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Neurology for the Speech-Language Pathologist
Neurology for the Speech-Language Pathologist
Neurology for the Speech-Language Pathologist
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Neurology for the Speech-Language Pathologist

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Neurology for the Speech-Language Pathologist presents the fundamentals in understanding the nervous system in the context of communication. The book takes into consideration the nervous anatomic systems, such as sensory pathways. The text first introduces the speech-language neurology, and then proceeds to discussing the organization and neural function of the nervous system. Next, the book relates the nervous anatomic systems to language, speech, and hearing. The text also covers clinical speech syndromes and disorders. The book will be most useful to speech pathologists and therapists. Neurologists and neurosurgeons will also greatly benefit from the text.
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Release dateOct 22, 2013
ISBN9781483141992
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    Neurology for the Speech-Language Pathologist - Russell J. Love

    Neurology for the Speech-Language Pathologist

    Second Edition

    Russell J. Love, Ph.D.

    Wanda G. Webb, Ph.D.

    Division of Hearing and Speech Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee

    Butterworth-Heinemann

    Table of Contents

    Cover image

    Title page

    Dedication

    Copyright

    Speech Pathology and Neurology: Intersecting Specialties

    Preface to the Second Edition

    Preface to the First Edition

    Chapter 1: Introduction to Speech-Language Neurology

    Publisher Summary

    Why Neurology?

    Historical Roots: Development of a Brain Science of Speech-Language

    How to Study

    Summary

    Chapter 2: The Organization of the Nervous System I

    Publisher Summary

    The Human Communicative Nervous System

    Divisions of the Nervous System

    Summary

    Chapter 3: The Organization of the Nervous System II

    Publisher Summary

    The Peripheral Nervous System

    The Protection and Nourishment of the Brain

    The Blood Supply of the Brain

    General Principles of Neurologic Organization

    Summary

    Chapter 4: Neuronal Function in the Nervous System

    Publisher Summary

    Neuronal Physiology

    Myelin

    Summary

    Chapter 5: Neurosensory Organization of Speech and Hearing

    Publisher Summary

    Bodily Sensation

    Sensory Examination

    Anatomy of Oral Sensation

    Oral Sensory Receptors

    The Visual System

    Central Auditory Nervous System

    Summary

    Chapter 6: The Neuromotor Control of Speech

    Publisher Summary

    The Pyramidal System

    The Corticobulbar Tracts

    Lower and Upper Motor Neurons

    Alpha and Gamma Motor Neurons

    The Extrapyramidal System: The Basal Ganglia

    The Cerebellar System

    Summary

    Notes

    Chapter 7: The Cranial Nerves

    Publisher Summary

    Introduction

    The Cranial Nerves for Smell and Vision

    The Cranial Nerves for Speech and Hearing

    Cranial Nerve Cooperation: The Act of Swallowing

    Summary

    Chapter 8: Clinical Speech Syndromes of the Motor Systems

    Publisher Summary

    The Dysarthrias

    Upper Motor Neuron Lesions: Spastic Dysarthria

    Lower Motor Neuron Lesions: Flaccid Dysarthria

    Mixed Upper and Lower Motor Neuron Lesions

    Extrapyramidal Lesions: Dyskinetic Dysarthrias

    The Cerebellum and the Cerebellar Pathway Lesions: Ataxic Dysarthria

    Other Mixed Dysarthrias with Diverse Lesions

    Summary

    Chapter 9: The Cerebral Control of Speech and Language

    Publisher Summary

    Cerebral Anatomy

    Interhemispheric Connections

    Cerebral Cortex

    Association Pathways

    The Clinicopathologic Method and Neuroimaging

    Cerebral Blood Supply

    Summary

    Chapter 10: The Central Language Mechanism and Its Disorders

    Publisher Summary

    A Model for Language and Its Disorders

    Aphasia Classification

    Associated Central Disturbances

    Testing and Treating the Language Impairment in Traumatic Brain Injury

    Summary

    Chapter 11: Language Mechanisms in the Developing Brain

    Publisher Summary

    Brain Growth

    Cerebral Plasticity

    Development of Language Dominance

    Childhood Language Disorders

    Summary

    Chapter 12: Clinical Speech Syndromes and the Developing Brain

    Publisher Summary

    Developmental Motor Speech Disorders

    Diagnosis of Neurologic Disorder with Primitive Reflexes

    Oral and Pharyngeal Reflexes

    Assessing Mastication and Deglutition

    Summary

    Synopsis of Medical Conditions Related to Communication Disorders

    Bedside Neurological Examination

    Screening Neurologic Examination for Speech-Language Pathology

    Glossary

    Index

    Dedication

    To Barbara and Joe

    Copyright

    Copyright © 1992 by Butterworth–Heinemann, a division of Reed Publishing (USA) Inc.

