338 Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from

TACTILE PERCEPTUAL RIVALRY AND TACTILE-AMORPHOSYNTHESIS IN THE LOCALIZATION OF CEREBRAL LESIONS With special reference to parietal lobes By S. FAZLULLAH, M.B.(Osm.), D.T.M. & H. Late Senior House Physician, Lowestoft and North Suffolk Hospital; late Medical Registrar, Barrow and Furness Group of Hospitals, Lancs.; Medical Registrar, Pontefract and Castleford Group of Hospitals, Yorks.

Introduction mine the incidence of extinction or inattention Recently attention of neurologists has been phenomena in patients with space occupying directed to the clinical value of using bilateral lesions and other lesions in various parts of the simultaneous and ipsilateral double stimuli in central nervous system. The observations were testing cutaneous sensations. If two similar recorded in 38 cases, diagnosis being made as a stimuli are applied simultaneously on the two result of careful histories, physical examinations, sides of the body, eyes being closed, the patient confirmed by special investigations, operative and announces that he feels the object only on the post-mortem findings. unaffected side. When each side is tested sepa- the is Procedure rately, object readily appreciated correctly. copyright. This sensory suppression phenomenon on the Each patient was blindfolded and tested for affected side is termed as tactile-amorphosynthesis extinction: (inattention or extinction). This phenomenon is (a) By application of simultaneous stimuli with not rare and is frequently observed in parietal cotton wool, pin prick, vibration, and thermal lesions. contacts, (i) on homologous areas of face, Oppenheim (I885, 191I) first described this shoulders, wrists, hips and feet, (ii) on heterolo- method of testing in a lady of 74 years with right gous areas: left wrist and right foot, right wrist and hemiplegia and termed it as ' double stimulation.' left foot, (iii) on two areas of the same side of the Head and Holmes (1911) observed this phe- body: face and shoulder, shoulder and hand, face http://pmj.bmj.com/ nomenon in cortical disorder by using weight in and hand, shoulder and hip, and hip and foot. two hands simultaneously, so that when asked, the Patients were instructed to report on the location patient described the one in the normal hand. of the stimulus and its nature. Stereognostic Since then several others have observed this methods were also used: two similar objects were phenomenon. Bender (I945) observed this phe- placed in patient's hands simultaneously and the nomenon in parietal lobe lesion on the hemiplegic patient was asked to report on the size, shape and side and termed as extinction. Since he nature of the were also drawn then, object. Figures on October 1, 2021 by guest. Protected has demonstrated it in patients with cerebro- simultaneously on the two sides of the body and vascular accidents, affecting other portions of the the patient was asked to report on their identi- cerebral hemisphere, diffuse brain lesions, and fication. Even the cruder stimuli such as rub- lesions of other parts of the central nervous bing, scratching, and seizure of the patient's two system. Critchley (I949), in his masterly review hands simultaneously may be used to demon- on this phenomenon, suggested a self-explanatory strate this phenomenon. term,' tactile inattention.' Recently Brain (I955) (b) By salt and sugar being applied simul- termed this sensory suppression as 'perceptual taneously on the two sides of the tongue. The rivalry' which is more informative about its nature. patient was asked to rinse the mouth with water At present, there is no general agreement about and report on the location and nature of the the nature of this sensory defect and terminology. taste. Somesthetic sensations were tested by pin prick and touch applied simultaneously on the Material two sides of the tongue. Tactile and painful The purpose of the present study was to deter- bilateral simultaneous stimuli were also applied FAZLULLAH: Tactile in the Localization Cerebral Lesions

July 1956 Perceptual Rivalry of 339 Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from on the left side of the tongue and the right side of strated the 'double simultaneous stimulation the face, the right side of the tongue and the left level' in 50 cases of spinal cord disease. side of the face, to note extinction of the face or (d) No extinction. Extinction was not observed the tongue stimulus. in two cases with superficial parietal lesions (parietal lobe meningioma and angioma). In the Results early stage of parietal tumours, especially when EXTINCTION OR TACTILE PERCEPTUAL RIVALRY superficial or benign, even in the presence of sensory loss, tactile inattention or extinction is (a) Well defined extinction. Six cases with deep not observed. In the case with parietal meningi- and ten of extensive parietal lesions