syndrome, in which case the lesions are found in the frontal lobe and angular gyrus, respectively An anomic type of aphasia is often an early sign of Alzheimer and Pick disease (minor degrees of it are common in old age) and is a principal feature of a number of the degenerative lobar cerebral atrophies (see Chap 39) Finally, anomic aphasia may be the only residual abnormality after partial recovery from Wernicke s, conduction, transcorticosensory, or (rarely) Broca s aphasia (Benson) Isolation of the Language Areas (Transcortical Aphasias) The identifying feature of these language disturbances is a preservation of the ability to repeat Destruction of the vascular border zones between anterior, middle, and posterior cerebral arteries usually as a result of prolonged hypotension, carbon monoxide poisoning, or other forms of anoxic-ischemic injury may effectively isolate the intact motor and sensory language areas, all or in part, from the rest of the cortex of the same hemisphere In the case reported by Assal and colleagues, for example, multiple infarcts had isolated all of the language area In transcortical sensory aphasia, so named by Lichtheim and further de ned by Goldstein, the patient suffers a de cit of auditory and visual word comprehension, making writing and reading impossible Speech remains uent, with marked paraphasia, anomia, and empty circumlocutions; however, unlike the de cit in Wernicke s and conduction aphasia, the ability to repeat the spoken word is preserved Facility in repetition, in extreme degree, takes the form of echoing, parrot-like, word phrases and songs that are heard (echolalia) In a series of 15 such patients, CT and isotope scans have uniformly disclosed a lesion in the posterior parieto-occipital region (Kertesz et al) This locale explains the frequent concurrence of transient visual agnosia and hemianopia In general, this disorder has a good prognosis Presumably, in transcortical sensory aphasia, information from the nonlanguage areas of the cerebrum cannot be transferred to Wernicke s area for conversion into verbal form The paraphasia is thought to result from the weakened control of the motor language areas by the auditory and visual areas, though the direct connection between them, presumably the arcuate fasciculus, is preserved Preservation of this direct connection is said to account for the ability to repeat Reading and auditory comprehension suffer because the sensory information does not reach the central integrative centers In transcortical motor aphasia ( anterior isolation syndrome, dynamic aphasia of Luria) the patient is unable to initiate conversational speech, producing only a few grunts or syllables Comprehension is relatively preserved, but repetition is strikingly intact,.