    All rights reserved.

    No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

    Every effort has been made to ensure that the drug dosage schedules within this text are accurate and conform to standards accepted at time of publication. However, as treatment recommendations vary in the light of continuing research and clinical experience, the reader is advised to verify drug dosage schedules herein with information found on product information sheets. This is especially true in cases of new or infrequently used drugs.

    Recognizing the importance of preserving what has been written, it is the policy of Butterworth–Heinemann to have the books it publishes printed on acid-free paper, and we exert our best efforts to that end.

    Library of Congress Cataloging-in-Publication Data

    Love, Russell J.

    Neurology for the speech-language pathologist / Russell J. Love, Wanda G. Webb; illustrations by Donna B. Halliburton; additional illustrations by Paul Gross.—2nd ed.

    p. cm.

    Includes bibliographical references and index.

    ISBN 0-7506-9076-3 (pbk.)

    1. Language disorders. 2. Neurolinguistics. 3. Speech disorders. 4. Neurology. I. Webb, Wanda G. II. Title.

    [DNLM: 1. Brain—physiology. 2. Brain—physiopathology. 3. Communicative Disorders—physiopathology. WL 300 L897n]

    RC423.L68 1992

    616.85′5—dc20

    DNLM/DLC

    for Library of Congress 91-20760

    CIP

    British Library Cataloguing in Publication Data

    Love, Russel J.

    Neurology for the speech-language pathologist. —2nd ed.

    I. Title II. Webb, Wanda G.

    616.855

    ISBN 0-7506-9076-3

    Butterworth–Heinemann

    80 Montvale Avenue

    Stoneham, MA 02180

    10 9 8 7 6 5 4 3 2 1

    Printed in the United States of America

    FOREWORD

    Speech Pathology and Neurology: Intersecting Specialties

    Howard S. Kirshner, M.D.

    Neurology is the study of the effects of disease in the nervous system—brain, spinal cord, cerebellum, nerves, and muscles—on human behavior. The neurologist examines specific functions—higher cortical functions; cranial nerve functions; motor, sensory, and cerebellar functions—all to localize disorders to specific areas of the nervous system. These lesion localizations, along with the clinical history of how the deficit developed and the results of laboratory tests, allow a precise diagnosis of the disease process.

    Speech and communication are among the most complicated functions of the human brain, involving a myriad of interactions between personality, cognitive processes, imagination, language, emotion, and lower sensory and motor systems necessary for articulation and comprehension. These functions involve brain pathways and mechanisms, some well understood and others only beginning to be conceptualized. The brain mechanisms underlying higher functions such as language are known largely through neurological studies of human patients with acquired brain lesions. Animal models have shed only limited light on these complex disorders. Stroke has historically been a great source of information, as this experiment of nature damages one brain area while leaving the rest of the nervous system intact. For over a century, patients with strokes and other brain diseases have been studied in life, and the clinical syndromes have then been correlated with brain lesions found at autopsy. Recently, new methods of brain imaging have made possible the simultaneous study of a lesion in the brain and a deficit of communication in the same patient. These advances in brain imaging, including computerized axial tomography (CT scan), magnetic resonance imaging, and positron emission tomography (PET), have brought about a burgeoning of knowledge in this area.

    In this book, Drs. Love and Webb have laid the factual groundwork for the understanding of the nervous system in terms of the organization of the brain, descending motor and ascending sensory pathways, and cranial nerves and muscles. Understanding these anatomic systems makes possible the understanding and classification of syndromes of aphasia, alexia, dysarthria, and dysphonia, as well as the effects of specific, localized disease processes on human speech and communication. All these subjects are clearly and accurately reviewed. The speech pathologist who studies this book should have a much improved comprehension of the brain mechanisms disrupted in speech-and language-impaired patients, and, thereby, a greater understanding of the disorders of speech and language themselves.