exhibited con- oma, presenting with Jacksonian fits in left foot stant and well defined extinction or tactile inatten- with left-sided ataxia, neither sensory loss nor tion with the parietal lobe syndromes, according to extinction was present on the left side. The case the involvement of the dominant (left) or the sub- of angioma (parietal) presented with subarachnoid ordinate (right) cerebral hemisphere. Out of the haemorrhage. Cases with strict frontal, tem- 23 parietal lobe disease cases examined, 21 poral lesions and raised intracranial pressure showed extinction or tactile inattention; 14 cases showed no extinction. One case of deep fronto- manifested well defined and constant extinction temporo-parietal glioblastoma exhibited extinction with the right parietal lobe syndromes. in association with right parietal and frontal lobe (b) Incomplete extinction. Four cases of parietal syndromes. Bender states that the two stimuli lesions showed incomplete extinction, i.e. stimulus should be equal in intensity. In cases of deep on the abnormal side was dull, delayed, felt im- parietal lesions with marked extinction, this pre- perfectly, inconstantly and incorrectly localized. caution is not necessary. A powerful pin prick, In such cases the extinction was best demon- on the abnormal side, is suppressed by a light strated by astereognosis when the size, shape, touch on the normal side. Dissimilar stimuli, weight and physical property of the stimulus was such as cotton wool, on the healthy side, can not recognized correctly on the abnormal side. suppress pin prick on the affected side. If the The palm writing method was useful in such stimulus is and maintained more than cases. Inconstant extinction was very strong (incomplete) three seconds, the single sensation may give way copyright. observed in the superficial or less extensive slowly to double. In cases with a superficial lesions. parietal lesion showing less defined or incomplete (c) Ipsilateral extinction. On application of extinction, the two stimuli should be equal in two ipsilateral simultaneous stimuli, one on the intensity and nature, i.e. cotton-cotton or pin face and the other on the hand, the stimulus on prick-pin prick. In cases of deep parietal the distal segment was suppressed. This sup- lesions this precaution is not essential. pression was noted in the four cases of parietal lesions with cortical sensory loss, i.e. hemianaes- EXTINCTION OF INATTENTION OR TACTILE thesia, astereognosis, two-point discriminative loss, AMORPHOSYNTHESIS http://pmj.bmj.com/ ataxia, graphaesthesia and postural defect. This Extinction is abolished temporarily if the eyes ipsilateral extinction was observed also infre- are opened, patient's attention is directed towards quently, in lesions of the mid-brain and spinal the affected side, repeated stimuli are applied and cord (Table 2). In one case of spinal cord glioma pressure continued for a long time. This phe- (astrocytoma G II), two stimuli were applied nomenon was not observed in well defined extinc- simultaneously, one on the face and the other tion with deep parietal neoplasm, encroaching on below the supposed level of the lesion. This the thalamus, or extensive and rapidly destructive on October 1, 2021 by guest. Protected lower area previously had been found to be parietal lesions when attention does not play any sensitive to some degree on single stimulus, the part in suppression of inattention. patient feeling the upper stimulus only. Additional trials were made, stimulating simultaneously the DISPLACEMENT PHENOMENON (Tactile same facial area and successively more rostral Alloaesthesia) portions of the lower area, so that the level of the Patients with extinction, also, showed displace- lesion was approached by the lower stimulus, at ment phenomenon. When a stimulus was applied which the patient felt the lower stimulus equal to on the affected side it was felt at a distant point, the upper one in intensity. Shapiro and Feldman on the same side or on the opposite side of the (I952) termed this level as the 'level of double proximal mirror image point of the body, i.e. a simultaneous stimulation.' This level in this stimulus from the foot is felt at the thigh or hip, patient coincided with the anatomical level, con- that from the hand at the shoulder. In such firmed by myelography and operative findings. cases, it may be assumed that the stimulus, by Recently Shapiro and Feldman (1952) demon- blocking thalamo-cortical impulses at the primary POSTGRADUATE MEDICAL JOURNAL 340 July 1956Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from zones of sensation, has moved to the secondary lesions. Six cases with well defined extinction zones of sensation with the predominant homo- tion of taste, painful and tactile stimuli. Extinction lateral representation. Extinction may be a form was observed on the sensory deficit side and of