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there is also an undifferentiated central integrative mass action, in which the degree of de cit is to a considerable extent in uenced by the size of the lesion Thus a strict division of aphasias into executive and receptive, while still a strong practical concept, is not fully borne out by clinical observation Nevertheless, there are several localizable language functions in the perisylvian cortex Carl Wernicke, of Breslau, Germany, more than any other person, must be credited with the anatomic-psychologic scheme upon which many contemporary ideas of aphasia rest Earlier, Paul Broca (1865), and, even before him, Dax (1836), had made the fundamental observations that a lesion of the insula and the overlying operculum deprived a person of speech and that such lesions were always in the left hemisphere Wernicke s thesis was that there were two major anatomic loci for language: (1) an anterior locus, in the posterior part of the inferior frontal lobe (Broca s area), in which were contained the memory images of speech movements, and (2) the insular region and adjoining parts of the posterior perisylvian cortex, in which were contained the images of sounds (Meynert had already shown that aphasia could occur with lesions in the temporal lobe, Broca s area being intact) Wernicke believed that the bers between these regions ran in the insula and mediated the psychic re ex arc between the heard and spoken word Later, Wernicke came to accept von Monakow s view that the connecting bers ran around the posterior end of the sylvian ssure, in the arcuate fasciculus Wernicke gave a comprehensive description of the receptive or sensory aphasia that now bears his name The four main features, he pointed out, were (1) a disturbance of comprehension of spoken language and (2) of written language (alexia), (3) agraphia, and (4) uent paraphasic speech In Broca s aphasia, by contrast, comprehension was intact, but the patient was mute or employed only a few simple words Wernicke also theorized that a lesion interrupting the connecting bers between the two cortical speech areas would leave the patient s comprehension undisturbed but would prevent the intact sound images from exerting an in uence on the choice of words Wernicke proposed that this variety of aphasia be called Leitungsaphasie, or conduction aphasia (called central aphasia by Kurt Goldstein and deep aphasia by Martin and Saffran) Careful case analyses since the time of Broca and Wernicke have repeatedly borne out these associations between a receptive (Wernicke) type of aphasia and lesions in the posterior perisylvian region and between a predominantly (Broca) motor aphasia and lesions in the posterior part of the inferior frontal lobe and the adjacent, insular, and opercular regions of the frontal cortex The concept of a conduction aphasia, based on an interruption of pathways between Wernicke s and Broca s zones, has been the most dif cult to accept, because it presupposes a neat separation of sensory and motor functions, which is not in line with contemporary views of sensorimotor physiology of the rest of the nervous system or with the recent analyses of language by cognitive neuropsychologists (Margolin) Nevertheless, there are in the medical literature a number of descriptions and we have certainly encountered cases that conform to the Wernicke model of conduction aphasia; the lesion in these cases may lie in the parietal operculum, involving the white matter deep to the supramarginal gyrus, where it presumably interrupts the arcuate fasciculus and posterior insular subcortex (this issue is discussed further on) How these regions of the brain are organized into separable but interactive modules and how they can be activated and controlled by a variety of visual and auditory stimuli and frontal mo-.

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tivational mechanisms, resulting in the complex behavior of which we make casual daily use in interpersonal communication, is just beginning to be studied by linguists and cognitive neuropsychologists They, for example, are dissecting language into its most basic elements phonemes (the smallest units of sound recognizable as language), morphemes (the smallest meaningful units of a word), graphemes, lexical and semantic elements (words and their meanings), and syntax (sentence structure) In general, as a restatement of the Wernicke-Broca scheme, phonologic dif culties correlate with left frontal lesions; semantic-comprehension dif culties, with left temporal lesions; and alexia and agraphia, with inferior parietal lesions These elements, or modules, have been diagrammed by psycholinguists as a series of boxes and are connected to one another by arrows to indicate the ow of information and the manner in which it in uences the spoken output of language These boxologies, as they are called, are not inconsistent with current psychologic theory, which views language functions as the result of synchronized activity in vast neuronal networks made up of many cerebrocortical regions and their interconnecting pathways (Damasio and Damasio, 1989) On the other hand, despite this level of theoretical sophistication, attempts to delineate the anatomy of speech and language disorders by means of brain imaging techniques in aphasic patients have been disappointing Using computed tomography (CT), RochLeCours and Lhermitte were unable to establish a consistent correspondence between the type of aphasia and the demonstrable lesion Also, Willmes and Poeck, in a retrospective study of 221 aphasic patients, failed to demonstrate an unequivocal association between the type of aphasia and the CT localization of the lesion This poor correlation may in part be related to the timing and the crudity of the CT scan MRI scans performed soon after a stroke show somewhat more consistent correlations between the type of language disturbance and the location of lesions in the perisylvian cortex Functional magnetic resonance imaging (fMRI) while subjects are engaged in language production and comprehension may prove to be superior to anatomic correlations of brain lesions for understanding the language process, but so far only the broadest rules of localization can be con rmed Up to now, studies of blood ow and topographic physiology during the acts of reading and speaking, while generally af rming nineteenth-century models of language (see Price), have shown widespread activation of Wernicke s and Broca s areas as well as of the supplementary motor area and areas of the opposite hemisphere Although localization of the lesion that produces aphasia is in most instances roughly predictable from the clinical de cit, there are wide variations The inconsistency has several explanations, the most popular being that the net effect of any lesion depends not only on its locus and extent but also on the degree of cerebral dominance ie, on the degree to which the minor hemisphere assumes language function after damage to the major one According to this view, a left-sided lesion has less effect on language function if cerebral dominance is poorly established than if dominance is strong In likelihood there are variations among individuals in the distribution of the language areas in the left perisylvian area Another explanation invokes the poorly understood concept that individuals differ in the ways in which they acquire language as children This is believed to play a role in making available alternative means for accomplishing language tasks when the method initially learned has been impaired through brain disease The extent to which improvement of aphasia represents recovery.