BRAIN
AND
LANGUAGE
43,
475-486 (1992)
Phrenological Studies of Aphasia before Broca: Broca’s Aphasia or Gall’s Aphasia?’ JASON
W. BROWN AND KAREN L. CHOBOR
Department of Neurology,
New York University
Medical Center
God and brain, only God and brain2
Gall
The history of aphasia is usually taken to begin with Broca’s (1861a,b) discovery of the correlation of aphemia with damage to the posterior inferior portion of the frontal lobes and the subsequent relation to left hemisphere. That there were prior, even biblical, references to aphasia is not in dispute, nor that, according to Benton and Joynt (1960), almost all the clinical forms of aphasia had been described prior to 1800. The significance of Broca’s case studies, therefore, lies in the association of motor aphasia with focal pathology in the frontal lobe. This paper examines the status of aphasia localization prior to Broca, and, specifically, the extent to which Broca’s discovery may have been anticipated by the phrenologists. 0 1992 Academic Press, Inc.
Aphasiologists are generally familiar with Bouillaud’s (1825a) paper describing a series of cases of aphasia with involvement of the anterior lobes as well as some cases of posterior lesion without aphasia and his conclusion that the entirety of both frontal lobes was the site of “the organ of articulate language.” In this paper, Bouillaud distinguished the creation of words as signs from their production in speech and he proposed that “perhaps the gray matter of the anterior lobes might be the organ of the intellectual part of speech while the white substance is the organ Thanks to Bob Rieber and a referee for helpful contributions to this paper. Reprint requests should be addressed to Jason W. Brown, 66 East 79th Street, New York, NY 10021. ’ Presentation, Historical Conference on Brain Functions, Fort Myers, Florida January 2-5, 1991. ’ Ackerknecht & Vallois (1956); p. 20. 475 0093-934X/92 $5.00 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form resewed.
476
BROWN AND CHOBOR
that executes and coordinates the muscular movements necessary for speech production.” 3 These facts are well known. What is less familiar is that Bouillaud was a disciple of Gall, to whom he referred as a Copernicus, a Kepler, a Newton of physiology. Bouillaud was a founding member of the SociCtC Phrenologique and editor of its journal; Gall died on August 22, 1828 and the society was organized shortly thereafter (Ackerknecht & Vallois, 1956). The transition from Bouillaud to Broca is part of the history of aphasia while the transition from Gall to Bouillaud, and the phrenological sources of aphasia theory and localization, have not been the subject of extensive study. We know that the attribution of language to the frontal lobes was derived from Gall’s localization and that there were clear phrenological precedents for Broca’s paper. One can ask, therefore, what the phrenological concept was of language and language disorders prior to Broca, what sort of cases were described, and how precise was the localization of language?4 Did Gall provide documentation for the association of language to the frontal lobes other than the familiar observation of enlarged orbits-a sign of frontal expansion-in the presence of superior verbal memory? Gall distinguished two forms of language, the faculty of spoken language and the memory of words, or naming.5 The faculty of language was most highly developed in great literary and philosophical figures such as Bacon or Voltaire and was related to intellectual level. In constrast, a prodigious word memory could occur even in the presence of mental retardation as an isolated performance. Generally, skillful language use tended to accompany a good word memory, though there were exceptions, e.g., Rousseau. According to Gall both faculties were localized in distinct though neighboring regions6 As to the organ of the memory of words, Gall (1825) implicated the cerebral region resting on the posterior half of the roof of the orbit between XV and 39 (Figs. 1 and 2).’ This region (area XIV) corresponds 3 Bouillaud (1825a; p. 43) “Peut-&We que la substance grise des lobules anterieurs est l’organe de la partie intellectuelle de la parole, tandis que la substance blanche est I’organe qui execute et coordonne les mouvemens musculaires necessaires a la production de la parole.” Bouillaud’s claims of priority for the distinction of the intellectual or internal aspect of language and its productive or external aspect were accepted by Riese (1947; see below). 4 Broca (1861b; p. 407) distinguished his “localization by convolutions” from the phrenological “localization by regions or . compartments corresponding to invariable points on the skull.” (see below). 5 “Gall speaks of these two configurations as of two different organs under the names, an organ of words, and an organ of language” (Spurzheim, 1815). 6 Spurzheim (1815) and most later phrenologists, including Combe (1836), admitted only one organ of language situated on the transverse portion of the supra-orbital plate. ’ “Je regarde comme l’organe de la memoire des mots, cette partie cerebrale qui repose
BROCA’S APHASIA
OR GALL’S APHASIA
477
with the orbital gyrus adjacent to the pars orbitalis of the posterior inferior frontal convolution. Gall located the organ of the language sense (XV) on the mid portion of the supra-orbital plate. The organ for word memory (XIV) was slightly posterior to that for language, but these regions were continuous. Enlargement of the former organ giving a heightened word memory was associated with protrusion of the eyeballs (Fig. 3, top), whereas a prominence of the language organ resulted in pouched or swollen lower eyelids (Fig. 3, bottom; from Spurzheim, 1815). When the organ was reduced in size there was infolding of the lower eyelid (Combe, 1836). The area XV of Gall was initially numbered XXIX by Spurzheim (1815) corresponding with the surface notation on phrenological charts.’ This area was changed in later publications to area XxX111, which is the numbering used in most subsequent illustrations and/or phrenological heads. It is typically written on the orbit, just as Gall had done on skulls, cases, drawings of skulls and phrenological heads. Gall (1825) described several cases in support of this thesis, including demented, retarded and aphasic subjects, some with presumed frontal lobe damage. He mentioned two patients with wounds above the eye and loss of memory for proper names. A third case (Rampan) was described in greater detail. This was a 26-year-old man with a foil injury at the base of the nose on the left side. The sword penetrated about 3% inches through the ethmoid bone and pierced the postero-medial part of the left anterior frontal lobe. There was residual right hemiparesis, diplopia, impaired smell and taste, and disturbed memory for proper names but not objects. He was unable to recall the name of his physician (Baron Larrey) and referred to him as M. Chose. This and the following case are reproduced in entirety in the Appendix. Gall (1825) cited another case referred to him by Baron Larrey, surgeon to Napoleon,’ an apoplectic “unable to express in spoken language his feelings and ideas . . . He does what he is told to do (but) . . . is unable, at the moment, to articulate a word that is pronounced for him to repeat; but some moments afterwards this word escapes him involuntarily . . . It is not his tongue that is at fault, as he can move it quite well and he sur la moitie posterieure de la vofite de I’orbite, PI. IV, entre XV et 39” (Gail, 1825; Vol. 5, p. 18). ’ Spurzheim increased from 27 to 35 the number of “psychic organs” described by Gall (Temkin, 1953). ’ Napoleon was critical of phrenological studies, in part because he did not wish his scientists to learn anatomy from a German (Davies, 1955) but also because of resistance to the materialist idea that physiology could explain mental states (Capen, 1836). Nonetheless, the cranium of Napoleon, said to have been a poor specimen because its small size did not lend itself to phrenological examination (Ackerknecht & Vallois, 1956; p. lo), did wind up in a phrenological collection!
