Augusta Déjerine-Klumpke and the oustanding lesson on the anatomy of aphasia

On this day in 1908 Augusta Déjerine-Klumpke showed the anatomical evidences that lesions to an area deep to the left pars opercularis was associated with nonfluent aphasia.

She presented her results during the second meeting, on July 9,1908, of the Société de Neurologie de Paris and “constituted a highlight in the debate between the two foremost French theorists on the subject of aphasia, Joseph Jules Dejerine and Pierre Marie”.

Their points of view were radically divergent.

Dejerine represented the localizationist approach to aphasia.

Marie was against the localizationist and associationist approaches. In his view, there was only one type of aphasia – the Werniche’s aphasia -, caused by a lesion in the temporo-parietal association cortex and the other forms resulted from an extension of that lesion. For Marie, Broca’s aphasia was  the combination of Wernicke’s aphasia and anarthria and involved both the Wernicke’s area and the “quadrilateral” or “lenticular” space, consisting of the lenticular nucleus and white matter deep to the insula.

After the first meeting, in which Dejerine and Marie addressed the clinical symptomatology of aphasia, on July 9, the discussion moved on to the anatomical basis of language and pathological basis of the aphasias.

The first question concerned “the anatomical implications of Marie’s claim that the “anarthria” in Broca’s aphasia resulted from lesions of the “quadrilateral space” or “lenticular zone” and not from lesions of Broca’s area (the foot and cape of the third frontal convolution on the left)”.

“Is it possible to distinguish a zone, called the zone of the lenticular nucleus, or the lenticular zone, and what are its limits?”

 Joseph Dejerine began the discussion (as reported by Lecours and Caplan 1984):

I do not believe, as Monsieur Pierre Marie maintained in our last discussion, that the lesion which causes [motor] aphasia is located ‘anywhere in the quadrilateral space.’ I believe that a lesion of the quadrilateral which causes motor aphasia is located, quite precisely, in its superior anterior external portion, sectioning the undifferentiated white matter of the centrum semiovale subjacent to the cortex which forms the base of the anterior half of the superior marginal sulcus of the insula.

Pierre Marie insisted that the anterior limit of ‘his’ quadrilateral was behind F3.

But then he could deny neither (a) that he had written that the rostra limit of his quadrilateral is the anterior insulo-marginal sulcus (Marie, 1906a) nor (b) that, not long ago, he has explicitly considered the precentral and postcentral gyri as serious candidates for membership in his quadrilateral (Marie & Moutier, 1906) (as reported by Lecours et al.1992).

Marie has to surrender:

Yes indeed, the quadrilateral of which I have spoken certainly has a cortical component above and below [the one horizontal section that I have elected to represent it]. In particular, one can see that it includes a large part of the central motor convolutions.

 At this point Augusta Déjerine-Klumpke confronted directly with Pierre Marie:

I do not believe, as does Monsieur Marie, that such a lesion is located behind the third frontal convolution. 1 rather maintain that the anterior limit of the quadrilateral, as set by Monsieur Pierre Marie, separates this space only from a small area of the third frontal convolution, the orbital part, a part which no one has ever suggested is related to aphasia, and I claim that the foot and cape of the third frontal convolution [pars opercularis and triangularis] are entirely behind the anterior limits of the quadrilateral so defined. The pars opercularis and triangularis of F3 are part of the quadrilateral. They occupy its superior anterior external portion.

As summarized by Lecours and Caplan: “Marie had always represented the lenticular zone on a horizontal section passing under F3. But since he had said that the rostra1 limit of the quadrilateral is the anterior marginal sulcus of the insula and had just agreed that the quadrilateral included at least the inferior third of the pre- and postcentral gyri, it was legitimate to make cuts above this level of section. When this was done, it became apparent that all but the orbital portion of F3 lies behind the anterior marginal sulcus of the insula. Madame Dejerine proceeded to demonstrate these relationships with some of the best gross anatomical materials of the area ever prepared.”

Augusta Déjerine-Klumpke then showed the mutual relationships of Broca’s area and the anterior insula on a coronal cut of the left hemisphere passing through the foot of F3, immediately rostra1 to the pre-Rolandic sulcus, emphasizing the evidence that the foot and cape of F3 are part of the quadrilateral since they are above the superior marginal sulcus of the insula and not, as Pierre Marie maintained, rostra1 to its anterior marginal sulcus.

