J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.3.291 on 1 June 1968. Downloaded from

J. Neurol. Neurosurg. Psychiat., 1968, 31, 291-296

Congenital asymbolia and auditory imperception

B. 0. OSUNTOKUN, E. L. ODEKU, AND L. LUZZATO From the Departments ofPsychiatry and Neurology, Surgery (Neurosurgery Unit), and Pathology (Sub-department of Haematology), University College Hospital, Ibadan, Nigeria

Congenital indifference to pain (pain asymbolia) is sweating or of measles infection in early childhood. He a rare condition. Since Dearborn in 1931 described had suffered from discharge in the right earfor six months. the first case, 51 cases have been reported in the He had been a normal boy socially and showed no trace of psychotic behaviour except that he often reacted English literature. Congenital auditory imperception violently when angry or annoyed. The mother was well as an isolated defect is equally uncommon. It is throughout pregnancy and gave no history of rubella, perhaps the least uncommon of the various types of mumps, or measles. Delivery and the developmental congenital aphasia. We have recently studied a history of the propositus were normal. family in which two siblings showed an association The propositus is the third child of his mother (who of pain asymbolia and auditory imperception- was 25 years old when he was born) (see Fig. 1). A an association that has not been reported in the half-sister was similarly affected. His mother and the English literature as far as we know, although Ford half-sister's mother are unrelated. There was no family and Wilkins (1938) reported stuttering and specific history of left-handedness, skeletal deformities, prema- Protected by copyright. ture greying of hairs, white forelock, or goitre. reading disability associated with pain asymbolia. Examination showed a healthy-looking right-handed Boyd and Nie (1949) suggested that there is no boy, the height and weight being 96-5 cm and 13-5 kg specific 'underlying defect in pain asymbolia, but respectively. The skull was normal in shape and the that it is rather an aphasia-like disturbance and circumference of the head was 21-5 in. The face was also hence may be related to the congenital aphasia and normal and the eyes were without hypertelorism, blue perhaps be dependent upon lack of established sclerotics, or epicanthic folds. The upper central incisors cerebral dominance'. Alajouanine and Lhermitte were peg-shaped, resembling Hutchinson's teeth in (1965) believed that the congenital aphasia is congenital syphilis, but he had no other syphilitic characterized by a defect in language elaboration at stigmata of congenital syphilis. He had numerous scars on his feet and leg, but these were not remarkable in a the origin of which there may or may not be a Yoruba boy, who habitually walked bare-footed. The cerebral lesion. Our findings regarding the associa- skin of the axillae showed the presence of sweat. tion of pain asymbolia and auditory imperception Neurological examination showed normal sensorium. tend to support the view of Boyd and Nie. The fundi, comeal reflexes, and the other functions of the cranial nerves were found to be normal. There was

CASE REPORTS no detectable abnormality in the motor system, the http://jnnp.bmj.com/ muscles, the gait, and coordination being normal. Tendon CASE 1 B.D. (U.C.H. No. 156097), a 5-year-old boy of and superficial reflexes were normal. In the sensory Yoruba parentage, was first seen in April 1966. His system light touch was normal. Communication diffi- parents said he did not hear and talk properly. What he culty made temperature sense impossible to test. His said was an unintelligible semblance of normal speech. He reaction to noxious stimuli was, however, odd. He knew understood sign language very well. He would turn to the when he was being pricked by a pin, for he could tell the source or direction of a or voice, but appeared not difference by gesture between the sharp and blunt ends. to comprehend spoken words or commands unless He showed no withdrawal response, evasive or preventive