tactile alloaesthesia. sometimes displacement to the other side was observed, the significance of which is not known. DISORDER OF MOTILITY In two cases of deep right parietal glioblastoma, Catatonia without grasp reflex was observed in on bilateral simultaneous stimulation of two eight cases of parietal lesions (deep glioblastoma sides on the tongue, the left stimulus was extin- five, secondaries two, cortical atrophy one). One guished. Simultaneous stimuli (touch or pin case of a biparietal vascular lesion exhibited an prick) on the right side of the face and the left unusual phenomenon: on stimulation of the left side of the tongue, extinguished the left-side sole the left plantar reflex was extensor and at the tongue stimulus. Tactile or painful stimuli, same time the right plantar reflex was extensor as applied to the right side of the tongue and the well (crossed plantar extensor). On stimulation left side of the face, extinguished the left-face of the right sole the right plantar reflex was flexor, stimuli. whilst on application of simultaneous stimuli to both soles the left was extensor and the right was Other Findings flexor (extinction of the crossed plantar extensor). In the patients showing extinction cortical Cohn (1948) described extinction of the Babinski sensory loss was observed as astereognosis, ataxia, sign on bilateral simultaneous stroking of the loss of two-point discrimination, paraesthesia and soles, the extensor reflex on the contralateral side hemianaesthesia. In four cases astereognosis only of the parietal lesion was extinguished. This was observed. Visual field changes were observed extinction of the crossed plantar extensor phe- as follows: nomenon has not been described before. This (a) Homonymous hemianopia (six cases) with phenomenon was observed constantly for four right parietal syndrome. weeks only, then it regressed. This sign is (b) Balint's optic agnosia (two cases). analogous to ' Rothfield manoeuvre' (I932), i.e. (c) Left hemianopia with visual amorpho- on one side is said to or of left half of passive straight leg raising synthesis perceptual rivalry thecopyright. provoke a contralateral associated flexion move- space (two cases). ment in presence of either contralateral frontal or ipsilateral parieto-temporal lesion. This sign Parietal Lobe Syndromes with the other ones enables the clinician to Right parietal lobe syndromes were observed in localize the lesion. four cases of deep neoplasm (two encroaching on the thalamus) and in eleven cases with diffuse or UNILATERAL EXTINCTION OR PERCEPTUAL RIVALRY localized cortical lesions (vascular 5, cortical WITH ROSTROCAUDAL DOMINANCE atrophy I, head injury I, secondaries 3, angioma i). All cases with ipsilateral extinction also exhi- (a) LEFT PARIETAL SYNDROME. The followinghttp://pmj.bmj.com/ bited rostrocaudal dominance, i.e. if two stimuli signs were noted in four cases of left parietal were applied on one side of the body the proximal vascular lesions: suppresses the distal one. The face was con- (I) Gertsman syndrome.-Finger agnosia (mistake stantly dominant over the shoulder, wrist, hip and in recognition of finger). Right and left dis- foot. In no case did the lower stimulus extinguish orientation (unable to differentiate right and left). the perception of that applied on the face. This Agraphia (mistakes in writing). Dyscalculia (mis- fact reveals the dominance of the face over the takes in Nominal calculation). aphasia (mistakes on October 1, 2021 by guest. Protected rest of the body (Bender, I95 ; Cohn, I951; and in naming things). We know this syndrome Critchley, 1949). manifests after lesions of ' angular gyrus' on the left side. EXTINCTION OF TASTE AND SOMESTHETIC SENSA- (2) Parietal apraxia.-The patients exhibiting TIONS ON BILATERAL SIMULTANEOUS STIMULI (on this apraxia have lost their ability to understand the tongue and face) idea of the action or to execute the actions, though B6rstein (1940) observed sensory defect for there is no paralysis of the limbs. This apraxia touch, pain and taste in his three cases of parietal is produced by disruption of supra-marginal- lobe injury. He inferred that the cortical angular gyri with the motor cortex via the callosal representation of taste is near the parietal lobe body. Hence a callosal or supra-marginal-gyri operculum and that it is related more closely to lesion can produce the sam-e type of apraxia. the face and mouth area than to the olfaction area. (3) Construction apraxia.-In cases with left Bender and Daniel (1952) observed extinction of parieto-occipital lesions this apraxia is manifested taste and somesthetic sensation in parietal lobe as disturbances in drawing, especially of geo- FAZLULLAH: Tactile in the Localization Cerebral Lesions 341 July I956 Perceptual Rivalry of Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from metrical figures. In trying to copy the models, the paper-and-pencil tests. There is enough clinical patient draws a meaningless confusion of lines. evidence that this defect is a result of inco-ordina- Gross construction apraxia was noted in drawing tion between motor, sensory, visual and temporal from memory. This apraxia results due to inco- cortical function. ordination between motor, visual and sensory (8) Disorientation of space.