478
BROWN AND CHOBOR
FIG. 1. Areas XV and 39 on the orbital surface of the brain (from Gall, 1810; p. 15).
pronounces very well a great number of isolated words. It is not even his memory that is at fault, as he showed me very vividly that he was sorry to be unable to express himself on many things that he wished to tell me. He has lost nothing but the faculty of speech . . . (and is) unable to read and write.” Of interest, Gall attempted to “stimulate the action of the brain, not only by medicines administered internally, but also by friction-for example, by an ointment of tartrate of potash and antimony. (He claimed
BROCA’S APHASIA
OR GALL’S APHASIA
479
FIG. 2. Area XV on the mesial surface (from Gall, 1810).
that) by these means we have succeeded in restoring the faculty of speech!” lo Gall (1825)” reports an observation of Spurzheim, a stroke patient who “knew the qualities of objects and remembered their vocal signs, but could not pronounce them. If he was shown a colour, such as green, and was asked whether it was brown, yellow or any other colour but green, he replied “No”; as soon as the true colour was named, he said “Yes.” In another similar case, the “man understood all that was said to him, but could not pronounce the words he desired to speak. He asked for different things; if they brought the thing of which he had pronounced the name, he said at once, it is, or it is not that.” Gall mentioned that such patients may “speak languages that they had learned in infancy, but which they had completely lost when in health.” Gall went on to say “there exists a form of partial insanity limited to the faculty of speech, . . . (a phenomenon) impossible if the faculty of spoken language was not the function of a particular part of the brain.” After the descriptions of Gall and Spurzheim, there were many case ” Gall (1825); translation by Williams (1894; p. 219). ” In Williams (1894; p. 219).
480
BROWN AND CHOBOR
FIG. 3. In the top figure, the prominent eyes are associated with an exceptional word memory. In the lower figure, the swollen lower eyelids are a sign of a general facility in language. Areas 14 and 15 of Gall are combined as area 29 in the study by Spurzheim (1815).
reports of aphasia with frontal lobe damage. Hood (1822; see Whitaker & Grou, 1991) described an aphasia with a left frontal lesion at autopsy. In 1825, he reported a case of stroke in a 72-year-old man with rightsided weakness and intact mentation who showed struggle “to find words to convey his meaning” (see Whitaker & Grou, 1991). As mentioned above, Bouillaud (1825a) reviewed a number of aphasic casesand argued for a relation between language and the entirety of both anterior lobes. This was supported by a review of 114 cases of anterior
BROCA’S APHASIA
OR GALL’S APHASIA
481
lobe pathology with a speech disturbance (Bouillaud, 1825b). The distinction of language and naming implicit in the classification of Gall was changed to that of words as signs for ideas-an intellectual or internal aspect-and word articulation-the external or motoric component. This distinction has survived to this day, most notably in Marie’s (1906) concept of aphasia and anarthria. Andral (1834) described nine cases of aphasia, eight of whom had sustained left hemisphere lesions and the ninth bilateral lesions; he did not comment on the asymmetry. Two years later, Dax (1836), who was a student of phrenology, reported an association between aphasia and the left hemisphere. In the phrenological literature, there were continuing reports of aphasia with damage to the anterior (i.e., frontal) lobes. Otto (1834; p. 574) described a patient unable to speak who could point to desired objects. At autopsy, “one of the hemispheres of the brain was found to be diseased, and the other in a perfectly sound state, with the exception only of that part of it which is held by phrenologists to be the organ of language.” Inglis (1836) reported a young woman with a gunshot wound at the external orbital angle of the frontal bone and gave a detailed account of the aphasia. Smith and Niddrie (1839) reported a 14 year old with head injury and a wound under the left eyebrow initially unable to speak. In recovery, he could say IZOclearly, said “ius” for yes, “mud” for mother, and “mungd” for mug. He was unable to name objects but could demonstrate their use. Hytche (1840) described a case of possible aphasic migraine with pain over the left eye, lack of awareness for semantic paraphasia (“razor” for candlestick; “bread” for bacon; “Lapland” for Polynesia) which occurred “most in substantives, and occasionally, but very rarely, in verbs.” DISCUSSION
Gall’s localization of language in the frontal lobes was based on inferences from the evidence of cranioscopy and his collections of busts and skulls as well as reports of cases with brain pathology. Gall provided the first complete descriptions of an expressive aphasia with a proposed brain localization. For Gall and other phrenologists, the localization of language in the frontal lobes was the correct result of a mixed set of arguments, not the outcome of only clinical study. Indeed, it is worth considering that if Gall had limited his faculty localization to the two language areas, which were the basis for his organology, and not gone on to describe 25 other centers, he would have enjoyed greater respectability in the history of brain psychology. We might today speak of Gall’s aphemia or aphasia rather than the aphasia of Broca. Still, he deserves credit for employing the case material for the first time as a confirmation of a theory of the
482
BROWN AND CHOBOR