backed by appropriate gesticulations. He was however motor reactions, and no facial expression of pain to on September 29, 2021 by guest. capable of utilizing a limited vocabulary in Yoruba pin-prick venepuncture, intense pressure on the achilles language-thus he could say properly and in appropriate tendon, or to his skin being transfixed with a needle- circumstances 'baba', 'mama', 'odabo', 'kabo': Yoruba which he seemed to enjoy very much. He invited the words for 'father', 'mother', 'bye-bye', and 'welcome'. He examiner to repeat the tests while he remained all smiles. rarely cried, but shed tears normally when he did and There was no alteration in the pulse, blood pressure, appeared incapable of being easily hurt, his parents respiratory rate, and pupillary sizes to noxious stimuli. describing him as 'a very strong boy'. He was very prone The speech was abnormal. He undoubtedly heard to ulcers on his feet. His toilet habits were said to be voices but did not appreciate the symbolic significance of normal. There was no history of excessive or diminished most spoken words. Separated from a source of sound by 291 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.3.291 on 1 June 1968. Downloaded from

292 B. 0. Osuntokun, E. L. Odeku, and L. Luzzato a screen or a door he would correctly localize the source during which news got around of the 'wonder boy' who' by going round the screen or through the doorway. A could not feel pain. Subsequently about four weeks after similar finding was obtained using the Barany's sound hospitalization some laboratory technicians surrep- box. He appeared to be able to hear the high-pitched titiously paid him several visits, transfixing him with pins. ticking of an Omega wrist watch. He understood sign and needles and watching with awe how much he enjoyed language very well. He exhibited idioglossia-strange it. He appeared however to discover that he was being words most unintelligibly strung together,- but with regarded as a 'freak' and developed the greatest dislike of occasional recognizable normal words being produced. pins and neelles. He, would fly into an uncontrollable His vocabulary also improved in hospital and with rage and temper tantrums at the slightest exhibition of a. deliberate efforts to teach him. He showed no signs of pin or needle, but would allow himself with much plea- apraxia, and could dress himself and find his way around sure to be subjected to other forms of noxious stimuli the hospital. He could also copy simple figures reasonably like pressure on the tendon achilles and hot water at well. 75°C. There was no abnormality in the cardiovascular When seen and re-evaluated in his home eight months system. The blood pressure was 90/70 mm Hg and the after discharge from the hospital, he showed complete pulse 90/min with no evidence of postural hypotension. indifference to pin prick and venepuncture just as during Four-hourly recording of blood pressure, pulse, tem- his first visit to the hospital. His vocabulary had increased, perature, and respiration rate over a period of four and his speech was slightly more intelligible. weeks showed no abnormality. The chest and abdomen were normal. CASE 2 O.D., a half-sister of the boy (Case 1) was 4 Mental assessment Bedside testing showed a boy of years old when she was brought along with him to the average intelligence. A modification of the performance neurology clinic with the same complaints as described tests of intellectual process suggested for the Nutrition above for the boy. She showed similar abnormal speech survey of Nigeria in 1965 was used (U.S. Office of and stoical indifference to pain. Pregnancy and delivery International Research, 1966). Psychological tests like were normal, and development was normal except for the Cattell infantile intelligence scale are not suitable for disturbance of speech and reaction to pain. There was no Yoruba children as the background culture is different. history of otitis media. She shed tears normally on theProtected by copyright. His parents also said he was mentally normal. few occasions she cried. She was the third child of her Investigations Haemoglobin was 10-7 g/100 ml. mother who was about 28 years old when the propositus blood, M.C.H.C. was 32, white blood cell count was was born (see Fig. 1). 12,000 cu. mm with normal differential. The haemoglobin Examination showed a bright-looking right-handed electrophoretic pattern was AC. Thyroid function tests child with no neurological or physical deficit except in were normal: plasma bound iodine was 6-8 ,ug %, red her reaction to noxious stimuli and in understanding of blood cell uptake of 131triodothyronine was 11 2/l100 spoken words as described above for her half-brother. In ml. haematocrit (12-18 % range of normal); plasma addition, however, she had blue sclerotics. Her blood cholesterol was 138 %. Total serum protein was 7-6 g % pressure was 95/70 mm Hg and pulse rate was 90/min, (serum albumin was 3.4 g %) with normal electrophoretic with no evidepce of postural hypotension. Sweat could be strip. Serum electrolytes and blood urea were normal. felt in the axilla, and sweating and tearing were induced Serological test (Kahn test) for syphilis was negative in by subcutaneous Mecholyl. the blood and cerebrospinal fluid; the latter showed a Haematological indices were normal: haemoglobin protein content of 25 mg %, no cells, and the fluid was 11-7 g %, packed cell volume was 38 %, M.C.H.C. pressure was normal (110 mm cerebrospinal fluid). was 31, white cell count was 10,000/cu. mm with normal Biopsy of the skin, which was carried out without local differential count, and the haemoglobin electrophoretic anaesthesia soon after admission into the hospital, pattern was AA. Plasma bound iodine was 4-4 ,ug/100http://jnnp.bmj.com/ showed normal fine nerve fibres present in the dermis on ml., red blood cell uptake of 131triodothyronine was histological examination. A section fixed in formol- 13/100; haematocrit and serum cholesterol was 114 mg%. sucrose for neurite impregnation with silver showed no Total serum protein was 8 3 g % with a serum albumin abnormality. Paper chromatography of urine showed no of 3-6 g % and normal electrophoretic strip. Histology of abnormal aminoacids. Caloric tests showed normal skin sections showed normal fine nerve endings. Plain vestibular function. Otoscopy showed right chronic otitis radiographs of skull, sinuses, and chest, and tomograms media with central perforation. Unfortunately, the child of the petrous temporal bone revealed no abnormality. was too uncooperative for audiometry. Intradermal Paper chromatography of urine showed no abnormal Mecholyl (0.1 ml.) produced profuse sweating, and aminoacids. Otoscopy showed no abnormality. Caloric on September 29, 2021 by guest. subcutaneous Mecholyl (3 mg) produced sweating and tests for vestibular functions were normal. It is regretted tearing. Miosis was produced when Mecholyl was in- that the parents did not allow her to be admitted into stilled into the conjunctival sacs. Plain radiographs of hospital for further investigation. chest, skull, and sinuses were normal, as were tomographs of petrous bone. Cisternal pneumoencephalography FAMILY STUDY The family was visited and examined in showed no abnormality. Bell stimuli produced K- the village where the members lived. Blood was collected complexes and spindles in the electroencephalogram for determination of certain genetic markers: ABO, obtained during barbiturate-induced sleep. MNSs, and Rh groups, haemoglobin electrophoretic Progress The patient was in hospital for eight weeks, pattern, glucose 6 phosphate dehydrogenase (G-6-P-D), J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.3.291 on 1 June 1968. Downloaded from