-The patients were cortex. The temporal qualities are also dis- unable to recognize depth of the space. One case rupted with the other cortices. complained that the windows and walls were (b) RIGHT PARIETAL SYNDROME. Among the inclining towards her. She exhibited biparietal syndromes the following were noted: syndrome with opticagnosia, due to cerebral (I) Anosognosia.-The patient catnot perceive embolism. the defective function such as hemiplegia. Five (9) Agnosia ofleftportion ofspace.-The patients cases with vascular lesions denied the existence of were unable to perceive sensation coming from hemiplegia on the left side. the left portion of the space (visual-auditory and (2) Hemiasomatognosia.-The patient is unable extra-personal stimuli). Six cases had homony- to focus attention on the paretic side and states mous hemianopia, another two had no homony- that the paretic half of the body is strange. Eight mous visual field defect but still they neglected cases of right parietal lesions showed this the left half of the space and body. One case of syndrome. right parietal angioma and another of vascular (3) Metamorphognosia.-The patient feels that a lesion complained, 'if the bus is on my left side portion of the body is heavy and thick. I will walk into it, and I am unable to read words (4) Corporeal agnosia.-The patient feels that and lines on the left side of the newspapers since sensation of half of the body or the extremity is my illness.' In this type of visual agnosia the lost. patient is unable to perceive visual stimuli coming (5) Phantom sensations.-The patient feels that from the left portion of the space. Denny Brown a portion of the body has doubled. Six cases of (I953) explained this syndrome as a visual amor- deep parietal neoplasm, one case of cortical phosynthesis of spatial stimuli or visual perceptual atrophy and five cases of vascular lesion com- rivalry. that plained their left arm was heavy, thick, funny (Io) Anaesthoagnosia.-In six cases with deep copyright. and did not belong to them. parietal lesions there was profound sensory loss (6) Transposition of parts of the body.-The of the left half of the body with anosognosia and patient feels that a part of the body is transferred to disorder of the left half of the body awareness. another part or beyond the body. One of the cases Potzl (1924) believes that a lesion of the thalamus of biparietal vascular lesion was asked to show his is significant in the production of this syndrome. left hand;, he started searching for his left arm In this series two cases with deep parietal glio- everywhere in the bed, then he opened the locker blastoma encroaching on the postero-lateral to see if his left hand was there. When he was thalamus exhibited sensory loss and body aware- asked to do anything with the left hand he always ness disturbances on the affected side. One of http://pmj.bmj.com/ did it with the right, neglecting the left side of the such cases had painful syndrome but no thalamic body. Three cases with deep parietal neoplasm, dyaesthesia. two cases with secondaries, and one case with (ii) Balint optic ataxia.-Balint (I909) first cortical atrophy also exhibited this phenomenon. described this syndrome which he called ' psychic (7) Construction apraxia.-This was noted in 14 paralysis of visual fixation' in which disturbance cases of right parietal lesions. This apraxia is an of visual fixation is associated with optic ataxia and common event in cases of and visual inattention. These are unable important parietal patients on October 1, 2021 by guest. Protected disease. It is essentially an executive defect to see two things at the same time. They are unable within the visuo-spatial domain and is associated to co-ordinate voluntary ocular movements in re- with other spatial disorders and visual disorienta- sponse to sudden visual stimuli. There is visual tion. It is an interference with the formative inattention for the objects. The patients are activity (arranging, drawing, copying models) and unable to see the object in the left peripheral field. disorder of the spatial part of the task. Patients Most prominent visual stimuli (those falling on the with right parietal disease, when asked to copy macula) actually reach consciousness, the others models or draw maps of things seen before illness, at the periphery are not seen. make meaningless confusions and mistakes in Gordon Holmes (I9I8) described this syndrome construction of one-two-three dimensional figures. in bilateral parietal or angular-supramarginal gyri Drawings show splitting of details with simul- lesions. Two cases of cerebral embolism with taneous neglect of left side of the objects. Ordi- bilateral parietal syndrome exhibited this visual narily at the bedside this defect can be demon- phenomenon. They were unable to see in the strated by the use of matchsticks and the use of left half of the peripheral field, revealed by the 342 POSTGRADUATE MEDICAL JOURNAL July 1956Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from