localization of language, even if the material was not the primary source of the theory. Broca (1861a; p. 330) pointed out that the study of pathological cases did not have the privileged status it received under Bouillaud. He wrote that the phrenological’* localization of aphemia was “most often in the most anterior part of the frontal lobe not far from the eyebrow and above the orbital roof . . . (while in Broca’s patient the localization was) much further back, much nearer to the coronal suture than the superciliary arch” (Broca, 1861a; translated by Bonin, 1960). In this, Broca chose to emphasize the cranial localization, not the localization in the brain, which was quite close to the lesion site in Broca’s two patients. Broca selfservingly referred to Gall’s localization by “bumps” instead of convolutions (see footnote 4) when, in fact, the bumps played a secondary part in Gall’s cranioscopy.‘3 Gall’s main goal was a cerebral organology to establish an anatomy and physiology of the brain (Ackerknecht & Vallois, 1956). If we examine the transition from Gall, through Bouillaud to Broca, the progress is largely that of the prominence given to the clinical pathology. For Gall, brain damage was one of many sources of evidence for faculty localization. The casesof aphasia had an importance no greater than the occurrence of a selective giftedness in word memory or language ability and the associated physiognomic markers. The importance of Bouillaud’s work was in the emphasis it gave to cases of brain damage as a unique source of information on localization. This was a conceptual shift without which Broca’s discovery could not have occurred. Along with this shift in thinking, the frontal localization of speech, largely speculative in Gall’s hands, took on a measure of clinical authority thanks largely to Bouillaud’s 1825 papers and his advocacy of a frontal speech area. Viewed in this light, Broca’s discovery seems predictable, even inevitable. Moutier (1908) pointed out that in the localization of language, Broca was as much the culmination of the phrenological period as the beginning of the scientific one. The one mystery is why Bouillaud waited 35 years before submitting his thesis to an anatomical test. What, in retrospect, seems an obvious step to us was obviously not so clear at the time. The transition from Gall to Bouillaud to Broca was a transition from a stage where the clinical material supported a philosophical system to one where the clinical material was decisive in establishing the factual basis of the system, to one I2 The term, phrenology, was suggested to Spurzheim by Thomas Forster in 1815. Gall preferred to use the term cranioscopy. I3 In spite of the criticism of Gall, Broca was a leader in the field of craniometry, arguing for a close relationship between brain volume and intelligence (see the discussion by Gould, 1981; pp. 82-107).
BROCA’S APHASIA
OR GALL’S APHASIA
483
where the clinical material itself required documentation. This, of course, is also the history of the evolution of the scientific method. In addition to the change in anatomical thinking, there was also a change from Gall’s concept of separate centers for word memory and language to Bouillaud’s distinction of an intellectual and an articulatory component, a distinction that was largely accepted by Broca. The classification of aphasia into a disorder of internal and external speech, instead of language and word memory, is of equal importance in the subsequent course of aphasia study, for example, in the documentation of posterior aphasia and the idea of a parietal conceptual field that was so crucial to later typologies. Viewed in the historical context, one can see that Broca’s finding was less a discovery than the outcome of two shaping ideas: the role of case study in language localization; and the concept of language which determined what aspect of language was localized. Finally, it should be noted that much of Gall’s theory continues to motivate current research. The relation of regional brain size to functionthe cerebral organology-has been revived in studies of the asymmetry of the language area. The relation of the convolutions of the brain to the skull, at least with respect to the inner table, appears in both the asymmetry studies and the use of fossil endocasts in physical anthropology, while the idea of genetically encoded faculties that are only fine-tuned by the environment pervades work on modularity and philosophy of mind. APPENDIX
Case 1 M. Edouard de Rampan, age de vingt-six ans, recut avec un fleuret, dont la pointe avait CtC rompue sur le plastron, un coup a la partie moyenne de la region canine gauche, pres de l’aile du nez, dans une direction oblique de bas en haut, et un peu de dehors en dedans. L’instrument penetra a la profondeur de trois pouces et demi environ, a travers la fosse nasale gauche, traversa la lame criblee de l’ethmo’ide pres de l’insertion de la faux du cerveau, et parait avoir perArC, dans une direction verticale et un peu oblique d’avant en arriere, a la profondeur de cinq a six lignes dans la partie interne posterieure du lobe anterieur gauche du cerveau, de maniere a se rapprocher de la partie anterieure du mesolobe. Le malade Cprouva une hemorragie tres considerable dans l’instant mtme de la blessure, et il est sorti une t&s grande quantite d’esquilles par le nez et par la bouche. Tous les organes des sens ont CtCparalyses a l’instant meme, mais ils ont repris peu a peu leurs fonctions, et il ne reste plus maintenant que les alterations suivantes: La vue a CtCperdue totalement de l’aeil gauche pendant un mois; elle est retablie aujourd’hui, mais le malade voit les objets doubles.
