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The conventional teaching, based on correlations between various disorders of language and damage to particular areas of the brain, postulates four main language areas, situated, in most persons, in the left cerebral hemisphere (Fig 23-1) The entire language zone that encompasses these areas is perisylvian, ie, it borders the sylvian ssure Two language areas are receptive and two are executive, ie, the latter are concerned with the production (output) of language The two receptive areas are closely related and embrace what has been referred to as the central language zone The main receptive area, subserving the perception of spoken and probably of internal language, occupies the posterior-posterosuperior temporal area (the posterior portion of area 22) and Heschl s gyri (areas 41 and 42) The posterior part of area 22 in the planum temporale is referred to as Wernicke s area A second receptive area, subserving the perception of written language, occupies the angular gyrus (area 39) in the inferior parietal lobule, anterior to the visual receptive areas The supramarginal gyrus, which lies between these auditory and visual language centers, and the inferior temporal region, just anterior to the visual association cortex, are probably part of this central language zone as well Here are located the integrative centers for cross-modal visual and auditory language functions The main executive, or output, region, situated at the posterior end of the inferior frontal convolution (Brodmann s areas 44 and 45), is referred to as Broca s area and is concerned with motor aspects of speech In some models, visually perceived words are

39 45 44 22 21 20 Figure 23-1 Diagram of the brain showing the classic language areas, numbered according to the scheme of Brodmann The elaboration of speech and language probably depends on a much larger area of cerebrum, indicated roughly by the entire shaded zone (see text) Note that areas 41 and 42, the primary auditory receptive areas, are shown on the lateral surface of the temporal lobe but extend to its superior surface, deep within the sylvian ssure 22 41 42

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given expression in writing through a fourth language area, the socalled Exner writing area in the posterior part of the second frontal convolution, a concept that is still controversial in view of the fact that widely separated parts of the language zone may cause a disproportionate disorder of writing In any case, there are two parallel systems for understanding the spoken word and producing speech and for the understanding of the written word and producing writing They develop separately but are the integral components of the semantic system These sensory and motor areas are intricately connected with one another by a rich network of nerve bers, one large bundle of which, the arcuate fasciculus, passes through the isthmus of the temporal lobe and around the posterior end of the sylvian ssure; other connections may traverse the external capsule of the lenticular nucleus (subcortical white matter of the insula) Many additional corticocortical connections and other ber systems lead into the perisylvian zones and project from them to other parts of the brain Furthermore, the visual receptive and somatosensory zones are integrated in the parietal lobe, and the auditory receptive zones in the temporal lobe Of special importance for the production of speech are the short association bers that join Broca s area with the lower rolandic cortex, which, in turn, innervates the muscles of the lips, tongue, pharynx, and larynx The putative Exner writing area is similarly integrated with the motor apparatus for the muscles of the hand The perisylvian language areas are also connected with the striatum and thalamus and with corresponding areas in the minor (nondominant) cerebral hemisphere through the corpus callosum and anterior commissure (see Fig 22-6) There has been considerable difference of opinion concerning the status of cortical language areas, and objection has been made to calling them centers, for they do not represent histologically circumscribed structures of constant function Moreover, a competent neuroanatomist would not be able to distinguish the cortical language areas microscopically from the cerebral cortex that surrounds them Some of the perceptive areas are polymodal, ie, they are activated by auditory, visual, and tactile stimuli Presumably, their function is integrative The lack of comparability with the motor and sensory regions of the cortex is demonstrated by observations during the electrical stimulation of the anterior cortical language areas while the patient is alert and talking (during craniotomy under local anesthesia); stimulation may induce a simple vocalization, usually a single-vowel monotone, but otherwise causes only an arrest of speech Similarly, electrical stimulation of Wernicke s area causes errors of speech, such as stumbling over a word or saying the wrong word As indicated earlier, knowledge of the anatomy of language has come almost exclusively from the postmortem study of humans with focal brain diseases Two major theories emerged from these studies One has subdivided the language zone into separate afferent (auditory and visual) receptive parts, connected by identi able tracts to the executive (efferent-expressive) centers Depending on the exact anatomy of the lesions, a number of special syndromes are elicited The other theory, advanced originally by Marie (he later claims to have changed his mind) and supported by Head, Wilson, Brain, and Goldstein, favored the idea of a single language mechanism, roughly localized in the opercular, or perisylvian, region of the dominant cerebral hemisphere The aphasia in any particular case was presumably due to the summation of damage to input or output modalities relative to this central language zone Undeniably, there is, within the perisylvian language area, recognizable afferent and efferent localization as discussed above, but.

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