TABLE I.-LOCALIZATION OF LESION WITH EXTINCTION

No. of Nature of lesion Site of lesion cases Parietal syndrome Associated clinical findings Glioblastoma Deep R. temporo- 3 R. parietal syndrome: Anosog- Papilloedema; L. hemianaesthesia parietal nosia; body image disorder on (cortical type); L. homonymous L. half of body; construction hemianopia; raised C.S.F. pro- apraxia; neglect of L. half of tein, crossed plantar extensor in body one Secondaries Deep R. temporo- 3 do. . do. parietal Cortical atrophy R. I do. Epileptic fits with status epi- lepticus; L. hemiplegia; L. hemianaesthesia (cortical); L. homonymous hemianopia Glioblastoma R. deep fronto- I Frontal and R. parietal syndrome Papilloedema; raised C.S.F. pro- temporo-parietal (body image disorder) tein; L. hemiparesis; L. homo- nymous hemianopia; L. hemi- anaesthesia Vascular Lesions (a) Thrombosis L. parietal 2 L. parietal syndrome (Gertsman R. hemiparesis syndrome, colour agnosia, per- severation of visual agnosia) (b) Embolism R. parietal 5 R. parietal syndrome: Anosog- L. hemiparesis; L. hemianaes- nosia; body image disorder; thesia (cortical); L. homony- neglect of L. side; R. and L. mous hemianopia in 3; nil in z parietal syndromes in 2 cases; with Balint optic agnosia; crossed construction apraxia plantar extensor in I Head injuries R. parietal 3 R. parietal syndrome in I case; L. hemiplegia in i; astereognosis (closed) nil in 2 in 2 cases only; extinction only in I.

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Angioma R. parietal R. parietal syndrome: Construc- L. hemianopia; L. hemiplegia;copyright. tion apraxia; agnosia of L. half L. hemianaesthesia; two sub- of the space arachnoid haemorrhages three-flower test; they missed the flower in the and tinnitus, developed electric shock-like pain on left peripheral field and recognized the right and the right half of the body without thalamic dys- middle one. There was no fundal change or acuity aesthesia. She exhibited ataxia, astereognosis of vision defect. They complained that they and hemianaesthesia on the right half of the body. could not see two things shown simultaneously The clinical features suggest that the pain is of in the left half of their visual field and used to miss central origin7 rather than thalamic, in view of the http://pmj.bmj.com/ objects, words and lines of sentences on the left absence of over-reaction to stimuli. This fact side while reading newspapers. In counting lines, suggests inhibition of thalamus by the parietal they could count one or two and would neglect lobe via parieto-thalamic fibres, the release of other lines further on the left. As soon as the which results in the painful syndrome. object left the central field there was great difficulty in localizing it. There was a complete inability to Discussion to estimate the distance between two objects. In It has been thought that 'extinction' was a on October 1, 2021 by guest. Protected lighting a cigarette, the patient found difficulty in specific sign of parietal lobe disease. This sign touching the end of it with the flame and said: is observed frequently in parietal lobe disease as ' I can see only one at a time.' This defect of shown in the Tables I and 2. Infrequently this vision was seen more frequently in the left sign is observed in lesions of the sensory tracts in peripheral field than in the right. other regions, such as the spinal cord and brain In reality this visual agnosia is a special dis- stem, as is shown in two cases of brain stem and turbance in conception or amorphosynthesis of in one of spinal cord glioma, which gives a clinical spatial stimuli, hence it can be called visual- proof of the existence of a separate pari-eto-tectum amorphosynthesis or visual perceptual rivalry. and parieto-spinal projections, apart from parieto- thalamic connections. Peele (1942), in a most Parietal Pain Syndrome (pseudo-thalamic searching study on the important and complex syndrome) parietal projections, found that each parietal lobe One case, who had two attacks of subarachnoid gives rise to association fibres to other parietal haemorrhage, used to get frequent fainting attacks areas and projection fibres not only to the thalamus July 1956 FAZLULLAH: Tactile Perceptual Rivalry in the Localization of Cerebral Lesions 343 Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from TABLE 2.