484
BROWN
AND
CHOBOR
L’odorat Ctait totalement Cteint; il est retabli a present, et le malade peut distinguer les liqueurs alcooliques odorantes des liqueurs inodores. Le gout Ctait Cgalement aboli; il s’est retabli peu a peu sur le c&C droit de la langue, de maniere que la moitie droite de cet organe percoit trb bien les saveurs, tandis que le cot6 gauche est prive de cette faculte; la totalite de cet organe est entrainee a droite, par opposition a l’hemiplegie qui existe du c&C droit, la bouche &ant dejetee a gauche. L’oui’e, abolie d’abord dans l’oreille du c&C de la blessure, s’est retablie par la suite, et il ne reste plus qu’un bourdonnement. La voix qui s’etait perdue Cgalement s’est retablie de meme, et il ne reste plus qu’un leger begayement. La force des organes generateurs est conservee entierement. 11survint une hemiplegie de tout le c&C droit; ii ne reste plus aujourd’hui qu’une paralysie du membre thoracique et abdominal de ce meme cot& pour la locomotion seulement, la sensibilite y existant intacte. La memoire des noms a CtC totalement eteinte, et ne se produit aujourd’hui que tres difficilement, tandis que la memoire des images, et de tout ce qui est susceptible de demonstration, est dans l’integrite la plus parfaite. L’aberration mentale qui a exist6 dans les premiers temps dans les organes de I’intellect, a cesse aujourd’hui; mais tout ce qui a rapport a son amour-propre, a ses succb militaires, etc., le jette dans un &at d’alienation et de melancolie profondes, tandis que les conversations qui ont rapport a sa famille, a ses proches, a ses amis, lui rendent sesfaculties. Le malade se rappelait tres bien la personne, la figure et les traits de M. le baron Larrey; il l’aurait reconnu sans aucune difficulte; il le voyait toujours devant ses yeux (expressions du malade), et cependant il ne se rappelait pas son nom, et le designait par celui de M. Chose. Case 2
Un soldat que M. le baron Larrey a eu la complaisance de m’envoyer, est dans un &at a-peu-pres semblable. C’est Cgalement a la suite d’une attaque d’apoplexie que cet homme se trouve dans I’impossibilite d’exprimer, par le langage park, ses sentimens et ses idees. Sa figure ne Porte aucune trace d’un derangement de l’intellect. Son esprit trouve la reponse aux questions qu’on lui address; il fait tout ce qu’on le prie de faire. Je lui montrai un fauteuil, et je lui demandai s’il savait ce que c’etait; il me repondit en s’etablissant dans le fauteuil. 11est incapable d’articuler sur-le champ un mot qu’on prononce pour le lui faire repeter; mais quelques instans apres, ce mot lui Cchappe involontairement. Dans son embarras, il montre du doigt la partie inferieure de son front; il temoigne de l’impatience, et indique par des gestes que c’est de la que vient son impuissance de parler. Ce n’est point sa langue qui est embarrassee, car il la fait mouvoir avec une grande agilite,
BROCA’S APHASIA
OR GALL’S APHASIA
485
et il prononce tres bien un grand nombre de mots isolb. Ce n’est pas non plus sa memoire qui est en defaut, car il me temoigna tres vivement qu’il Ctait fache de ne pas pouvoir s’exprimer sur beaucoup de chases qu’il etit voulu me raconter. II n’y a d’aboli chez lui que la faculte de parler. Ce soldat, tout comme le malade de M. Pinel, n’est plus capable ni de lire ni d’ecrire. REFERENCES Ackerknecht, E., & Vallois, H. 1956. Franz Joseph Gall, inventor of phrenology and his collection. Madison: Univ. of Wisconsin Medical School. Andral 1834. Maladies de l’encephale. Clinique medicale. 3rd ed., pp. 391 and 531. Benton, A., & Joynt, R. 1960. Early descriptions of aphasia. Archives of Neurology, 3, 205-222. Bouillaud, J. 1825a. Recherches cliniques propres a demontrer que la perte de la parole correspond a la lesion des lobules anterieurs du cerveau, et a confirmer l’opinion de M. Gall, sur le siege de I’organe du language article. Arch. Gen. de Med. 8, 25-45. Bouillaud, J. 1825b. Traite clinique et physiologique de l’encephalite ou inflammation du cerveau. Paris. Broca, P. 1861a. Remarques sur le siege de la faculte du language articule, suivies d’une observation d’aphemie (perte de la parole). Bulletin de la societe anatomique de Paris 36, 330-357. Broca, P. 1861b. Nouvelle observation d’aphemie produite par une lesion de la moitie posterieure des deuxieme et troisieme circonvolutions frontales. Bulletin de la socitte anatomique de Paris 36, 398-407.
Capen, N. 1836. Phrenology, in connection with the study of physiognomy. Boston: Marsh, Capen and Lyon. Combe, G. 1836. System of phrenology. Boston: Maclachlan, Stewart and Anderson. vol. 4th ed., 2. Davies, J. 1955. Phrenology, fad and science. New Haven, CT: Yale Univ. Press. Dax, M. 1836. Lesions de la moitit gauche de I’endphale coincidant acec I’oubli des signes de la pensee (read at Montpellier, 1836. Gaz. Hebdom. 1865, 2nd. ser. II, 259-260. Forster, T. 1815. Sketch of the New Anatomy and Physiology of the Brain and Nervous System of Drs. Gall and Spurzheim Considered as Comprehending a Complete System of Phrenology. Gall, F. 1825. Sur les fonctions du cerveau et sur celles de chacune de ses parties. Paris:
Boucher. Gall, F., & Spurzheim, G. 1810-1815. Anatomie etphysiologie du systeme nerveux en general et du cerveau en particulier. Paris: Schoell. Gould, S. 1981. The mismeasure of man. New York: Norton. Hollander, B. 1909. The unknown life and works of Dr. Francis Joseph Gall. London: Siegle, Hill and Co. Hood 1822. Edinburgh Phrenological Journal. Hood 1825. Transactions of the Phrenological Society. Hytche, E. 1840. Edinburgh Phrenological Journal, 13, 344. Inglis, J. 1836. Case of injury sustained by the organ of language. Edinburgh Phrenological Journal, 10, 68. Marie, P. 1906. La troisieme circonvolution frontale gauche ne joue aucun role special dans la fonction du langage. Semaine Medicale 23 Mai, XXVI, 241-247. Moutier, F. 1908. L’Aphasie de Broca. Paris: Steinheil.
486
BROWN AND CHOBOR
Ombredane, A. 1951. L’Aphasie et l’elaboration de la pen&e explicite. France: Presses Universitaires de France. P. 13. Otto 1834. Edinburgh Phrenological Journal, 8, 574. Riese, W. 1947. The early history of aphasia. Bulletin of the History of Medicine. 21, 322334. Smith, G., & Niddrie, D. 1839. Affection of the faculty of language from an injury of the brain. Edinburgh Phrenological Journal, 12, 155. Spurzheim, J. 1815. The physiognomical system of Drs. Gall and Spurzheim; etc. London: Baldwin, Cradock and Joy. Temkin, 0. 1953. Remarks on the neurology of Gall and Spurzheim. In E. Underwood (Ed.), Science, medicine and history. London: Oxford. Von Bonin, G. 1960. Some papers on the cerebral cortex. Springfield: Thomas. Whitaker, H., & Grou, C. 1991, April. Spurzheim’s legacy: The case of Adam McConochie. Presentation at the Annual Meeting of the American Academy of Neurology, Boston. Williams, W. 1894. A vindication of phrenology. London: Chatto and Windus. Young, R. 1970. Mind, brain and adaptation in the nineteenth century. Oxford: Clarendon.
