Heilman K M, Tucker D M, Valenstein E
Brain. 1976 Sep;99(3):415-26. doi: 10.1093/brain/99.3.415.
Altholgh Lichtheim recognized that Wernicke's 'reflex arch' (primary auditory area, to Wernicke's area, to Broca's area, to primary motor area) was important for repetition, he recognized that other areas of the brain (for example, area of concepts or semantic area) must be important in comprehension and voluntary speech. He suggested that Wernicke's area (phonemic area) not only projected to Broca's area (as Wernicke suggested) but that it also projected to the area of concepts. A lesion of this latter pathway or in the area of concepts would produce a syndrome where repetition was intact but comprehension was impaired (e.g. transcortical sensory aphasia). Lichtheim also thought that the area of concepts projected directly to Broca's area and that voluntary speech was mediated by this pathway. Although Lichtheim's model could explain the mechanism underlying transcortical aphasia, his schema could not explain anomic aphasia. Unlike Lichtheim's schema, Kussmaul's schema suggested that the area of concepts projects back to Wernicke's area before projecting to Broca's area. With this schema, a patient with a hypothetical lesion which interrupted the pathway from the area of concepts to Wernicke's area (but did not interrupt the pathway from Wernicke's area to the area of concepts) should be anomic, with normal comprehension and repetition. In order for this latter schema to be plausible there should also be a lesion which interrupts the pathway from Wernicke's area to the area of concepts but does not interrupt the pathway which goes from the area of concepts to Wernicke's area. A patient with this hypothetical lesion should comprehend poorly; however, in spite of poor comprehension, naming and repetition should be intact. We report a patient who demonstrates poor comprehension with intact naming and repetition. This patient could also read aloud but could not comprehend written language. Not only could this patient name objects but he could demonstrate their use. These observations suggest that comprehension of written language is mediated by a different pathway than the recognition of visually presented objects.
尽管利希海姆认识到韦尼克的“反射弧”（初级听觉区、到韦尼克区、到布洛卡区、到初级运动区）对复述很重要，但他也认识到大脑的其他区域（例如，概念区或语义区）在理解和自主言语中必定很重要。他提出韦尼克区（音素区）不仅投射到布洛卡区（如韦尼克所建议的），而且还投射到概念区。后一条通路或概念区的损伤会导致一种综合征，即复述正常但理解受损（例如，经皮质感觉性失语）。利希海姆还认为概念区直接投射到布洛卡区，自主言语由这条通路介导。尽管利希海姆的模型可以解释经皮质失语症的潜在机制，但他的模式无法解释命名性失语症。与利希海姆的模式不同，库斯莫尔的模式表明概念区在投射到布洛卡区之前先投射回韦尼克区。根据这个模式，一个假设性损伤中断了从概念区到韦尼克区的通路（但没有中断从韦尼克区到概念区的通路）的患者应该是命名性失语，理解和复述正常。为了使后一种模式合理，还应该有一个损伤中断从韦尼克区到概念区的通路，但不中断从概念区到韦尼克区的通路。患有这种假设性损伤的患者理解能力应该很差；然而，尽管理解能力差，但命名和复述应该正常。我们报告了一名患者，其表现为理解能力差但命名和复述正常。这名患者也能大声朗读，但不能理解书面语言。这名患者不仅能说出物体的名称，还能演示其用途。这些观察结果表明，书面语言的理解是由一条不同于视觉呈现物体识别的通路介导的。