Congenital pain asymbolia and auditory imperception 293


Generation 0-~ Clinically normal Not seen Age: 70 years Normal clinically Age: 38 years (Not Bled)

Generation II _0 32 I Age (years) 30 40 M ABO A/0 0/0 A/A * N 4 Rhesus cde /cDE or cDe,/cdE cDe/cde cDe/cde i AINSS Ms/Ns MIs/Ns Ns/Ns c Haemoglobin BBA/CA/B BA/BA BA/BA > G6PD Gd /Gd GdA Gd /Gd z X 6PGD Norimial Normal Normal Clin. exam. Normal Normal Absenit knee and ankle jerks

Genieration 1 III Protected by copyright. Age (years) 12 9 5 15 3 12 8 4 2 ABO 0/0 A/0 (not seen) A/O A/O A/O Said to be normal A/0 Rhesus cDe,/cdE or cde/cDE cDe/cde cDe/cdE or cde/cDE cDe/cde cDe/cde cde/cde MNSS Ns'Ns MIs/Ms Ns/Ns Ms/Ns Ns/Ns Ns/Ns Haemoglobin B /Bc BA/BA BA/Bc BA/BA BA/BC BA/BA G6PD Gd Gd /Gd GdB GdB GdB GdA/Gd13 6PGD Normiial Normal Normal Normiial Normal Nornmal Clin. exami. Normal Normal Pain asymbolia INornmal Normiial Normal Pain asynmbolia Normal + word deafness + word deafniess