    Perhaps the most important by-product of this book should be a closer interaction between neurologists and speech pathologists. Neurologists understand the anatomic relationships of the brain and its connections, but they often fail to use speech and language to their full limits in assessing the function of specific parts of the nervous system. A careful analysis of speech and language functions can supplement the more cursory portions of the standard neurological examination devoted to these functions. Thus detailed aphasia testing supplements the neurologist’s bedside mental-status examination, and close observation of palatal, lingual, and facial motion during articulation supplements the neurologist’s cranial nerve examination. The neurologist’s diagnosis of the patient’s disorder, on the other hand, should aid the speech pathologist in understanding the nature and prognosis of the speech and language disorder. The neurologist and speech pathologist should ideally function as a team, each complementing the efforts of the other. In order for this teamwork to occur, however, each specialist must comprehend the other’s language. To this end, Drs. Love and Webb have made the language of the neurologist understandable to speech pathologists. As a neurologist who has worked closely with both of them, I applaud them for this important accomplishment.

    Preface to the Second Edition

    Our goals in this second edition have been to update various sections of the book to make the material more current and accessible to the student. Approximately 30 percent of the illustrations have been redrawn to increase their clarity. The reader will find expanded coverage of neuroimaging techniques, dysphagia, and neurologic models, and new discussions of subcortical aphasia, progressive aphasia, subcortical dementia, traumatic brain injury, attention deficit–hyperactivity disorder, and autism. Numerous minor corrections have been made, and references have been updated where necessary.

    R.J.L. and W.G.W.

    Preface to the First Edition

    The spur for this book was a time-honored one. We found the current crop of textbooks inappropriate to the needs of our students. The senior author in particular has spent considerable effort in recent years attempting to adapt neurology textbooks designed for medical students to the needs of students in speech-language pathology. The results of these efforts often have been frustrating and less than ideal. Therefore, this book is designed as an introduction to neuroanatomy, neurology, and neuropsychology for the student and practicing clinician interested in neurogenic communication disorders. We hope it will be helpful to students without medical training. It is not designed to replace the excellent textbooks now available that have been prepared for courses in adult aphasia, motor speech disorders, and developmental neurologic speech and language problems in children. Rather, it is hoped that this book will serve as a primary textbook for an introductory course in the neurology of speech and language, or as a supplementary source in those usually standard courses in the curriculum that deal with neurogenic communication disorders. This book is aimed at advanced undergraduates and beginning graduate students as well as the working speech-language pathologist.

    For authors primarily trained in the field of speech-language pathology rather than neurology, a project like this demands reliance on colleagues in neurology to assist in the development of the work. Howard S. Kirshner, M.D., Department of Neurology, Vanderbilt University School of Medicine, went above and beyond the call of duty in bringing his expertise to bear on this project. He not only read the text for accuracy, but also made important suggestions concerning the organization and clarity of the book. He was extremely patient with our attempts to oversimplify a complex area of knowledge that is rarely grasped completely by the individual who has not had some training in the biological sciences. We are indebted to him for his careful attention to the manuscript, but we wish to indicate that we alone are responsible for errors of fact and flaws in organization and clarity in the text. We are indebted as well to several members of the editorial staff, past and present, of Butterworth–Heinemann. These include David Coen, Arthur Evans, Julie Stillman, and Margaret Quinlin. Finally, no book can be successfully completed without competent secretarial support. We wish to thank Tammy Richardson, Betty Longwith, Dot Blue, Sherri Culp, Solveig Hultgren, Julie Michie, and Gloria Proctor.

    Textbooks grow from seeds of inspiration usually planted by outstanding teachers. We would particularly like to acknowledge Harold Westlake, Ph.D., professor emeritus, School of Speech, Northwestern University, and the late Joseph Wepman, Ph.D., University of Chicago. Both of these scholar-clinicians provided a vision of the role of the speech-language pathologist in the study, diagnosis, and management of neurologic communication disorders. Without their inspiration and contribution as role models, this book probably would not have been written.

    R.J.L. and W.G.W.