-LOCALIZATION OF LESION WITH IPSILATERAL EXTINCTION No. of Nature of lesion Site of lesion cases Parietal syndrome Associated clinical findings Glioma L. parietal I -R. hemiparesis; R. hemianaes- thesia; R. ataxia; R. astereog- nosis; C.S.F. protein + + Angioma L. parietal I - Two attacks of subarachnoid haemorrhage; frequent fainting attacks; R. ptosis; sensory loss R. half of body with pseudo- thalamic syndrome; R. ataxia; R.-sided astereognosis Glioma L. parietal I- Eplipetic fits; R. ptosis; R. di- plopia; R. side ataxia; parietal hemianaesthesia on R. half of face and arms; C.S.F. pro- tein + + Angioma Mid-brain - Transient faints, since 7 years; vertigo; dysphagia; slurred speech; L. V lesion; R. VI lesion; L. VII lesion (upper motor neuron); R. hemianaes- thesia; R. hemiparesis; recurrent trigeminal neuralgia Glioma Mid-brain - L. hemianaesthesia; L.L. VII lesion (upper motor neuron); L. VIII lesion; nystagmus; ataxia on L.; defective upward conjugate deviation; C.S.F. pro- tein raised Astrocytoma L. cerebello- - L. hemiparesis; L. ataxia (cere- pontine angle bellar) nystagnus; L. V, VI,

VIII lesions copyright. Secondaries L. cerebellum with - Vertigo; L. hemiparesis; L. as- brain stem dis- tereognosis placement to R. Astrocytoma Spinal cord I - Radicular pain R. leg; spastic monplegia R. leg with patchy sensory loss up to L4; C.S.F. zanthoschromia and but also to the few fibres are involved, (pulvinar postero-lateral parts) thalamo-parietal projection http://pmj.bmj.com/ mid-brain, medulla, pons and spinal cord. The therefore no sensory defect occurs. parietal lobe is represented in the pulvinar and It is interesting to note that extinction pheno- in postero-lateral part of the thalamus. menon is usually found in patients with evidence Ipsilateral extinction (unilateral extinction) in of cortical sensory deficit and anosognosia; it is this series was observed in superficial benign not always present in such cases, and it also occurs parietal lesions, such as angioma, glioma, localized in the absence of such deficit. In five cases of head injury and vascular lesions which permit parietal lesions there was no sensory loss, but greater adaptation of cerebral functions. Perhaps, extinction was observed. on October 1, 2021 by guest. Protected in such cases, large numbers of thalamo-parietal All the patients with extinction phenomena also fibres are spared from damage. showed face dominance and ipsilateral extinction Constant and well defined extinction was ob- when two simultaneous stimuli were applied on served in cases with deep parietal neoplasm, two areas on the same side of the body. Raised encroaching on the thalamus, widespread and intracranial pressure had no influence on rapidly destructive cerebral lesions. Parietal lobe extinction. syndromes were associated with well defined ex- Face stimulus extinguished the opposite tongue tinction in cases with deep parietal neoplasm and stimulus and similarly tongue stimulus extin- rapidly destructive lesions or diffuse cerebral guished opposite face stimulus. This fact shows lesions. It is noteworthy that extinction phe- that the face and the tongue areas are close nomenon is not universally demonstrable in together in the parietal lobe. parietal disease. Two cases of proved parietal Bender (1949) recently found that light pressure neoplasm (meningioma, angioma) did not show stimulus elicits extinction better in several patients extinction. In superficial lesions, perhaps, very than painful stimulus, and also emphasized the 344 POSTGRADUATE MEDICAL JOURNAL July I956Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from

TABLE 3.-LOCALIZATION OF LESION WITH NO EXTINCTION No. of Nature of lesion Site of lesion cases Parietal syndrome Associated clinical findings Angioma R. parietal lobe I Subarachnoid haemorrhage Meningioma R. parietal lobe I Jacksonian fits in the L. foot; L. hemiparesis (marked L.L.); L. ataxia; paraesthesia L. foot Secondaries Frontal lobe I Frontal-lobe syndrome Meningioma Frontal lobe I Frontal-lobe syndrome Loss of smell; C.S.F. protein + + Compound fracture Frontal area I Porencephaly Temporal (L.) I Temporal epilepsy; subarachnoid haemorrhage Abscess Temporal 3* Chronic ear infection; status epi- lepticus in I; meningitis in 2; C.S.F. +++ (sterile pus) Neuroma R. 8th nerve I Headache; blindness; papilloe- dema; nerve deafness; raised intracranial pressure Cerebral embolism R. cerebral 2 - L. hemiparesis * Bilateral i, unilateral 2 value of testing extinction on non-homologous that ' expectant attention ' is not directed to the areas as well. Ziegler (I952) observed well affected side in parietal lesion. They claim that defined or constant extinction in deep parietal the sensory cortex is the site for ' attention' and lesions and inconstant extinction in superficial all the complex manifestations of awareness, hence lesions. In the presented material six cases of