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Acute right hemiplegia and transient expressive aphasia occurred in a 7-year-old girl a few days after nonspecific constitutional symptoms and the appearance of a large right submandibular lymph node. Biopsy of this node and lack of other evident cause suggested a diagnosis of cat-scratch disease. Carotid arteriography showed a localized arteritis of the supraclinoid part of the left internal carotid artery and the left middle cerebral artery, involving also some lenticulostriate vessels. Computerized tomography demonstrated infarction in the left internal capsule. The size of this infarct and the angiographic abnormalities improved 6 weeks after onset, and coincided with clinical recovery. Cat-scratch disease may have caused the localized arteritis.

A 58-year-old woman developed acute, transient expressive aphasia and right arm weakness. Evaluation revealed subclinical cardiomyopathy and a ventricular mural thrombus that were attributed to adriamycin therapy. Adriamycin cardiomyopathy predisposed the patient to ventricular thrombus formation and subsequent arterial embolization.

Language and speech were studied in a young child with perinatally acquired bifrontal lesions. Bilateral frontal pathology seriously interfered with the development of intelligible speech and resulted in a persistent expressive aphasia. Analysis of the neuropsychological profile indicated impairments in intelligence and language comprehension. These deficits, however, were considered secondary to the profound speech programming disorder. The findings indicate that, despite the plasticity of the immature central nervous system, bilateral frontal injury sustained at an early age precludes the development of intelligible speech. Furthermore, structurally intact cortical regions outside the territories of the speech zones fail to mediate normal speech and language development.

A 3 year old boy who had acquired HIV infection transplacentally developed the classical features of AIDS encephalopathy, spastic diplegia and expressive aphasia. His computed tomogram showed cerebral atrophy. Treatment with zidovudine and weekly infusions of gammaglobulin led to considerable clinical improvement and an almost normal computed tomogram nine weeks later.

SYNOPSIS Information on the prevalence of headache in an ambulatory elderly population was collected from 1,284 participants in a health screening program in Dunedin, Florida. Association between headache and possible risk factors including age, sex, reported symptoms and diseases, drug use, physical characteristics, and sleep patterns were studied. Eleven percent of women and 5 percent of men reported frequent headaches. There was no relationship between age and reported headache in this elderly population. The most commonly reported positions for headache were frontal (35.2 percent) and all over (29.7 percent). In women there was a significant correlation between headache and the total number of other diseases and symptoms reported (p

Summary I. Classical clinical neurology rarely recognizes any reading ability in the right hemisphere (RH) of right handed adults. In particular, the syndrome of alexia without agraphia highlights the failure of the RH to read when the left angular gyrus is disconnected from visual stimuli. I suggest that the disconnection account of alexia without agraphia is inadequate. Following cerebral commissurotomy (split brain), the disconnected RHs seem mute but may have some capacity for phonological encoding as shown by recognition of pictures with homonymous or rhyming names. But the extent of phonological encoding in these RHs is insufficient to translate orthography into sound during RH reading. II. Such phonological encoding can also be preserved in acquired expressive aphasia in the absence of naming. Reading in the disconnected hemispheres of two complete commissurotomy patients and in the isolated hemispheres of three hemispherectomy patients was assessed with reading subtests from common aphasia batteries. The results show a pattern of reading in the disconnected RHs that is consistent with the hypothesis that the RH supports reading in many alexic aphasics. In particular, the disconnected RHs seem to read words “ideographically”, without intermediate translation of orthography into sound. III. Reading without phonological recoding, as well as a preponderance of semantic errors in RH misreadings, both suggest that the RH is particularly likely to support reading in cases of acquired “deep dyslexia”. Clinical testing of alexia should incorporate tasks requiring pointing to multiple choice pictures rather than speech responses, in the manner used for RH testing. IV. Together with data from reading following hemispherectomy and from hemifield studies in normal subjects, the split brain results suggest that interhemispheric interaction with the LH facilitates the involvement of the normal RH in reading beyond what is apparent in the disconnected RH. Congenital failure of such interhemispheric interaction may result in certain forms of developmental dyslexia.

SINCE THE PAPERS of Trotter,1Putnam, and Cushing2on chronic subdural hematoma were published, neurologists and neurosurgeons have been well aware of this entity. Its protean manifestations make its inclusion in the differential diagnosis of encephalopathy practically mandatory, especially when there is a history of trauma. In the following two cases, subdural hematoma was strongly suspected, but the final diagnosis in both was encephalopathy of unknown cause associated with trauma. Report of Cases Case 1.— Approximately five weeks before admission, a 73-year-old man was struck by a car and rendered unconscious. He was hospitalized elsewhere, his condition improved, and he was discharged after six days. During the ensuing weeks, he was more or less lethargic and withdrawn. Five days prior to hospitalization he began to have difficulty in walking and talking. He was disoriented to time, had a poor memory, and a mild expressive aphasia. The face-hand test

A 27-year-old woman with Peutz-Jeghers syndrome since age 11 years was hospitalized with a sudden onset of weakness of the right extremity, an expressive aphasia, and a three-month history of back pain. Liver and wholebody scintigrams demonstrated multiple metastatic disease; the brain scintigraphic study was compatible with infarction of the left hemisphere. Postmortem examination two weeks after these studies showed extensive metastases in bone, liver, brain, lung, and left ovary. The source of the metastases was a malignant change from Peutz-Jeghers polyps. (JAMA239:2268-2269, 1978)