    1

    Introduction to Speech-Language Neurology

    Publisher Summary

    This chapter presents an introduction to speech-language neurology. The brain is the source of all speech and language behavior. Hence, current knowledge concerning its anatomy and functioning must be studied and absorbed by a speech-language pathologist. But it is not the responsibility of the clinical speech-language pathologist to diagnose a neurologic disorder. This function is in the realm of the physician. Nevertheless, it is the responsibility of the speech-language pathologist to assess all relevant aspects of speech and language in those with a known or suspected neurologic disorder. The study of the relationship between the brain and speech and language function has a rich history in the past hundred twenty-five years, and the disciplines of speech-language pathology and neurology have often cooperated in the study of neurologically based communication disorders. Employing both verbal reasoning (left-hemisphere function) and visual imagery (right-hemisphere function) contributes to a successful experience.

    We must admit that the divine banquet of the brain was, and still is, a feast with dishes that remain elusive in their blending, and with sauces whose ingredients are even now a secret.

    —MacDonald Critchley, The Divine Banquet of the Brain, 1979

    Why Neurology?

    Every student of communicative disorders realizes without being taught that the brain is the source of all speech and language behavior. Nevertheless, many students shy away from achieving a basic understanding of the neural mechanisms of speech, language, and hearing because they believe the nervous system is overwhelmingly complex and abstruse. This complexity and obscurity, they fear, will lead only to perplexity and frustration if they attempt serious study of neuroanatomy and neurophysiology.

    To compound this attitude, many academic training programs in communicative disorders treat the neurologic aspects of their discipline only superficially, arguing that this aspect of our knowledge is more properly the domain of medicine. In fact, some training programs in communicative disorders would make neurology the exclusive domain of the physician. The arguments generally cited for this point of view are, first, that neurology has little relevance to diagnosis or the day-to-day clinical management of the communicatively disordered client, and, second, that operant/behavioral management principles have been demonstrated to be effective in improving the speech and language of clients. These principles assume no neurologic explanation. This general position is expressed by Starkweather (1983).

    Effective as behavioral principles have been in the diagnosis and management of communicative disorders, elevation of operant techniques to a central position in both the theory and practice of speech and language pathology may force the speech-language pathologist into the role of a mere technician, expert at dealing with only one facet of a multifaceted problem. This limited view will never permit a complete understanding of the disorders of speech and language.

    There has been an increasing interest in the neurologic aspects of speech and language pathology in the past two decades. Language development and its disorders are being studied in the context of developmental neurology and biological explanation (Lenneberg, 1967). A clearer understanding of the motor disorders of speech has been gained in the last two decades, and the literature on dysarthria and apraxia of speech has been expanded impressively. Interest in the study and treatment of aphasia has so increased that there is now a subspeciality called clinical aphasiology. Research and writing on cerebral speech and language disorders and their mechanisms are no longer solely the province of neurologists, as was almost always the case in the past. Today, the speech-language pathologist, the neuropsychologist, and the neurolinguist are major contributors to the ever-growing abundance of literature on neurologic communication disorders.

    In a significant manner this literature reflects the fact that the modern-day speech-language pathologist is playing an expanded and crucial role in the rehabilitation of persons with neurologic disorders. Since World War II, the speech pathology service has become an accepted service in the standard rehabilitation center and many general hospitals. As the role of the speech-language pathologist expands in the rehabilitation of the neurologic patient, the neurologic information and background expected to be part of the academic training will be considerably larger in scope. Future speech-language pathologists will view themselves as important students and contributors to the field of neuroscience. Speech pathology will be one of several specialties contributing to the discipline of behavioral neurology.

    It should be emphasized that it is not the responsibility of the clinical speech-language pathologist to diagnose a neurologic disorder. This function is in the realm of the physician. Nevertheless, it is the undeniable responsibility of the speech-language pathologist to assess all relevant aspects of speech and language in those with a known or suspected neurologic disorder. The speech-language pathologist must be accountable for understanding the results of this speech-language assessment in terms of the underlying neurological mechanisms. Further, the clinical speech-language pathologist must be conversant with current methods of neurologic diagnoses and treatment as they apply to persons with communicative disorders. The neurologist’s point of view toward speech and language disorders should be familiar to every clinician. In turn, the neurologist must be conversant with assessment methods and therapy procedures of the communication disorders specialist. This is particularly crucial now, since both disciplines have developed relatively independently in the past half century, sometimes to the detriment of both professions and the people they serve.