* Probable because of three childreni group A could be AO FIG. 1. Family Study and 6-phosphogluconate dehydrogenase deficiency michael, 1959; Baxter and Olszewski, 1960). Most http://jnnp.bmj.com/ (6-PGD). ABO, Rhesus, and MNSs groups were deter- cases have occurred in children, although a number mined by standard tube technique with potent antisera. of cases have been reported in adults (Dearborn, Haemoglobin type was determined by starch-gel electro- 1931; Kunkle and Chapman, 1942; Magee, Schnei- phoresis in tris-borate buffer at pH 8-6. Glucose- der, and Rosenzweig, 1961). Ogden et al. (1959) 6-phosphate dehydrogenase electrophoretic variants were examined as previously described (Luzzatto and Allan, enumerated criteria to establish the diagnosis and 1965). 6-phospho-gluconic dehydrogenase was analysed to differentiate it from sensory neuropathies and by the same technique, except that 6-phosphogluconate spinal cord disorders such as syringomyelia and replaced glucose-6-phosphate in the staining of the gel. tumours. Pinsky and DiGeorge (1966) discussed on September 29, 2021 by guest. The results are shown in Figure 1. lucidly the differential diagnosis of congenital or hereditary causes of insensitivity to pain. These DISCUSSION authors stressed that mental subnormality and familial dysautonomia should be excluded. We There have been several reviews of the literature on have also observed some partial but reversible pain asymbolia or congenital indifference to pain insensitivity to pain in patients with severe protein- (Ford and Wilkins, 1938; Critchley, 1956; Fanconi calorie deficiency (Kwashiorkor) probably due to and Ferrazzini, 1957; Ogden, Robert, and Car- the apathy and mental retardation characteristic of J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.3.291 on 1 June 1968. Downloaded from

294 B. 0. Osuntokun, E. L. Odeku, and L. Luzzato the clinical syndrome. The diagnosis of congenital of Parkinsonism, Brain (1961) has suggested the indifference to pain should be made only in the possibility that the corpus striatum is more directly absence of demonstrable lesion in the peripheral concerned in speech through its corticothalamic and nerves, spinal cord, thalamus, and the cerebral thalamo-cortical connexion. Although Schilder and cortex. Exhaustive post-mortem studies in two cases Stengel (1931) described an acquired asymbolia for showed no significant evidence of any structural pain caused by a lesion in the posterior parietal lesion in the central nervous system except for an region of the dominant hemisphere, the nature of equivocal diminution in the number of myelinated the defect in congenital indifference to pain is fibres in the subcallosal fasciculus in one case. The unknown, despite post mortem studies on two cases physiological significance of this is unknown (Magee, 1963; Baxter and Olszewski, 1960). (Magee, 1963; Baxter and Olszewski, 1960). Our Swanson, Buchan, and Alvord (1965) report cases satisfy the criteria of Ogden et al. (1959). The absence of small primary classical pain-temperature other conditions that may simulate congenital neurones in the spinal ganglia, dorsal roots, spinal indifference to pain, such as congenital sensory cord, and medulla oblongata, and at all levels in the neuropathy, hereditary sensory radicular neuro- spinal cord the absence of Lissauer's tract-the pathy, familial sensory neuropathy with anhidrosis, myelinated tract just lateral to the entering posterior and familial dysautonomia (Pinsky and DiGeorge, root which continues into the superficial dorsal grey 1966) were also excluded. It should be stressed, horn. But the case they described, familial sensory however, that in congenital indifference to pain, neuropathy with anhidrosis, is different from con- only the affective component of the response to genital indifference to pain. painful stimuli is absent. The neurophysiology of pain has recently been It has been suggested that indifference to pain the subject of controversy (Gerard, 1960; Melzack may wax and wane and tend to subside as the and Wall, 1965). Although Critchley (1956) suggests patient becomes older, partly because of regression that congenital indifference to pain may simply lie of the disorder and partly because other qualities of at one end of a pain spectrum, at the other end ofProtected by copyright. sensation and intellectual functions take over as which are patients who are constitutionally hyper- substitutes (Magee et al., 1961). A mentally normal sensitive to pain, it is still possible that cortical child may learn to recognize those things which are integration of pain may be defective in those who injurious and thereby avoid damage to himself. appear stoical to pain. A patient after frontal Our patient, fully capable of learning, objected to lobectomy still feels pain, but does not worry so being treated as a circus animal by laboratory much about it-that is, the Sherringtonian concept technicians, especially when confronted with a pin of pain as the sensory adjunct of an imperative or needle, but showed complete indifference to other protective reflex no longer applies to him. Morphine forms of noxious stimulation. This suggests that does not raise the threshold of pain receptors to such subsidence or disappearance of congenital peripheral stimulation but possibly acts at the cor- indifference to pain is the result of an avoidance tical level: the message comes to the nervous system reflex to such conditioning stimuli as evoked either as before but no longer seems as important as demonstrable trauma or disagreeable psychological formerly (Gerard, 1960). These suggest that the effects. In the classical pattern of a conditioned integrity of the cerebral cortex is necessary for the