Language disorders in children with congenital rubella syndrome (CRS) have usually been associated with autism, deafness or mental retardation, or to some combination of these. The present report concerns a child with CRS and expressive aphasia not attributable to the three named causes. This now 12 year old girl was born in Sept. 1964 to a mother who was exposed to and had symptoms consistent with rubella near the time of conception. Pregnancy lasted 42 weeks; birth wt. was 2380 gm (older sibs were 3600 and 4500 gm). No abnormalities were noted then or later. She could drink fluids without difficulty; she choked frequently on solids. There was drooling and “snorting” throughout childhood. Development was age-appropriate except for speech. She said “mama” at age 16 mos. but never progressed further. At age 4 a neurologist suggested an isolated bulbar palsy as the cause of the speech disorder. EEG was normal. Hearing is entirely normal. She is in an age-appropriate grade in public school, communicating with the aid of the sign language of the deaf, which has been taught to her by volunteers. She is aphasic with severe motor involvement of the lips and tongue. Performance is good on non-verbal developmental tests. In the evaluation of language disorders in children with CRS isolated neuromuscular disease such as shown by this patient should be considered.

• A 30-year-old man was admitted to the hospital with a history of sudden onset of bizarre behavior and difficulty in speaking that initially was attributed to drug intoxication. Examination disclosed a confused young man with receptive and expressive aphasia. A late systolic murmur was heard in the mitral area and echocardiography confirmed the presence of mitral valve prolapse. A computed tomographic scan of the head and cerebral angiography showed abnormalities consistent with an infarct of the left temporo-occipital region. Since no other predisposing factors were present, this patient's stroke was probably related to mitral valve prolapse. (Arch Intern Med1982;142:1215-1216)

To the Editor.— The usual signs and symptoms of acute cholecystitis have been well described.1The picture is one of a patient with pain in the right hypochondrium with associated vomiting and fever. The signs include tenderness with guarding and rigidity in the right hypochondrium, although fibrinous adhesions from the gallbladder to surrounding structures are common findings at the time of operation. A friction rub over the surface of the acutely inflamed gallbladder may not have been previously described.2The following case report illustrates this finding, not mentioned in standard texts. Report of a Case.— A 45-year-old white man with a history of aphasia and memory loss underwent an exploratory craniotomy, at which time a falx meningioma was removed through a left frontoparietal incision. The postoperative course was complicated by severe cerebral edema resulting in a marked expressive aphasia and dense right hemiplegia. Three weeks following surgery, the

To the Editor:— The beneficial effect of altitude on a patient with aphasia following cerebral thrombosis is worthy of note. The following information was received by an executive assigned to a post in Japan. While there his wife, who had accompanied him, suffered a major stroke. The onset of the cerebral vascular accident occurred April 6, 1964, at which time she lost her speech entirely, experiencing a partial paralysis of the right leg, right arm and hand with some paralysis of her face and mouth. In addition to the complete expressive aphasia, there appeared to be some receptive aphasia, including the inability to understand the written word, although she was alert to the spoken word. Within a few days she started to recover. First the use of the leg and arm gradually returned, followed by the ability to print very crudely a few words and to say one or two

Introduction Plan of the Research The Problem of Classification The Classification Adopted The Expressive Disorder The Receptive Disorder The Expressive-Receptive Disorder The Amnesic Disorder Cases of General Deterioration and Confusion with Aphasia Report of the Examination of an Interesting Case of Predominantly Expressive Aphasia The Regression of Symptoms Apraxia and Agnosia General Conclusions with Regard to the Control Group of Patients with Left Hemiplegia The Relation of Language and Thought Localization Summary and Conclusions INTRODUCTION Dr. Charles K. Mills, after whom this lecture is named, richly deserved this honor, for in the fifty years of his membership in the American Neurological Association his literary contributions to the scientific advancement of neurology were probably greater than those of any other member. His devotion and loyalty to the association are well shown in the fact that during his long membership he missed only one meeting. He was fortunate in that his work

Expressive aphasia has most generally been considered to be a loss in expressive language function as the consequence of destruction or damage of the cerebral cortex. While there has been considerable agreement concerning the facts of brain damage, substantial disagreement has attended attempts to define the mechanisms by means of which cortical destruction results in a disruption of speech and language. Explanations of mechanism have ranged from extreme localization theories, in which specific cytoarchitectonic areas have been identified as the loci of various expressive language functions, to general functional theories, such as that of Goldstein, 1 who argues in terms of the general reorganization of cortical properties and the modification of general psychological attributes. In the course of working with a population of patients with expressive aphasia over a period of years, it appeared increasingly to us that too much attention had been devoted to the negative symptoms (i. e.

Various paraneoplastic autoimmune phenomena have been reported in patients with myelodysplastic syndromes. We describe a patient who developed expressive aphasia as a paraneoplastic complication of chronic myelomonocytic leukemia (CMML). Awareness of the various possible manifestations of CMML may aid in the early recognition of the condition.