    Historical Roots: Development of a Brain Science of Speech-Language

    Speech-language pathology has many of its roots in neurology. In 1861 the French physician, Pierre Paul Broca (1824–1880), studied the brains of two patients who both sustained a language loss and a motor speech disorder. This allowed him to localize the human speech center to a definite circumscribed area of the left hemisphere, and a brain science of speech and language was irrevocably established. Broca’s discovery went far beyond the now classic description of an interesting brain disorder called aphasia. Possibly foremost among his conclusions was the assertion that the two hemispheres of the brain were asymmetrical in function and that the left cerebral hemisphere contained the speech center in the majority of the population. Important implications of asymmetry of the brain are even now coming to light in neuroscience research some thirteen decades later. Asymmetry of function is more pervasive than was thought earlier. It extends well beyond speech to other brain areas and their functions.

    Another conclusion that has had everlasting importance for neurology since Broca’s death is that specific behavioral functions appear to be associated with clearly localized sites in the brain. The collorary of this observation is that behavioral dysfunction can point to lesions at specific sites in the nervous system. The concept of localization of function in the nervous system has been demonstrated repeatedly by clinical and research methods since Broca first articulated it over a century ago. This observation was so profound that it became a significant historical force in the establishment of the medical discipline of clinical neurology. Much of clinical neurology is dependent on the physician’s ability to lateralize and localize a lesion in the nervous system.

    Very important for speech-language pathology was the fact that Broca’s discovery stimulated a period of intensive search for a workable explanation of the brain mechanisms of speech and language. Probably no period in the history of neurologic science has so advanced the understanding of communication and its disorders as those years between the date of Broca’s discovery and World War I.

    One of the first and foremost outcomes of this intensive study of speech-language brain mechanisms was the establishment of neurologic substrata for modalities of language deficit other than the expressive oral language described by Broca. In 1867 William Ogle published a case that demonstrated that a cerebral writing center was independent of Broca’s center for speech. Carl Wernicke (1848–1905) in 1874 identified an auditory speech center in the temporal lobe; it was associated with comprehension of speech as opposed to Broca’s area in the frontal lobe, which was an expressive speech center. Lesions in Broca’s area produced a motor aphasia, in Wernicke’s area a sensory aphasia. In 1892 Joseph Dejerine identified mechanisms underlying reading disorders. Disorders of cortical sensory recognition, or the agnosias, were named by Sigmund Freud in 1891, and in 1900 Hugo Liepmann comprehensively analyzed the apraxias—disorders of executing motor acts resulting from brain lesion.

    Early Language Models

    Of the many neurological models of the cerebral language mechanisms that were generated soon after Broca’s great discovery, Wernicke’s 1874 model has best withstood the test of time. Wernicke stressed the importance of cortical language centers associated with the various language modalities, but he also emphasized the importance of association fiber tracts connecting areas or centers. Like his teacher Theodore Meynert (1833–1892), he understood that the connections in the brain were just as important as the centers for a complete picture of language performance (Meynert, 1885). In addition, Wernicke organized the symptoms of language disturbance in such a way that they could be used diagnostically to predict the lesion site in either connective pathways or centers in the language system. Ironically, the Wernicke model was eclipsed until the last half of the twentieth century, when it was revitalized and expanded by Norman Geschwind (1926–1984) and his followers (Geschwind, 1974).

    Wernicke’s model came under criticism by the English neurologist Henry Head (1926). He lumped Wernicke with a cadre of early neurologists he considered the more flagrant of the diagram makers, implying that they constructed language models that were highly speculative and not supported by empirical evidence. Current methods of neurologic investigation, including electrical cortical stimulation, isotope localization of lesions, computerized tomography, and regional blood flow studies in the brain, have generally vindicated Wernicke’s model of language.

    Neurologic speech mechanisms, as opposed to language mechanisms, also received attention in the late nineteenth century. In 1871 the famous French neurologist Jean Charcot (1825–1893) described the scanning speech that he associated with disseminated sclerosis, now known as multiple sclerosis (Charcot, 1890). The term scanning, probably inappropriate, has also been widely used to describe speech with cerebellar or cerebellar pathway lesions (see Chapter 8). In 1888 an English neurologist, William Gowers (1846–1915), surveyed the neurologic speech disorders, known as dysarthrias, in a well-known textbook titled A Manual of Diseases of the Nervous System.