AND
LANGUAGE
43,
475-486 (1992)
Phrenological Studies of Aphasia before Broca: Broca’s Aphasia or Gall’s Aphasia?’ JASON
W. BROWN AND KAREN L. CHOBOR
Department of Neurology,
New York University
Medical Center
God and brain, only God and brain2
Gall
The history of aphasia is usually taken to begin with Broca’s (1861a,b) discovery of the correlation of aphemia with damage to the posterior inferior portion of the frontal lobes and the subsequent relation to left hemisphere. That there were prior, even biblical, references to aphasia is not in dispute, nor that, according to Benton and Joynt (1960), almost all the clinical forms of aphasia had been described prior to 1800. The significance of Broca’s case studies, therefore, lies in the association of motor aphasia with focal pathology in the frontal lobe. This paper examines the status of aphasia localization prior to Broca, and, specifically, the extent to which Broca’s discovery may have been anticipated by the phrenologists. 0 1992 Academic Press, Inc.
Aphasiologists are generally familiar with Bouillaud’s (1825a) paper describing a series of cases of aphasia with involvement of the anterior lobes as well as some cases of posterior lesion without aphasia and his conclusion that the entirety of both frontal lobes was the site of “the organ of articulate language.” In this paper, Bouillaud distinguished the creation of words as signs from their production in speech and he proposed that “perhaps the gray matter of the anterior lobes might be the organ of the intellectual part of speech while the white substance is the organ Thanks to Bob Rieber and a referee for helpful contributions to this paper. Reprint requests should be addressed to Jason W. Brown, 66 East 79th Street, New York, NY 10021. ’ Presentation, Historical Conference on Brain Functions, Fort Myers, Florida January 2-5, 1991. ’ Ackerknecht & Vallois (1956); p. 20. 475 0093-934X/92 $5.00 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form resewed.
476
BROWN AND CHOBOR
that executes and coordinates the muscular movements necessary for speech production.” 3 These facts are well known. What is less familiar is that Bouillaud was a disciple of Gall, to whom he referred as a Copernicus, a Kepler, a Newton of physiology. Bouillaud was a founding member of the SociCtC Phrenologique and editor of its journal; Gall died on August 22, 1828 and the society was organized shortly thereafter (Ackerknecht & Vallois, 1956). The transition from Bouillaud to Broca is part of the history of aphasia while the transition from Gall to Bouillaud, and the phrenological sources of aphasia theory and localization, have not been the subject of extensive study. We know that the attribution of language to the frontal lobes was derived from Gall’s localization and that there were clear phrenological precedents for Broca’s paper. One can ask, therefore, what the phrenological concept was of language and language disorders prior to Broca, what sort of cases were described, and how precise was the localization of language?4 Did Gall provide documentation for the association of language to the frontal lobes other than the familiar observation of enlarged orbits-a sign of frontal expansion-in the presence of superior verbal memory? Gall distinguished two forms of language, the faculty of spoken language and the memory of words, or naming.5 The faculty of language was most highly developed in great literary and philosophical figures such as Bacon or Voltaire and was related to intellectual level. In constrast, a prodigious word memory could occur even in the presence of mental retardation as an isolated performance. Generally, skillful language use tended to accompany a good word memory, though there were exceptions, e.g., Rousseau. According to Gall both faculties were localized in distinct though neighboring regions6 As to the organ of the memory of words, Gall (1825) implicated the cerebral region resting on the posterior half of the roof of the orbit between XV and 39 (Figs. 1 and 2).’ This region (area XIV) corresponds 3 Bouillaud (1825a; p. 43) “Peut-&We que la substance grise des lobules anterieurs est l’organe de la partie intellectuelle de la parole, tandis que la substance blanche est I’organe qui execute et coordonne les mouvemens musculaires necessaires a la production de la parole.” Bouillaud’s claims of priority for the distinction of the intellectual or internal aspect of language and its productive or external aspect were accepted by Riese (1947; see below). 4 Broca (1861b; p. 407) distinguished his “localization by convolutions” from the phrenological “localization by regions or . compartments corresponding to invariable points on the skull.” (see below). 5 “Gall speaks of these two configurations as of two different organs under the names, an organ of words, and an organ of language” (Spurzheim, 1815). 6 Spurzheim (1815) and most later phrenologists, including Combe (1836), admitted only one organ of language situated on the transverse portion of the supra-orbital plate. ’ “Je regarde comme l’organe de la memoire des mots, cette partie cerebrale qui repose
BROCA’S APHASIA
OR GALL’S APHASIA
477
with the orbital gyrus adjacent to the pars orbitalis of the posterior inferior frontal convolution. Gall located the organ of the language sense (XV) on the mid portion of the supra-orbital plate. The organ for word memory (XIV) was slightly posterior to that for language, but these regions were continuous. Enlargement of the former organ giving a heightened word memory was associated with protrusion of the eyeballs (Fig. 3, top), whereas a prominence of the language organ resulted in pouched or swollen lower eyelids (Fig. 3, bottom; from Spurzheim, 1815). When the organ was reduced in size there was infolding of the lower eyelid (Combe, 1836). The area XV of Gall was initially numbered XXIX by Spurzheim (1815) corresponding with the surface notation on phrenological charts.’ This area was changed in later publications to area XxX111, which is the numbering used in most subsequent illustrations and/or phrenological heads. It is typically written on the orbit, just as Gall had done on skulls, cases, drawings of skulls and phrenological heads. Gall (1825) described several cases in support of this thesis, including demented, retarded and aphasic subjects, some with presumed frontal lobe damage. He mentioned two patients with wounds above the eye and loss of memory for proper names. A third case (Rampan) was described in greater detail. This was a 26-year-old man with a foil injury at the base of the nose on the left side. The sword penetrated about 3% inches through the ethmoid bone and pierced the postero-medial part of the left anterior frontal lobe. There was residual right hemiparesis, diplopia, impaired smell and taste, and disturbed memory for proper names but not objects. He was unable to recall the name of his physician (Baron Larrey) and referred to him as M. Chose. This and the following case are reproduced in entirety in the Appendix. Gall (1825) cited another case referred to him by Baron Larrey, surgeon to Napoleon,’ an apoplectic “unable to express in spoken language his feelings and ideas . . . He does what he is told to do (but) . . . is unable, at the moment, to articulate a word that is pronounced for him to repeat; but some moments afterwards this word escapes him involuntarily . . . It is not his tongue that is at fault, as he can move it quite well and he sur la moitie posterieure de la vofite de I’orbite, PI. IV, entre XV et 39” (Gail, 1825; Vol. 5, p. 18). ’ Spurzheim increased from 27 to 35 the number of “psychic organs” described by Gall (Temkin, 1953). ’ Napoleon was critical of phrenological studies, in part because he did not wish his scientists to learn anatomy from a German (Davies, 1955) but also because of resistance to the materialist idea that physiology could explain mental states (Capen, 1836). Nonetheless, the cranium of Napoleon, said to have been a poor specimen because its small size did not lend itself to phrenological examination (Ackerknecht & Vallois, 1956; p. lo), did wind up in a phrenological collection!