In her conclusion she claimed:

Every central lesion which involves the external capsule, the putamen and the ventricular ependima above the level of the caudate nucleus also sections the undifferentiated white matter of the centrum semiovale, including the fibers subjacent to the pars triangularis and opercularis of F3, whenever the lesion is located in front of a plane which passes through the middle section of the anterior commissure. To base an argument on a central lesion in order to conclude that the third convolution plays no role in aphasia, when the central lesion is of this nature, would be similar to saying that hemiplegias and hemianopsias that result from central lesions show that the Rolandic and calcarine cortices play no role in hemiplegia and hemianopsia.

Her anatomical evidences demostrated that motor aphasia was the result of section of the fibers coming from the anterior language zone, either through a direct lesion of the convolutions in this zone, or through a subcortical lesion, or through an extension of a central lesion into the centrum semiovale.

Pierre Marie replied thanking Déjerine-Klumke and adding that:

No one who has cut a certain number of brains would not know that the third frontal convolution can spread to a variable degree behind the insular region.

There is no reason for me to include the third frontal convolution in my (sic) quadrilateral or in my (sic) lenticular zone; on the contrary, when I gave the limits of this zone in a horizontal section of the brain, I was careful to specify that the external portion of this zone is formed by the convolutions of the insula. Thus, everything outside of the insula is not part of my (sic) quadrilateral. Please, Madame Dejerine, calm down (Que Madame Dejerine se tranquilhe). I have no intention of annexing the third frontal convolution to my (sic) quadrilateral. since the entire campaign which I have waged is to prove that the third frontal convolution plays no role in Broca’s aphasia.

Augusta Déjerine-Klumpke was not intimidated by his attack and and replied turn back:

May I suggest that Monsieur Pierre Marie realize that, however well the relationships between the third frontal convolution and the insula are known, they deserve to be recalled and made explicit in this debate . If Monsieur Pierre Marie had had them in mind at the time of his earliest work, he would certainly not have fallen into the mistake that he made in saying that the third frontal convolution is not situated in the quadrilateral space and, along with its white matter, is found entirely in front of this space, and he would have defined his quadrilateral differently, at least with respect to its height. I criticize Monsieur Pierre Marie for not having made more than a single horizontal cut in this area and for not having been concerned with the superior limit of his quadrilateral space or of the lesions he examined. If he had done so, he might have excluded the foot and cape of F3 from the quadrilateral by considering its superior border to be the natural limit of the insula or of the putamen, that is, the superior marginal sulcus of the insula, because the orbital portion of F3 is in front of the insula and the pars triangularis and opercularis of F3 are above it. But by including the motor convolutions in the cortex of the quadrilateral space, the pars triangularis and opercularis clearly become part of this space, as I have shown. Moreover, lesions which occupy the anterior superior external portion of the quadrilateral space always involve fibers to and from F3, when such lesions affect the undifferentiated white matter of the centrum semiovale. It is unimportant that the pars triangularis and opercularis of F3 are not part of the insula. What is important is the connection between F3 and the centmm semiovale. Now, as I have just shown, this connection is via fibres coursing along the superior lip of the superior marginal sulcus of the insula through a large area which corresponds, in its antero-posterior dimension, to the entire length of the anterior convolution ol* the insula. This is precisely the anterior half of the quadrilateral space. Lesions of the quadrilateral space produce a motor aphasia only when they affect this area and section fibers coming from the anterior language zone which consists of the Rolandic operculum and the pars triangularis and opercularis of the third frontal convolution.

Agusta Dejerine-Klumpke‘s outstanding speech caused a great sensation in the assembly.

Twenty-five members of the Société were present and among them there were Andre-Thomas, Souques, Brissaud, Ballet, Dupré, Babinski, Roussy, Raymond, Guillain, and Moutier.

To maintain Pierre Marie’s clinical approach of the anterior aphasias and also his claim that posterior aphasias showed a disorder of intelligence it became necessary to dissociate from the anatomical and pathological basis.

“The role of the white matter of the centrum semiovale and of the central grey matter in language is just beginning to be explored. That the area described by Madame Dejerine-the pars triangularis and opercularis of F3 and the Rolandic operculum-plays a role in language and contributes to the role of subjacent white matter through its efferent fibers is not in doubt” (Lecours and Caplan 1984).

  • Lecours A.R., Caplan D. (1984): Augusta Dejerine-Klumpke or the lesson of anatomy. Brain and Cognition 3: 166–197 .
  • Lecours A.R., Chain F., Poncet M., Nespoulous J.L., Joanette Y. (1992): Paris 1908: The hot summer of aphasiology or a season in the life of a chair. Brain and Language 42: 105–152.

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