Studying patients with brain trauma suffered during World War I, Head conceived all aphasia as impairment in “symbolic formulation and expression” (vol 1, p 218) in which speech, reading, and writing were affected in concert. He denounced “diagram makers” like Bastian and Wernicke for “serene dogmatism” (vol 1, p 57) [39] and championed Hughlings Jackson’s writings.
Along similar lines, Kurt Goldstein (1878–1965), a pupil of Wernicke who worked in Germany and the United States, proposed that the fundamental impairment in brain-injured patients was in “abstract attitude.” Like Hughlings Jackson, Goldstein denied “a simple relation between a symptom and a lesion in a circumscribed area” (p 50) [40]. Symptoms were influenced by the “condition of the rest of the brain, and even of the whole organism” (p 256) [41].
Apraxia and Agraphia
Hugo Liepmann (1863–1925) in Berlin offered a theoretical framework for apraxia, disorders characterized by the failure to carry out motor tasks despite the ability to do so [42]. In 1907, Liepmann and Otto Maas (1874–1965) reported the case of a man with unilateral agraphia [43]. He had right-sided weakness. Despite normal speech and speech understanding, he was unable to follow commands requiring the use of his left arm. He could not write, copy text, or use anagram letters to spell his name. An autopsy showed damage from a large stroke in the distribution of the anterior cerebral artery. Involvement of the rostral corpus callosum and white matter tracts disrupted connections between anterior regions of the 2 cerebral hemispheres. Liepmann and Maas [43] attributed agraphia to apraxia of the left hand due to the disruption between motor cortex of the right hemisphere, which controlled left hand movements, and left hemisphere areas responsible for goal-oriented movements.
1965: Rediscovery and New Directions
There were exceptions, such as Solomon Henschen (1877–1930) in Sweden and Johannes Nielsen (1890–1969) in Los Angeles, but the center–pathway model fell out of vogue during the early and middle decades of the 20th century. Ascendant views of Marie, Head, and Goldstein were reinforced by the works of Swiss pathologist Constantin von Monakow (1853–1930) on diaschisis (focal brain lesions exerted distant effects) and the American psychologist Karl Lashley (1890–1958) on equipotentiality (one part of the cortex could take over when another part was damaged).
In Boston, Geschwind revived earlier formulations of alexia and agraphia based on Dejerine’s center-pathway model. He was inspired by unexpected findings described by Roger Sperry (1913–1994) in split-brain patients, who had undergone corpus collosotomy, the surgical separation of the 2 cerebral hemispheres, to control intractable epilepsy [44]. With neuropsychologist Edith Kaplan (1924–2009), Geschwind reported a patient with agraphia of the left hand, which they interpreted as a functional disconnection of the 2 cerebral hemispheres [45]. Delving into the older neurological literature, Geschwind was “troubled by the fact that people who had left their mark so indelibly in many areas of neurology, such as Wernicke, Bastian, Dejerine, Charcot, and many others, could apparently have shown what was asserted to be the sheerest naiveté and incompetence in the area of higher functions” (p 215) [46]. In his landmark article of 1965, “Disconnexion syndromes in animal and man,” [2] Geschwind discussed Dejerine’s case of alexia without agraphia [35] and Liepmann and Maas’s case of unilateral agraphia [43]. These cases and others were adduced in support of a critical role for pathway lesions in disconnecting functionally discrete cortical regions [2]. Geschwind reinterpreted the left angular gyrus as a center for visual-auditory associations required for memories of the “‘rules of translation’ from written to spoken language” (p 279) [2]. For alexia without agraphia, the disconnection was between visual cortex and the left angular gyrus. For apraxic agraphia, the disconnection lay between right hemisphere motor cortex and left hemisphere language areas.
Geschwind’s disconnection theory – in conjunction with research of colleagues Harold Goodglass (1920–2002), Frank Benson (1928–1996) and others at the Boston University Aphasia Research Center – rekindled interests in what has become known as behavioral neurology [47] and led to new approaches to the study of aphasia, alexia, and agraphia, and of brain-behavior relations more generally. More than half a century after their rediscovery, the classic formulations of Dejerine and Liepmann retain their heuristic value.
References
1Broca P: Perte de la parole, ramollissement chronique et destruction partielle du lobe antérieur gauche du cerveau. Bull Soc Anthropol (Paris) 1861;2:235–238.
2Geschwind N: Disconnexion syndromes in animals and man. Brain 1965;88:237–294, 585–644.
3Henderson VW: Alexia and agraphia. Handb Clin Neurol 2010;95:583–601.
4Henderson VW: History of disorders of writing and reading; in Barr WB, Bieliauskas LA (eds): The Oxford Handbook of History of Clinical Neuropsychology. Oxford, Oxford University Press, 2018.
5Gall FJ: Sur les Fontions du Cerveau, vol 5. Organologie ou Exposition des Instincts, des Penchans, des Sentimens et des Talens, ou des Qualités Morales et des Facultés Intellectuelles Fondamentales de l’Homme et des Animaux, et du Siége de leurs Organes. Paris, J-B Ballière, 1825.
6Bouillaud J: Recherches cliniques propres à démontrer que la perte de la parole correspond à la lésion des lobules antérieurs du cerveau, et à confirmer l’opinion de M. Gall, sur le siège de l’organe du langage articulé. Arch Gen Med 1825;8:25–45.
7Marcé LV: Mémoire sur quelques observations de physiologie pathologique tendant a démontrer l’existence d’un principe coordinateur de l’écriture et ses rapports avec le principe coordinateur de la parole. C R Mem Séances Soc Bio (Paris) 1856;3:93–115.
8Aubertin E: Reprise de la discussion sur la forme et le volume du cerveau. Bull Soc Anthropol (Paris) 1861;2:209–220.
9Broca P: Remarques sur le siège de la faculté du langage articulé, suivies d’une observation d’aphémie (perte de la parole). Bull Soc Anatom (Paris) 1861;6 (2nd series):330–357.
