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cerebrum (The term operculum refers to the cortex that borders the sylvian ssure and covers or forms a lid over the insula, or island of Reil) In other words, the lesion in the usual form of Broca s aphasia extends well beyond the so-called Broca s area (Brodmann s areas 44 and 45) Furthermore, persistence of Broca s aphasia is associated with the larger type of lesion, illustrated in Fig 23-2 It is noteworthy that in one of Broca s original patients, whose expressive language had been limited to a few verbal stereotypes for 10 years before his death, inspection of the surface of the brain (the brain was never cut, although CT scans have since been made) disclosed an extensive lesion encompassing the left insula; the frontal, central, and parietal operculum; and even part of the inferior parietal lobe posterior to the sylvian ssure The Wernicke s area was spared, refuting the prediction at the time of Marie Inexplicably, Broca attributed the aphasic disorder to the lesion of the frontal operculum alone Broca ignored the rest of the lesion, which he considered to be a later spreading effect of the stroke Perhaps he was in uenced by the prevailing opinion of the time (1861) that articulation was a function of the inferior parts of the frontal lobes The fact that Broca s name later became attached to a discrete part of the inferior frontal cortex helped to entrench the idea that Broca s aphasia equated with a lesion in the Broca s area However, as pointed out above, a lesion con ned only to this area gives rise to a relatively modest and transient motor speech disorder (Mohr et al) or to no disorder of speech at all (Goldstein) Motor speech disorders, both severe Broca s aphasia and the more restricted and transient types, are most often due to a vascular lesion Embolic infarction in the territory of the upper (rolandic, superior) division of the middle cerebral artery is the most frequent type of stroke and results in the most abrupt onset and sometimes the most rapid regression of aphasia (hours or days), depending on whether the ischemia proceeds to tissue necrosis Even with the latter, however, ischemia around the zone of infarction causes a more extensive syndrome than one might expect from the infarct itself, ie, the physiologic impairment initially exceeds the pathologic Because of the distribution of the superior branch of the middle cerebral artery, there are a frequently associated right-sided faciobrachial paresis and a left-sided manual-brachial apraxia (socalled sympathetic apraxia), due probably to interruption of the bers that connect the left and right motor cortices Atherosclerotic thrombosis, primary or metastatic tumor, subcortical hypertensive, traumatic or anticoagulant-induced hemorrhage, and seizure, should they involve the appropriate parts of the motor cortex, may also declare themselves by a Broca s aphasia A closely related syndrome, pure word mutism (aphemia), causes the patient to be wordless (mute) but leaves inner speech intact and writing undisturbed Anatomically, this is believed to be in the nature of a disconnection of the motor cortex for speech from lower centers and is described with the dissociative speech syndromes discussed further on in this chapter Wernicke s Aphasia This syndrome comprises two main elements: (1) an impairment in the comprehension of speech, basically an inability to differentiate word elements or phonemes, both spoken and written, and (2) a relatively uent but paraphasic speech (further de ned below) The location of the lesion in cases of Wernicke s aphasia is the left superior lateral temporal lobe near the primary auditory cortex reveals the major role of the auditory region in the regulation of language The defect in language is manifest further by a varying inability to repeat spoken and written.

function from Fig 1313 can then be used to determine the least-squaresfit: >> S=113 18 3 45 G 8 9l; >> v=f 007 0Ll 02 , O2ja A jl 5 0iir 03t, 1; > > L a , r ' 2 l = L i n r e g r ( 1 r - j,1 , / v ) 164A22 12=

To reach a more general Perl audience, you might want to post a question or announcement to one of the many Perl newsgroups These are available on many ISP s Usenet news servers, and many will be happy to add them to their list if you ask nicely The list is summarized in Table C-2 If you want to browse existing and expired messages, check out the wwwdejanewscom website, which archives these and many other groups for you

Figure 23-2 Cerebral structures concerned with language output and articulation B5 Broca s area; C5 pre- and postcentral gyri; S5 striatum Areas 43, 44, and 45 are Brodmann s cytoarchitectonic areas A lesion in any one of the components of this output network (B, C, or S) can produce a mild and transient Broca s aphasia Large lesions, damaging all three components, produce severe, persistent Broca s aphasia with sparse, labored, agrammatic speech but well-preserved comprehension (Illustration courtesy of Dr Andrew Kertesz)

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Used to announce news from the Perl world This includes new book releases, new version releases, and occasionally major Perl module releases

>> vm-Ira(2)

words The involvement of visual association areas or their separation from the primary visual cortices is a common accompaniment that is re ected in an inability to read (alexia) In contrast to Broca s aphasia, the patient with Wernicke s aphasia talks volubly, gestures freely, and appears strangely unaware of his de cit Speech is produced mostly without effort; the phrases and sentences appear to be of normal length and are properly intoned and articulated These attributes, in the context of aphasic disturbances, are referred to, as already mentioned, as uency of speech Despite the uency and normal prosody, the patient s speech is remarkably devoid of meaning The patient with Wernicke s aphasia produces many nonsubstantive words, and the words themselves are often malformed or inappropriate, a disorder referred to as paraphasia A phoneme (the minimal unit of sound recognizable as language) or a syllable may be substituted within a word (eg, The grass is greel ); this is called literal paraphasia The substitution of one word for another ( The grass is blue ) is called verbal paraphasia or semantic substitution and is even more characteristic of Wernicke s aphasia Neologisms ie, syllables or words that are not part of the language may also appear ( The grass is grumps ) Fluent, paraphasic speech may be entirely incomprehensible (gibberish or jargon aphasia) Fluency, however, is not an invariable feature of Wernicke s aphasia In some patients speech may be hesitant, in which case the block tends to occur in the part of the phrase that contains the central communicative (predicative) item, such as a key noun, verb, or descriptive phrase The patient with such a disorder conveys the impression of constantly searching for the correct word and of having dif culty in nding it Although the motor apparatus required for the expression of language is intact, patients with Wernicke s aphasia have great dif culty in functioning as social organisms because they are deprived of the main means of communication They cannot understand fully what is said to them; a few simple commands may still be executed, but there is failure to carry out complex ones They cannot read aloud or silently with comprehension, tell others what they want or think, or write spontaneously Written letters are often combined into meaningless words, but there may be a scattering of correct words In trying to designate an object that is seen or felt, they cannot nd the name, even though they can sometimes repeat it from dictation; nor can they write from dictation the very words that they can copy The copying performance is notably slow and laborious and conforms to the contours of the model, including the examiner s handwriting style All these defects, of course, are present in varying degrees of severity In general, the disturbances in reading, writing, naming, and repetition parallel in severity the impairment in comprehension There are, however, exceptions in which either reading or the understanding of spoken language is disproportionately affected Some aphasiologists thus speak of two Wernicke syndromes In terms of the Broca-Wernicke schema, the motor language areas are no longer under control of the auditory and visual areas The disconnection of the motor speech areas from the auditory and visual ones accounts for the impairment of repetition and the inability to read aloud Reading may remain uent, but with the same paraphasic errors that mar conversational language The occurrence of dyslexia (impaired visual perception of letters and words) with lesions in the temporal lobe is explained by the fact that most individuals learn to read by transforming the printed word into the auditory form before it can gain access to the integrative centers in the posterior perisylvian region Only in the congenitally deaf is.

Appendix C:

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