reflex that is not reinforced, eight months later, our full appreciation of pain (British Medical Journal, http://jnnp.bmj.com/ first patient had lost the avoidance response to pin 1961). There is, of course, a tremendous variability prick that he acquired during his stay in the hospital. in the reaction of a given individual to a given Bony changes, such as fractures, aseptic necrosis, painful stimulus. In the intense emotion of a battle osteomyelitis, and also neuropathic joints reported the severely wounded soldier feels little pain, but in in the literature, were not seen in our cases (West- the calmer atmosphere of the hospital base he may lake, 1952; Houwen, 1961; Silverman and Gilden, require large doses of (Beecher, 1959). 1959, Gwinn, Barnes, Tucker, and Johnson, 1966). Pavlov's dogs, which received electric shocks, burns,

The association of pain asymbolia with auditory or cuts followed consistently by the presentation of on September 29, 2021 by guest. imperception shown in the present report suggests food, eventually responded to these stimuli as that the site of the responsible lesion may be cortical signals for food and failed to show even the 'tiniest or subcortical, involving the projection fibres to the and most subtle signs of pain' (Pavlov, 1928). dominant temporal lobe. Brain (1961) localizes pure On the other hand, a lesion to account for con- word deafness to the auditory receptor area in the genital indifference to pain may be molecular or dominant hemisphere. In explaining the aphasia enzymatic, as has been postulated for congenital sometimes resulting from stereotactic operations on aphasia (Eisenson, 1963). Becak, Becak, and the globus pallidus or optic thalamus for the relief Schmidt in 1963 reported two siblings with con- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.3.291 on 1 June 1968. Downloaded from