    World War I

    World War I had a profound influence on the study of speech and language mechanisms resulting from neurologic insult. With a large population of head-injured young men with penetrating skull wounds, some neurologists felt an urgency for treatment. A handful of dedicated neurologists provided therapy for these traumatic language disorders because the profession of speech pathology was not yet born. Not until the next decade did the profession really began. Lee Edward Travis has the distinction of being the first individual in the United States to specialize in the field of speech and language disorders at the doctoral level. In 1927 he became the first director of the speech clinic at the University of Iowa. His special interest was in stuttering, and he began to study it in a neurologic context. Influenced by the neuropsychiatrist, Samuel Terry Orton (1879–1948), Travis researched the hypothesis that stuttering was the result of brain dysfunction, specifically an imbalance or competition between the two cerebral hemispheres to control the normal bilateral functioning of the speech musculature. Orton’s hypothesis of dysfunctioning neural control of the speech musculature has generally been discredited, but his hemisphere competition theory of stuttering still surfaces from time to time in different guises to explain certain communication disorders.

    Although several of the founders of speech pathology in the United States believed that psychological explanations were more rewarding for understanding speech and language problems, there were notable exceptions. In particular, Harold Westlake of Northwestern University; Robert West of the University of Wisconsin; Jon Eisenson, now of California State University; and Joseph Wepman of the University of Chicago were all advocates of neurologic principles in communication disorders.

    Modern Times

    World War II, bringing in its wake thousands of traumatic aphasic servicemen, utilized neurologists, psychologists, and speech pathologists in treatment programs for the first time. This effort produced a series of books and articles on aphasia rehabilitation, but perhaps the most notable for the neurologically oriented speech-language pathologist was Wepman’s Recovery from Aphasia (1951). It served as a textbook of language disorders for the growing number of students in the field and often served as their first introduction to a major neurologic communicative disorder.

    The study of neurologic speech mechanisms was greatly advanced after World War II by the work of Wilder G. Penfield (1891–1976) and his colleagues in Canada. Penfield, a neurosurgeon, used the technique of electrical cortical stimulation to map cortical areas directly, particularly speech and language centers. In 1950 in The Cerebral Cortex of Man and in 1959 in Speech and Brain Mechanisms, he documented his observations on cerebral control of speech and language function and wrote on the concepts of subcortical speech mechanisms and infantile cerebral plasticity.

    The decades of the 1960s and 1970s were marked by several advances of neurologic concepts in communication and its disorders. Newer linguistic theory, particularly that proposed by Noam Chomsky (1972, 1975), emphasized the universal features and innate mechanisms reflected in language. The biological aspects of language and speech were highlighted by the linguist and psychologist Eric Lenneberg (1967). He specifically placed language acquisition in the context of developmental neurology. The split-brain studies, reported by Roger Sperry and his colleagues (1969), when the commissural tracts between the hemispheres were severed, indicated specific functions of the right hemisphere as different from the left.

    Major anatomical differences in the right and left language centers were also demonstrated in the human brain. Most significant are larger areas in the left temporal lobe in the fetus, infant, and adult (Wada, Clark, & Hamm, 1975; Witelson & Pallie, 1973; Geschwind & Levitsky, 1968). These differences suggest an anatomical basis for cerebral dominance for language and contradict a theory of progressive lateralization of speech centers.

    Throughout the 1960s and 1970s considerable attention was paid to neurologic speech disorders. Neurologists and speech pathologists in the Mayo Clinic Neurology Department (Darley, Aronson, & Brown, 1969a, b, 1975) documented the acoustic-perceptual characteristics of the major dysarthrias in a viable classification scheme. This work has stimulated widespread study of the various adult dysarthrias in the speech science laboratories of the country.

    The 1960s and 1970s were also marked by the development of three psychometrically sound and widely used aphasia tests—The Minnesota Test of Differential Diagnosis of Aphasia (Schuell, 1965); the Porch Index of Communicative Ability (Porch, 1967, 1971); and the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1972). Coupled with newer diagnostic neuroimaging techniques such as computerized axial tomography (CT) scanning, magnetic resonance imaging (MRI), positron emission tomography (PET), and single photon emission tomography (SPECT), these behavioral language tests allowed more accurate study of the correlations between brain and language behavior.