478
BROWN AND CHOBOR
FIG. 1. Areas XV and 39 on the orbital surface of the brain (from Gall, 1810; p. 15).
pronounces very well a great number of isolated words. It is not even his memory that is at fault, as he showed me very vividly that he was sorry to be unable to express himself on many things that he wished to tell me. He has lost nothing but the faculty of speech . . . (and is) unable to read and write.” Of interest, Gall attempted to “stimulate the action of the brain, not only by medicines administered internally, but also by friction-for example, by an ointment of tartrate of potash and antimony. (He claimed
BROCA’S APHASIA
OR GALL’S APHASIA
479
FIG. 2. Area XV on the mesial surface (from Gall, 1810).
that) by these means we have succeeded in restoring the faculty of speech!” lo Gall (1825)” reports an observation of Spurzheim, a stroke patient who “knew the qualities of objects and remembered their vocal signs, but could not pronounce them. If he was shown a colour, such as green, and was asked whether it was brown, yellow or any other colour but green, he replied “No”; as soon as the true colour was named, he said “Yes.” In another similar case, the “man understood all that was said to him, but could not pronounce the words he desired to speak. He asked for different things; if they brought the thing of which he had pronounced the name, he said at once, it is, or it is not that.” Gall mentioned that such patients may “speak languages that they had learned in infancy, but which they had completely lost when in health.” Gall went on to say “there exists a form of partial insanity limited to the faculty of speech, . . . (a phenomenon) impossible if the faculty of spoken language was not the function of a particular part of the brain.” After the descriptions of Gall and Spurzheim, there were many case ” Gall (1825); translation by Williams (1894; p. 219). ” In Williams (1894; p. 219).
480
BROWN AND CHOBOR
FIG. 3. In the top figure, the prominent eyes are associated with an exceptional word memory. In the lower figure, the swollen lower eyelids are a sign of a general facility in language. Areas 14 and 15 of Gall are combined as area 29 in the study by Spurzheim (1815).
reports of aphasia with frontal lobe damage. Hood (1822; see Whitaker & Grou, 1991) described an aphasia with a left frontal lesion at autopsy. In 1825, he reported a case of stroke in a 72-year-old man with rightsided weakness and intact mentation who showed struggle “to find words to convey his meaning” (see Whitaker & Grou, 1991). As mentioned above, Bouillaud (1825a) reviewed a number of aphasic casesand argued for a relation between language and the entirety of both anterior lobes. This was supported by a review of 114 cases of anterior
BROCA’S APHASIA
OR GALL’S APHASIA
481
lobe pathology with a speech disturbance (Bouillaud, 1825b). The distinction of language and naming implicit in the classification of Gall was changed to that of words as signs for ideas-an intellectual or internal aspect-and word articulation-the external or motoric component. This distinction has survived to this day, most notably in Marie’s (1906) concept of aphasia and anarthria. Andral (1834) described nine cases of aphasia, eight of whom had sustained left hemisphere lesions and the ninth bilateral lesions; he did not comment on the asymmetry. Two years later, Dax (1836), who was a student of phrenology, reported an association between aphasia and the left hemisphere. In the phrenological literature, there were continuing reports of aphasia with damage to the anterior (i.e., frontal) lobes. Otto (1834; p. 574) described a patient unable to speak who could point to desired objects. At autopsy, “one of the hemispheres of the brain was found to be diseased, and the other in a perfectly sound state, with the exception only of that part of it which is held by phrenologists to be the organ of language.” Inglis (1836) reported a young woman with a gunshot wound at the external orbital angle of the frontal bone and gave a detailed account of the aphasia. Smith and Niddrie (1839) reported a 14 year old with head injury and a wound under the left eyebrow initially unable to speak. In recovery, he could say IZOclearly, said “ius” for yes, “mud” for mother, and “mungd” for mug. He was unable to name objects but could demonstrate their use. Hytche (1840) described a case of possible aphasic migraine with pain over the left eye, lack of awareness for semantic paraphasia (“razor” for candlestick; “bread” for bacon; “Lapland” for Polynesia) which occurred “most in substantives, and occasionally, but very rarely, in verbs.” DISCUSSION
Gall’s localization of language in the frontal lobes was based on inferences from the evidence of cranioscopy and his collections of busts and skulls as well as reports of cases with brain pathology. Gall provided the first complete descriptions of an expressive aphasia with a proposed brain localization. For Gall and other phrenologists, the localization of language in the frontal lobes was the correct result of a mixed set of arguments, not the outcome of only clinical study. Indeed, it is worth considering that if Gall had limited his faculty localization to the two language areas, which were the basis for his organology, and not gone on to describe 25 other centers, he would have enjoyed greater respectability in the history of brain psychology. We might today speak of Gall’s aphemia or aphasia rather than the aphasia of Broca. Still, he deserves credit for employing the case material for the first time as a confirmation of a theory of the
482
BROWN AND CHOBOR
