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what is said to him, despite relatively adequate comprehension the hallmark of conduction aphasia Contrariwise, normal repetition in an aphasic patient (transcortical aphasia) indicates that the perisylvian area is largely intact In fact, the tendency to repeat may be excessive (echolalia) Preserved repetition is also characteristic of anomic aphasia and occurs occasionally with subcortical lesions Disorders con ned to naming, other language functions (reading, writing, spelling, etc) being adequate, are diagnostic of amnesic, or anomic, aphasia and referable usually to lower temporal lobe lesions These de cits can be quanti ed by the use of any one of several examination procedures Those of Goodglass and Kaplan (Boston Diagnostic Aphasia Examination, or BDAE) and of Kertesz (Western Aphasia Battery, or WAB) are the most widely used in the United States The use of these procedures will enable one to predict the type and localization of the lesion in approximately twothirds of the patients, which is not much better than detailed bedside examination Using these tests, aphasia of the Broca, Wernicke, conduction, global, and anomic types accounted for 392 of 444 unselected cases studied by Benson Treatment The sudden onset of aphasia would be expected to cause great apprehension, but except for cases of pure or almost pure motor disorders of speech, most patients show remarkably little concern It appears that the very lesion that deprives them of speech also causes at least a partial loss of insight into their own disability This reaches almost a ludicrous extreme in some cases of Wernicke s aphasia, in which the patient becomes indignant when others cannot understand his jargon Nonetheless, as improvement occurs, many patients do become discouraged Reassurance and a program of speech rehabilitation are the best ways of helping the patient at this stage Whether contemporary methods of speech therapy accomplish more than can be accounted for by spontaneous recovery is still uncertain Most aphasic disorders are due to vascular disease and trauma, and they are nearly always accompanied by some degree of spontaneous improvement in the days, weeks, and months that follow the stroke or accident A Veterans Administration Cooperative Study (Wertz et al) has suggested that intensive therapy by a speech pathologist does hasten improvement Also, Howard and colleagues have shown increased ef cacy of word retrieval in a group of chronic stable aphasics treated by two different techniques More studies of this type, which control for the effects of the patient s motivation and the interest of family and therapist, are needed In an interesting personal experiment by Wender, a classicist who had become aphasic, practice of Greek vocabulary and grammar led to recovery in that language, but there was little recovery of her facility with Latin, which was not similarly exercised One must decide for each patient when speech training should be started As a rule, therapy is not advisable in the rst few days of an aphasic illness, because one does not know how severe or lasting it will be Also, if the patient suffers a severe global aphasia and can neither speak nor understand spoken and written words, the speech therapist is virtually helpless Under such circumstances, one does well to wait a few weeks until one of the language functions has begun to return Then the physician and therapist can begin to help the patient to use that function to a maximum degree In milder aphasic disorders, the patient may be sent to the speech therapist as soon as the illness has stabilized The methods of language rehabilitation are specialized, and it is advisable to call in a person who has been trained in this eld.

However, inasmuch as the bene t is also psychologic, an interested family member or schoolteacher can be of help if a speech therapist is not available in the community Frustration, depression, and paranoia, which complicate some aphasias, may require psychiatric evaluation and treatment The developmental language disorders of children pose special problems and are considered in Chap 28 Prognosis and Patterns of Recovery Some aspects of prognosis have been discussed above In general, recovery from aphasia due to cerebral trauma is usually faster and more complete than that from aphasia due to stroke The type of aphasia and particularly its initial severity (extent of the lesion) clearly in uence recovery: global aphasia usually improves very little, and the same is true of severe Broca s and Wernicke s aphasias (Kertesz and McCabe) The various dissociative speech syndromes and pure word mutism tend to improve rapidly and often completely Also, in general, the outlook for recovery from any particular aphasia is more favorable in a left-handed person than in a right-handed one Characteristically, in the course of recovery, a severe aphasia of one type may evolve into another type (global into severe Broca s; Wernicke s, transcortical, and conduction into anomic) patterns of recovery that may mistakenly be attributed to the effects of therapy It is in part because so many factors may in uence the mode of recovery from aphasia that the effectiveness of formal speech therapy has never been fully evaluated

sonants (eg, la-la-la-la, me-me-me-me, or k-k-k-k) bring out the particular abnormality Disorders of phonation call for a precise analysis of the voice and its apparatus during speech and singing If necessary, the movements of the vocal cords should be inspected with a laryngoscope and those of the tongue, palate, and pharynx by direct observation

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