Congenital pain asymbolia and auditory imperception 295 genital insensitivity to pain who had an unusual think it arises as a congenital defect (Berg, 1961). We substance in their urine and mosaic trisomy for a found no evidence of a psychogenic cause in our chromosome in the D (13-15) group. Late develop- cases. We could not demonstrate by standard ment of speech and poor articulation have been techniques and investigation any structural defect in described in association with indifference to pain in one of our patients who was fully investigated. familial dysautonomia (Riley-Day syndrome), a disorder believed to be due to abnormal metabolism GENETICS The familial incidence of congenital pain of pressor amine precursors (Riley, 1949; Riley, asymbolia or indifference to pain has been recorded 1957; Dancis and Smith, 1966; Smithells, 1967). by Magee et al. (1961), Silverman and Gilden (1959), This is tenable if the classical concepts of the and Houwen (1961). Pinsky and DiGeorge (1966) neurophysio-pathology of pain are rejected. Melzack reported two siblings with familial sensory neuro- and Wall (1965) wrote that 'the concept of a pain cen- pathy and anhidrosis. Congenital sensory neuro- tre in the brain is totally inadequate for the sequences pathy, although sporadic may be transmitted by a of behaviour and experience. Indeed the concept is dominant mode of inheritance (Ervin and Steinbach, pure fiction unless virtually the whole brain is con- 1960). Gillespie and Perucca (1960) suggested that sidered to be the pain centre because the thalamus, congenital indifference to pain is probably reces- the limbic system, the hypothalamus, the brain stem sively inherited. The study in respect of possible reticular formation, the parietal cortex and the genetic markers and linkage in the family reported frontal cortex are all implicated in pain . by us is largely negative. The fact that the two Other brain areas are obviously involved in the affected half-sibs had different mothers leads to the emotional and motor features of the behaviour almost inescapable conclusion that they both in- sequence. The idea of a terminal centre in the brain herited an abnormal gene from the father. Further, which is exclusively responsible for pain sensation the different sex of the two propositi virtually rules and response therefore becomes meaningless.' The out X-linkage. The pattern of inheritance is difficult Protected by copyright. pain relieving effect of anterolateral cordotomy and to interpret beyond these two points. If the abnormal thalamectomy does not mean that these areas carry gene were dominant, it should have given some a specific pain system. The lesions have multiple manifestations in the father; if it were recessive, we effects; they reduce the total number of responding would have to make the supplementary assumption neurones, change temporal and spatial relationships that both wives carried it-a very unlikely assump- among all ascending systems, and affect the des- tion in view of the great rarity of the condition. The cending feedback that controls transmission from only other alternative possibilities are the so-called peripheral fibres to dorsal horn cells (Sweet, 1959). 'incomplete penetrance' (of extreme degree since The congenital or developmental aphasias are the father was completely unaffected!) or interaction often of a non-organic nature and thought to be due with other gene(s) present in the propositi but not in to lag in the maturation of the part of the central their father. Linkage data obtained from this family nervous system which deals with the span of audi- are negative. Pain asymbolia does not appear to be tory attention and with language formulation closely linked to MSNs blood groups, since the two (Sheridan, 1961). They are often associated with propositi inherited Ns from their father, but so did cerebral non-dominance, of which there was no III-I and III-7 who were unaffected. Linkage to evidence in our patients. We were careful to exclude 6-P-G-D cannot be scored because there is no http://jnnp.bmj.com/ high-tone deafness in these patients as this may polymorphism in this family. Linkage to ABO mimic congenital auditory imperception very blood groups and haemoglobin type cannot be closely (Creak, 1932; Sheridan, 1961). Our patients, scored because the father is homozygous. The as in the cases cited by Allen (1952), could repeat Rhesus genes inherited by the propositi cannot be certain simple words. They did not show any feature identified without some risk of ambiguity. It can of childhood schizophrenia, or of infantile autism, only be assumed that the child 111-7 is illegitimate, two other conditions which may be confused with since neither of the alleged parents has the B gene. congenital auditory imperception or any of the on September 29, 2021 by guest. various types ofcongenital aphasias (Sheridan, 1961; SUMMARY Eisenson, 1963). It is hopefully expected that our patients will improve in their acquisition of language Two Yoruba siblings (a brother and a half-sister) -a not uncommon phenomenon in the congenital with a rare association of congenital auditory aphasias (Sheridan, 1961). There are those who imperception and indifference to pain have been regard developmental auditory imperception as studied and reported. The nature of the defect and psychogenic and who believe that imperception may the pathophysiology have been discussed with a follow infantile psychosis (Davis, 1957). Others brief review of the literature. 8 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.3.291 on 1 June 1968. Downloaded from

296 B. 0. Osuntokun, E. L. Odeku, and L. Luzzato

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