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Prosopagnosia by B J. Neurol. Neurosurg. Psychiat., 1959, 22, 124. PROSOPAGNOSIA BY B. BORNSTEIN and D. P. KIDRON From the Department of Neurology, Beilinson Hospital, Petah Tiqva, Israel "And what is the nature of this knowledge or recollection? I mean to ask, Whether a person, who having seen or heard or in any way perceived anything, knows not only that, but has a conception of something else which is the subject, not of the same but of some other kind of knowledge, may not be fairly said to recollect that of which he has the conception?" "And when the recollection is derived from like things, then another consideration is sure to arise, which is, Whether the likeness in any degree falls short or not of that which is recollected?" "The Philosophy of Plato " Phaedo (the Jowett translation). Does visual agnosia exist in a partial or isolated bances in sensation time, in adaptation time, in form, in which certain qualities only are affected, visual acuity, and in brightness discrimination. as opposed to generalized visual agnosia? Many Ettlinger (1956) rejected Bay's contentions. After workers cast doubt on this concept, maintaining analysing 30 cases of head injury, he showed that that partial visual agnosia is no more than a com- some patients had neither field nor perceptual bination of defects in vision, memory, and orienta- defects, others had field but not perceptual defects, tion, appearing together. and only in eight of the 30 patients were field and The clinical elucidation of partial visual agnosia perceptual defects found together. It is true that is likely to be affected by the patient's intellectual visual agnosia is frequently associated with homony- capacity, his mental state at the time of examination, mous hemianopsia, but despite this there are cases and his ability to cooperate without being influenced of hemianopsia without gnostic defects. either by fatigue or by suggestion on the part of There is a special type of visual agnosia called the examiner. prosopagnosia which means inability to recognize Critchley (1953), one of the leading workers in and identify known faces. The number of cases of this field, states critically that "it would be dangerous this condition described is small. Hecaen, to claim that a particular visual agnostic defect can Angelergues, Bernhardt, and Chiarelli (1957) col- occur in isolation". lected 25 cases described in the literature since 1932. There are some who consider visual agnosia as a In addition to the prosopagnosia, all the patients patho-physiological optical problem derived from except two showed various psychosensory distur- an organic lesion in the visual pathways, more bances as well, such as unilateral agnosia of space, especially the visual centres. Others maintain that constructive apraxia, loss of topographical memory, visual agnosia is merely a mental disturbance which alexia, acalculia, and in a few, optical disorders. prevents the patient from evaluating properly and The case history that follows is unusual in that integrating into the general mental visual picture we were able to follow up the dynamic development the various optical impressions, thus affecting the of the symptoms of which prosopagnosia was a level of awareness. marked feature. In the early stages of the illness Between these two extreme views is the more topographical disorientation, slight simultanagnosia, moderate one which holds that a physiological and achromatopsia were also found. optical disturbance is associated with mental upset. Bay (1952, 1953) subscribes to this view, saying Case Report that visual agnosia is not in itself a specific cerebral A.G., a man, aged 64, was formerly a merchant, and disturbance but one where visual pathway defects now is a clerk. He has two grown up children. He has are allied to mental disturbances. (Jung, 1954, who completed high school, speaks, reads, and writes five languages, and is right handed. He was well till five appraised Bay's book Agnosia and Lability of years ago, when he woke up suddenly from his sleep one Function stated "the author wrote a book about night because of severe dizziness. He got out of bed and agnosia in order to show that agnosia is a scientific immediately fell to the floor, where he remained uncon- phantom".) Bay described the disorders as fine scious for some minutes. The following morning he felt defects in the visual system in the form of distur- completely well and carried on with his usual work. No 124 PROSOPAGNOSIA 125 further details are available concerning this episode. His eye the doctor's house, the steps leading to his flat, family did not notice any particular change in him. Two but I couldn't find it. I wandered up and down the years later, when aged 61, he was again awakened at stairs in a few houses till I saw the doctor's plate on night by severe dizziness and a feeling of pressure in the one of the doors. A women opened the door but I didn't know who she was till I heard her say 'Come in head. He lost consciousness for some minutes and on Mr. G.'. I then realized that she was the doctor's recovering, suffered from headache for the next 24 hours. wife. The doctor examined me and advised me to go He felt quite well two days later and returned to work: to hospital. I remember that he measured my blood there were no paralyses, no speech disturbance, no visual pressure and gave me a prescription. As I knew I was defect, and no loss of orientation. in Dr. A's surgery I didn't pay any attention to his The present illness began five days before his admission face and didn't notice anything wrong in particular. to hospital. The patient woke up with severe frontal It was already dark and I reached home with dif- headache which lessened somewhat during the next three ficulty." hours. He had an appointment at noon of the same day and caught a bus in order to get there but on the way his The events of the next two days are not clear. The headache increased and he decided to go home instead. patient said he had headaches and noticed for the first He alighted from his bus as he had to change his route time that he did not see well with his left eye. He and on his way to another bus stop, on a road well remembered reading the paper, but with difficulty. He known to him, he felt all of a sudden that the whole understood what he read and could recall the items area appeared strange. He knew where he was and could later. not account for it. He managed to cross the road-he The next day his son came to visit him. The patient knew he had to do that-and boarded the correct bus in did not recognize him and only realized who it was when order to reach home. He paid his fare and received a he spoke. He returned to Dr. A. together with his son, ticket. The route, obviously well known to him, appeared and in his own words "I wouldn't have recognized the strange and for a time he thought he had caught the doctor if I hadn't known where I was going". wrong bus. He became anxious, gave the driver his He was referred to an eye specialist and on the way to address and asked him to see that he reached home the latter's consulting rooms found that the streets and should anything happen to him meanwhile. When he buildings appeared strange and unfamiliar. He remem- thought that he had reached his stop he alighted, but bered being examined by the eye specialist for more than not because he recognized the surroundings, which half an hour, an instrument was used (apparently a appeared unfamiliar to him, but because he estimated perimeter), and he was asked to read. He had no difficulty that sufficient time had elapsed in order to arrive at it. in recalling these details but could not remember the He remembered these details clearly. He also remembered doctor's face nor anything else about him that would that while on the bus he found it difficult to distinguish help in describing him, such as his height, colour of hair, men from women passengers. After getting off the bus, or facial features. "I stood in the street and asked passers by how to get to Till his admission to hospital 24 hours later he remained my home. I gave them my address and carried on in the in the care of his son, which was a great relief to him as direction indicated." After walking for about five he was still disorientated. Though on the whole his flat minutes, the approximate time needed to reach his home, still appeared unfamiliar to him the colour of the walls he could not find it. He again turned to passers by who and the pictures on the walls partially regained their told him to cross the road as the required number was former clarity. on the opposite side of the street. "I eventually reached The drive to the hospital, along a route well known to home, and though I knew it was my home, it seemed him, appeared strange. "I knew from memory what to strange to me."' He opened the door, entered the flat expect along the way-the various turnings, buildings, which he knew was his, but the room, furniture, and and landmarks, but when I passed these points they pictures appeared different. seemed different to what 1 had imagined." The patient was admitted during the afternoon and "The first thing 1 did was to go to the bathroom to was examined within a few hours.
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