a parietal lesion gives rise to disturbances in local deep parietal neoplasm and 12 diffuse parietal attention, in body scheme and in awareness of lesions showed well defined extinction. Three body unity. copyright. patients with the superficial parietal lesions exhibited less defined extinction and the two other Morphosynthesis cases showed no extinction. Denny Brown (I953) emphasized that the Mechanism of Extinction summation of spatial stimuli, under the term of ' morphosynthesis,' are part of the functions of Some authorities have tried to explain extinction lobes. phenomena physiologically (Bender, I945; and parietal Amorphosynthesis, conceptual and Brown, perceptual defects explains the extinction phe- Denny I953). Critchley (I949, I953) nomena, and many other sensory defects producedhttp://pmj.bmj.com/ believes that this is neither a physiological nor by parietal lesions. It is justifiable to call parietal psychological problem but is a defect in the local defect attention, because it is broken down by opening the sensory as tactile or visual amorpho- eyes and by repeated testing, hence he coined a synthesis. new self-explanatory term 'tactile inattention.' Bender states that attention plays no part, repeated Perceptual Rivalry the and area of stimulus, are Critchley ('949) and Denny Brown (I953) testing, varying type believe that there is a ' the essentials for the elicitation of' extinction.' rivalry' between the two on October 1, 2021 by guest. Protected Attention does play a part in incomplete extinc- stimuli at the highest cortical sensory level. That tion with less damage to parietal lobes. But in one on the sensory deficit side is suppressed and cases of deep-seated neoplasm, encroaching on fails to attain consciousness, the loss of one the thalamus or massive rapidly destructive stimulus leads to over-activity of the other and lesions, attention does not play any part in thus 'perceptual rivalry' results in inconstancy extinction of inattention. This suggests that the in all types of defects and also explains' extinction' thalamus and its peduncle are significant, where phenomena and many other parietal defects. The thalamo-cortical fibres are packed together. At term tactile or visual perceptual rivalry is more present we know nothing about the physiological informative and self-explanatory than tactile or basis of attention. visual inattention. Head and Holmes (1911) emphasized that localized defect of 'attention' is the basis of The Role of Thalamus and Callosal Body in many characteristic sensory defects, seen in Body Unity parietal lesion. Critchley (1949, 1953) believes Chang, experimentally, and Potzl, clinically, FAZLULLAH: Tactile in the Localization Cerebral Lesions

July 1956 Perceptual Rivalry of 345 Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from came to the conclusion that there is an intimate link involve the cortex, lie immediately deep to the between the callosal functions and the functions cortex and between the cortex and thalamus, or of the thalamo-cortical system. Cortical poten- actually invade the thalamic nuclear mechanism, tials can be observed by the stimulation of the in addition to ascending and descending thalamo- corporis callosum. In accordance with the ana- parietal pathways. tomical investigations of Chang, the anterior part In this series two cases with localized superficial of the callosum contains fibres from the anterior parietal neoplasms (meningioma and angioma),: brain, the posterior part from the posterior brain, showed neither extinction nor parietal syndrome, and the central part from the temporal and while one head injury case had extinction with parietal brain. Callosal fibres are dense in the right parietal syndrome, and two others with head posterior part (fibres from the posterior parietal injuries had no parietal syndrome except extinc- lobe). It is probable that this part is responsible tion. Four cases with deep localized parietal neo7 for the formation of a whole 'body sensation plasm and ten cases of extensive parietal lesion scheme ' without a mid-line in our mind. Accord- (cortical atrophy I, secondaries 2, and vascular ing to Hoff and Potzl there is swinging of impulses lesions 7) produced manifold parietal syndromes, between two hemispheres via the callosal body. Two parietal cases who had localized deep glio- They believe that there is a middle line in the blastoma, encroaching on the postero-lateral part thalamus dividing the body in two parts. Sensory of the thalamus, produced the same picture as and kinaesthetic impulses, if they pass over the that produced by the diffuse parietal lesions. middle line of the thalamus, inhibit stimuli of This fact suggests that destruction of the postero- homolateral side and stimuli of the contra-lateral lateral thalamus or its peduncle, extensive lesions side are accentuated. In the thalamus, sensations of