    These recent advances in clinical neurodiagnostic imaging techniques are leading to more precise visualization of neurophysiologic mechanisms of speech and language mechanisms in the brains of conscious subjects, but each technique provides different information. Computerized axial tomography scans have been used extensively to pinpoint the site of lesions in cases of brain damage. Magnetic resonance imaging scans surpass other imaging techniques in visualizing the structures of the head and neck; for instance, the corpus callosum, an important tract of fibers connecting the two cerebral hemispheres, can be clearly recognized in MRI scans. Single photon emission tomography procedures have been used to measure cerebral blood flow and blood volume in three-dimensional cross sections of the brain. Positron emission tomography provides three-dimensional quantification of glucose or oxygen metabolism in the brain and is a more direct measure of the function of neural tissue than cerebral blood flow, especially in patients with cerebral injury or disease. A PET scan allows the mapping of brain activity during different behavioral states. Each of these four techniques will do much to clarify brain-language relationships in the future and to aid speech-language pathologists in the management of communicatively disabled individuals (see Chapter 9).

    Thus, in only a century and a quarter there have been dramatic gains in knowledge about brain function as it relates to speech and language. Also in this time, a new discipline, speech-language pathology, was born. It has experienced tremendous growth and earned respect as a profession. Today’s speech-language pathologist is obligated to continue to advance the profession by being knowledgable in neuroanatomy and neurologic disease as they affect human communication.

    How to Study

    Most students in speech-language pathology receive a limited introduction in their undergraduate careers to the neurosciences. Often they have not been exposed to course work in the biological sciences. The majority of students are, of course, enrolled in courses designed to acquaint them with the anatomy and physiology of speech, but usually these courses focus on speech musculature. Students often do not receive an adequate introduction to neuroanatomy and neurophysiology of speech and language. It is assumed that students will learn these details in courses in aphasia, adult dysarthria, and rehabilitation of speech in cerebral palsy. Students find a neuroscience course taken as advanced undergraduates or beginning graduate students difficult.

    Students often say that neurology courses are difficult because they believe they must learn the technical term for each hill and valley in the complex anatomy of the brain. Second, the technical terms are unfamiliar ones, usually derived from Greek and Roman roots. We will concentrate on crucial terminology for an understanding of speech and language, but we will not burden the student with neuroanatomical terminology that does not affect speech and language directly. A glossary is provided at the end of the book to help readers with terminology.

    Part of the strategy in mastering any textbook in the biological sciences is to give the study of drawings, diagrams, and tables in the text as much time as the narrative sections of the textbook. If the reader can come away from a study of this textbook with a set of working mental images of the structures and pathways of the nervous system that are important to communication, and can recall them at critical times, then one of the purposes of this textbook will be realized.

    The reader, of course, must also master the verbal material in the text. An integration of verbal material with eidetic imagery means that students must call on all their brain power, bringing into play the special capacities of both the right and left hemispheres of the brain. We now know that the left hemisphere is specialized for its capacities of verbal analysis and reasoning, whereas the right hemisphere is specialized for its imagery functions. Utilization of functions of both hemispheres will facilitate learning in neurology.

    With our emphasis on imagery as one of the better ways to learn neurology, it should be no surprise that we urge readers to use as a teaching aid their own drawings of structures and pathways. Even crude sketches, carefully labeled, will teach the necessary anatomic relationship and will fix pathways, structures, and names in the mind.

    Anatomical Orientation

    In order to aid this visualization process of learning, we have used many drawings throughout the text. When viewing drawings in textbooks or creating your own set of anatomic sketches, one must constantly orient oneself in terms of the standard anatomical position and planes. The human body itself may be defined in terms of an anatomical position—one in which the body is erect, the head, eyes, and toes pointed forward. The limbs are at the side of the body and the palms face forward. From this fundamental position, other positions, planes, and directions may be defined. These positions, planes, and directions apply to the brain as well as other sections of the body. Three planes are traditionally defined:

    • The median plane, or section, passes longitudinally through the brain and divides the right from the left.

    • A sagittal plane divides the brain vertically at any point and parallels the medial plane.

    • A coronal, or frontal, section is any

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