localization of language, even if the material was not the primary source of the theory. Broca (1861a; p. 330) pointed out that the study of pathological cases did not have the privileged status it received under Bouillaud. He wrote that the phrenological’* localization of aphemia was “most often in the most anterior part of the frontal lobe not far from the eyebrow and above the orbital roof . . . (while in Broca’s patient the localization was) much further back, much nearer to the coronal suture than the superciliary arch” (Broca, 1861a; translated by Bonin, 1960). In this, Broca chose to emphasize the cranial localization, not the localization in the brain, which was quite close to the lesion site in Broca’s two patients. Broca selfservingly referred to Gall’s localization by “bumps” instead of convolutions (see footnote 4) when, in fact, the bumps played a secondary part in Gall’s cranioscopy.‘3 Gall’s main goal was a cerebral organology to establish an anatomy and physiology of the brain (Ackerknecht & Vallois, 1956). If we examine the transition from Gall, through Bouillaud to Broca, the progress is largely that of the prominence given to the clinical pathology. For Gall, brain damage was one of many sources of evidence for faculty localization. The casesof aphasia had an importance no greater than the occurrence of a selective giftedness in word memory or language ability and the associated physiognomic markers. The importance of Bouillaud’s work was in the emphasis it gave to cases of brain damage as a unique source of information on localization. This was a conceptual shift without which Broca’s discovery could not have occurred. Along with this shift in thinking, the frontal localization of speech, largely speculative in Gall’s hands, took on a measure of clinical authority thanks largely to Bouillaud’s 1825 papers and his advocacy of a frontal speech area. Viewed in this light, Broca’s discovery seems predictable, even inevitable. Moutier (1908) pointed out that in the localization of language, Broca was as much the culmination of the phrenological period as the beginning of the scientific one. The one mystery is why Bouillaud waited 35 years before submitting his thesis to an anatomical test. What, in retrospect, seems an obvious step to us was obviously not so clear at the time. The transition from Gall to Bouillaud to Broca was a transition from a stage where the clinical material supported a philosophical system to one where the clinical material was decisive in establishing the factual basis of the system, to one I2 The term, phrenology, was suggested to Spurzheim by Thomas Forster in 1815. Gall preferred to use the term cranioscopy. I3 In spite of the criticism of Gall, Broca was a leader in the field of craniometry, arguing for a close relationship between brain volume and intelligence (see the discussion by Gould, 1981; pp. 82-107).
BROCA’S APHASIA
OR GALL’S APHASIA
483
where the clinical material itself required documentation. This, of course, is also the history of the evolution of the scientific method. In addition to the change in anatomical thinking, there was also a change from Gall’s concept of separate centers for word memory and language to Bouillaud’s distinction of an intellectual and an articulatory component, a distinction that was largely accepted by Broca. The classification of aphasia into a disorder of internal and external speech, instead of language and word memory, is of equal importance in the subsequent course of aphasia study, for example, in the documentation of posterior aphasia and the idea of a parietal conceptual field that was so crucial to later typologies. Viewed in the historical context, one can see that Broca’s finding was less a discovery than the outcome of two shaping ideas: the role of case study in language localization; and the concept of language which determined what aspect of language was localized. Finally, it should be noted that much of Gall’s theory continues to motivate current research. The relation of regional brain size to functionthe cerebral organology-has been revived in studies of the asymmetry of the language area. The relation of the convolutions of the brain to the skull, at least with respect to the inner table, appears in both the asymmetry studies and the use of fossil endocasts in physical anthropology, while the idea of genetically encoded faculties that are only fine-tuned by the environment pervades work on modularity and philosophy of mind. APPENDIX
Case 1 M. Edouard de Rampan, age de vingt-six ans, recut avec un fleuret, dont la pointe avait CtC rompue sur le plastron, un coup a la partie moyenne de la region canine gauche, pres de l’aile du nez, dans une direction oblique de bas en haut, et un peu de dehors en dedans. L’instrument penetra a la profondeur de trois pouces et demi environ, a travers la fosse nasale gauche, traversa la lame criblee de l’ethmo’ide pres de l’insertion de la faux du cerveau, et parait avoir perArC, dans une direction verticale et un peu oblique d’avant en arriere, a la profondeur de cinq a six lignes dans la partie interne posterieure du lobe anterieur gauche du cerveau, de maniere a se rapprocher de la partie anterieure du mesolobe. Le malade Cprouva une hemorragie tres considerable dans l’instant mtme de la blessure, et il est sorti une t&s grande quantite d’esquilles par le nez et par la bouche. Tous les organes des sens ont CtCparalyses a l’instant meme, mais ils ont repris peu a peu leurs fonctions, et il ne reste plus maintenant que les alterations suivantes: La vue a CtCperdue totalement de l’aeil gauche pendant un mois; elle est retablie aujourd’hui, mais le malade voit les objets doubles.
