LAUSR

In 1908 on June 11th, on July 9th and 23rd, three symposiums devoted to aphasia were organized in Paris by Charcot's successor: Fulgence Raymond. This extraordinary Society of Neurology meeting was justified by an antagonism between Jules Dejerine and Pierre Marie about Broca's aphasia. Cases of loss of speech secondary to a lesion in the left cerebral hemisphere had been already reported by Littre in 1828, Dax in 1836 and Lordat in 1843. On April 18 1861, Paul Broca, a surgeon, reported the observation of a patient named Leborgne whose death took place in his unit. He had lost the ability to speak twenty years ago. Broca blamed this “aphemia” on the progressive softening of a frontal circumvolution (probably the third one), which he labeled as the language center in the brain. For Wernicke (1874), Broca's aphasia became the prototype for motor cortical aphasias. One hundred pages in The Neurological Journal , signed by M. Klippel, Head of the Society and Francois Moutier's thesis are the irreplaceable sources for this event. During the first meeting, a list of questions was disclosed. What was the debate's stake? In 1906, Pierre Marie published an article entitled “Revision about the Aphasia issue: the third frontal left circumvolution is not playing any specific role in the language function”. In 1892, he had written that Dejerine “was performing science as well as others were playing the lottery”, which almost caused an authentic fight. For Pierre Marie, Broca's aphasia was only adding up Wernicke's aphasia and anarthria to which he assigned a precise localization, “his quadrilateral space” encompassing basal ganglia and internal capsule ( Figure 1 ). On the contrary, Jules Dejerine was keeping to Broca's classical conception. The meeting on June 11th opened with this issue: are motor and sensory aphasias clinically different from one another? Dejerine showed than in sensory aphasia, verbal blindness and verbal deafness are a lot more intense than in motor aphasia in which they are either missing or less marked, to which Pierre Marie answered that these were only nuances and that there is only one type of aphasia. Andre Thomas, a Dejerine's student, proved the opposite, comparing the two entities seriatim. It came to total aphasia. For Dejerine, it was the association between a sensory aphasia and a motor one. For Pierre Marie, all the aphasias are total. Dejerine criticized the term “anarthria” which evokes neurological dysarthria. The patient affected with motor aphasia presents a reduced ability to speak but is able to utter some words without any difficulty to articulate and is able to sing. Dupre agreed. This led to the issue of pure motor aphasia. Then, Pierre Marie introduced the interesting concept of “inner language”, abolished in all types of aphasia and preserved in pure anarthria, which has to be distinguished from aphasia. The second confrontation was devoted to anatomy. F. Raymond attended it along with his Head Clinician Georges Guillain and Francois Moutier. Where are the limits of “Pierre Marie quadrilateral space”? Jules Dejerine regretted that a mere horizontal brain section did not take into account the volume under scrutiny's dorsal and ventral limits. Madame Dejerine enquired about the structures found there and asked (without obtaining any answer) which one of these was causing “anarthria”. She proved brilliantly that “the body and the foot of the third frontal circumvolution are situated backwards from this anterior limit and that going from this, the F3 foot and cap are part of the quadrilateral space in which they occupy the upper, anterior and external part”… hypothesis which is perfectly attested by “a vertical-transversal view but escapes from the too low view presented by P. Marie”. Brissaud agreed. For Dejerine, a lesion within the quadrangle is able to cause aphasia only if it affects the anterior, upper and external parts of the area, thus sectioning the nervous fibers issued from the anterior area devoted to language skills (that is to say F3 foot and cap). F. Moutier, called by P. Marie, reported data from six observations of common Broca's aphasia without any lesion within F3. Dejerine retorted that lesions could be present within the radiant crown and white matter, containing projection or association fibers from the frontal cortex. Then Pierre Marie asked Dejerine if, in his opinion, the term Broca's aphasia implied necessarily cortical lesions, “a complete mistake”? Mrs Dejerine repeated that Broca's aphasia was resulting from cortical lesions within F3 and from lesions in the frontal cortex's axons devoted to projection and association. P. Marie asked for convincing observations supporting this theory. Dejerine supported the Lelong's case published by Broca in 1861. Marie considered it as a case involving “a poor elderly man aged 84 and affected with senile dementia (!) and in whom aphasia was no more present than obvious cortical lesions except for senile atrophy”. The very detailed report published by Broca (which is reported in the book written by Philippe Mond-Broca) contradicts P. Marie's fantasy; actually, it was a Broca's aphasia of sudden onset and without dementia. Jules Dejerine then reported five typical observations of cases. A long discussion followed between Andre Thomas and Moutier. In his thesis, are reported 20 cases of Broca's aphasia, studied by serial sections without the frontal cortex being affected and three cases of patients suffering from left cortical lesion of F3 without aphasia. M. Dejerine studied these cases in detail again and found lacks in anamneses studies. During the last meeting, the role played by the lentiform nucleus and insula in language remained an unsettled question. Georges Guillain quoted Mills and Spiller who are assigning to the lentiform nucleus a role in phonation. Then was tackled the issue of aphasia as a fundamental disorder. P. Marie stated that it was an intelligence disturbance; finally, he raised his voice against the individualization of defined language areas along with a defined centre for words images supported by Wernicke. Klippel concluded: “We are all agreeing about the necessity of revising some of the issues, relating to aphasia”. These three days, initiated by Fulgence Raymond, showed pathological anatomy limits and opened a new neuro-linguistic pathway with Theophile Alajouanine.