484
BROWN
AND
CHOBOR
L’odorat Ctait totalement Cteint; il est retabli a present, et le malade peut distinguer les liqueurs alcooliques odorantes des liqueurs inodores. Le gout Ctait Cgalement aboli; il s’est retabli peu a peu sur le c&C droit de la langue, de maniere que la moitie droite de cet organe percoit trb bien les saveurs, tandis que le cot6 gauche est prive de cette faculte; la totalite de cet organe est entrainee a droite, par opposition a l’hemiplegie qui existe du c&C droit, la bouche &ant dejetee a gauche. L’oui’e, abolie d’abord dans l’oreille du c&C de la blessure, s’est retablie par la suite, et il ne reste plus qu’un bourdonnement. La voix qui s’etait perdue Cgalement s’est retablie de meme, et il ne reste plus qu’un leger begayement. La force des organes generateurs est conservee entierement. 11survint une hemiplegie de tout le c&C droit; ii ne reste plus aujourd’hui qu’une paralysie du membre thoracique et abdominal de ce meme cot& pour la locomotion seulement, la sensibilite y existant intacte. La memoire des noms a CtC totalement eteinte, et ne se produit aujourd’hui que tres difficilement, tandis que la memoire des images, et de tout ce qui est susceptible de demonstration, est dans l’integrite la plus parfaite. L’aberration mentale qui a exist6 dans les premiers temps dans les organes de I’intellect, a cesse aujourd’hui; mais tout ce qui a rapport a son amour-propre, a ses succb militaires, etc., le jette dans un &at d’alienation et de melancolie profondes, tandis que les conversations qui ont rapport a sa famille, a ses proches, a ses amis, lui rendent sesfaculties. Le malade se rappelait tres bien la personne, la figure et les traits de M. le baron Larrey; il l’aurait reconnu sans aucune difficulte; il le voyait toujours devant ses yeux (expressions du malade), et cependant il ne se rappelait pas son nom, et le designait par celui de M. Chose. Case 2
Un soldat que M. le baron Larrey a eu la complaisance de m’envoyer, est dans un &at a-peu-pres semblable. C’est Cgalement a la suite d’une attaque d’apoplexie que cet homme se trouve dans I’impossibilite d’exprimer, par le langage park, ses sentimens et ses idees. Sa figure ne Porte aucune trace d’un derangement de l’intellect. Son esprit trouve la reponse aux questions qu’on lui address; il fait tout ce qu’on le prie de faire. Je lui montrai un fauteuil, et je lui demandai s’il savait ce que c’etait; il me repondit en s’etablissant dans le fauteuil. 11est incapable d’articuler sur-le champ un mot qu’on prononce pour le lui faire repeter; mais quelques instans apres, ce mot lui Cchappe involontairement. Dans son embarras, il montre du doigt la partie inferieure de son front; il temoigne de l’impatience, et indique par des gestes que c’est de la que vient son impuissance de parler. Ce n’est point sa langue qui est embarrassee, car il la fait mouvoir avec une grande agilite,
BROCA’S APHASIA
OR GALL’S APHASIA
485
et il prononce tres bien un grand nombre de mots isolb. Ce n’est pas non plus sa memoire qui est en defaut, car il me temoigna tres vivement qu’il Ctait fache de ne pas pouvoir s’exprimer sur beaucoup de chases qu’il etit voulu me raconter. II n’y a d’aboli chez lui que la faculte de parler. Ce soldat, tout comme le malade de M. Pinel, n’est plus capable ni de lire ni d’ecrire. REFERENCES Ackerknecht, E., & Vallois, H. 1956. Franz Joseph Gall, inventor of phrenology and his collection. Madison: Univ. of Wisconsin Medical School. Andral 1834. Maladies de l’encephale. Clinique medicale. 3rd ed., pp. 391 and 531. Benton, A., & Joynt, R. 1960. Early descriptions of aphasia. Archives of Neurology, 3, 205-222. Bouillaud, J. 1825a. Recherches cliniques propres a demontrer que la perte de la parole correspond a la lesion des lobules anterieurs du cerveau, et a confirmer l’opinion de M. Gall, sur le siege de I’organe du language article. Arch. Gen. de Med. 8, 25-45. Bouillaud, J. 1825b. Traite clinique et physiologique de l’encephalite ou inflammation du cerveau. Paris. Broca, P. 1861a. Remarques sur le siege de la faculte du language articule, suivies d’une observation d’aphemie (perte de la parole). Bulletin de la societe anatomique de Paris 36, 330-357. Broca, P. 1861b. Nouvelle observation d’aphemie produite par une lesion de la moitie posterieure des deuxieme et troisieme circonvolutions frontales. Bulletin de la socitte anatomique de Paris 36, 398-407.
Capen, N. 1836. Phrenology, in connection with the study of physiognomy. Boston: Marsh, Capen and Lyon. Combe, G. 1836. System of phrenology. Boston: Maclachlan, Stewart and Anderson. vol. 4th ed., 2. Davies, J. 1955. Phrenology, fad and science. New Haven, CT: Yale Univ. Press. Dax, M. 1836. Lesions de la moitit gauche de I’endphale coincidant acec I’oubli des signes de la pensee (read at Montpellier, 1836. Gaz. Hebdom. 1865, 2nd. ser. II, 259-260. Forster, T. 1815. Sketch of the New Anatomy and Physiology of the Brain and Nervous System of Drs. Gall and Spurzheim Considered as Comprehending a Complete System of Phrenology. Gall, F. 1825. Sur les fonctions du cerveau et sur celles de chacune de ses parties. Paris:
Boucher. Gall, F., & Spurzheim, G. 1810-1815. Anatomie etphysiologie du systeme nerveux en general et du cerveau en particulier. Paris: Schoell. Gould, S. 1981. The mismeasure of man. New York: Norton. Hollander, B. 1909. The unknown life and works of Dr. Francis Joseph Gall. London: Siegle, Hill and Co. Hood 1822. Edinburgh Phrenological Journal. Hood 1825. Transactions of the Phrenological Society. Hytche, E. 1840. Edinburgh Phrenological Journal, 13, 344. Inglis, J. 1836. Case of injury sustained by the organ of language. Edinburgh Phrenological Journal, 10, 68. Marie, P. 1906. La troisieme circonvolution frontale gauche ne joue aucun role special dans la fonction du langage. Semaine Medicale 23 Mai, XXVI, 241-247. Moutier, F. 1908. L’Aphasie de Broca. Paris: Steinheil.
486
BROWN AND CHOBOR
Ombredane, A. 1951. L’Aphasie et l’elaboration de la pen&e explicite. France: Presses Universitaires de France. P. 13. Otto 1834. Edinburgh Phrenological Journal, 8, 574. Riese, W. 1947. The early history of aphasia. Bulletin of the History of Medicine. 21, 322334. Smith, G., & Niddrie, D. 1839. Affection of the faculty of language from an injury of the brain. Edinburgh Phrenological Journal, 12, 155. Spurzheim, J. 1815. The physiognomical system of Drs. Gall and Spurzheim; etc. London: Baldwin, Cradock and Joy. Temkin, 0. 1953. Remarks on the neurology of Gall and Spurzheim. In E. Underwood (Ed.), Science, medicine and history. London: Oxford. Von Bonin, G. 1960. Some papers on the cerebral cortex. Springfield: Thomas. Whitaker, H., & Grou, C. 1991, April. Spurzheim’s legacy: The case of Adam McConochie. Presentation at the Annual Meeting of the American Academy of Neurology, Boston. Williams, W. 1894. A vindication of phrenology. London: Chatto and Windus. Young, R. 1970. Mind, brain and adaptation in the nineteenth century. Oxford: Clarendon.