thalamo-parietal fibres, damage to angular- are localized on the contra-lateral side but due to supramarginal gyri and calloso-commissural fibres, the interlaminary nuclei of the thalamus, the result in parietal syndromes due to disruption of sensations of half of the body are combined in the sensory cortex with the temporal, occipital one, hence normally we do not feel a middle line. and motor cortices. Cortical functions this modify unity, being Mechanism of Parietal Lobe accentuated in the optic and acoustic field, hence Syndromes copyright. a thalamic or parietal lesion can produce this body Le Gros Clark and Boggon (i935) believe that unity defect. the thalamo-cortical fibres system is more complex Two cases of deep temporo-parietal glioblas- in man and there must be an intermingling of toma, encroaching on the postero-lateral part of the the complex corticofugal fibres, cortico-cortical thalamus and the posterior part of thc callosal association fibres and commissural tracts. Two body, exhibited gross body unity disturbance with cases of localized deep glioblastoma, involving the right parietal syndromes and well defined extinc- thalamic peduncle, give a clinical proof of this fact. tion. These two cases present a clinical proofof the They exhibited gross sensory loss and various importance of postero-lateral part of the thalamus parietal syndromes. http://pmj.bmj.com/ and posterior callosal body in the formation of In two cases of superficial parietal neoplasm body unity. (meningioma and angioma) and five other cases Henson (1949) described a case of deep right of benign superficial lesions with some cortical parieto-occipital glioblastoma with gross destruc- sensory loss such as astereognosis, ataxia, hemi- tion of the pulvinar of thalamus, exhibiting body anaesthesia, extinction and graphaesthesia, no unity disturbances, extinction and thalamic dysaes- parietal syndromes were observed. It is most thesia which was suppressed by simultaneous likely that, in these cases, thalamo-cortical and on October 1, 2021 by guest. Protected bilateral stimulation. Attention played no part in other association fibres are not involved exten- extinction of tactile inattention. In the presented sively, some fibres such as thalamo-marginal- material two cases with deep parietal neoplasm angular gyri being spared. and six cases of extensive parietal lesions exhibited These clinico-pathological observations may body unity disorders and sensory changes on the suggest that parietal lobes, due to their central affected side, but there was no extinction of position in the brain, have the function of com- inattention when patient's attention was directed bining and concentrating as well as dividing the to the affected part. This fact again emphasizes occipital, temporal, sensory cortex with the motor the importance of the thalamus and its peduncle cortex; suppressing the disturbing impulses, in the production of parietal sensory defects. facilitating the useful ones, and fixing them in distinct parts of the brain. Complex mental tasks, Cortical versus Subcortical Lesions of high intellectual order, require harmonious Small parietal lesions will probably produce integration of manifold impulses and disruption different clinical effects eccording to whether they of which leads to various syndromes, as released F 346 POSTGRADUATE MEDICAL JOURNAL July 1956Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from phenomena or due to amorphosynthesis of connections. Parietal-ataxia and hypotonia may stimuli and perceptual rivalry. be due to disruption of parieto-cerebellar con- Critchley (I953) believes that it is illogical to nections. conclude that these activities are part of parietal In conclusion, it can be said that the effects of function; for probably these are activities of the lesions of the parietal lobes, as described above, brain as a whole, integration of temporal, occipital are not limited to parietal lobes, but are also and sensory cortices may be concerned in three- followed by entire malfunction of the brain, due dimensional spatial quality, interconnection of to distortion of these combining impulses or vision and mobility is necessary for three-dimen- amorphosynthesis of the sensory stimuli, con- sional construction. The parietal lobe, by com- ceptual and perceptual defects. bining all these qualities, builds up the body scheme and corporeal awareness. Topographical Summary memory requires integration of manifold impulses. Twenty-three cases of parietal lesions are Recently Hoff (I953), using vector electro- described: encephalography, obtained a distinct picture from (i) 'Extinction' or 'tactile amorphosynthesis' left parieto-occipital lesions. He tried to prove was observed in the 21 parietal lesions. Extinc- the functional difference between the two parietal tion is the specific sign of the parietal disease and lobes with inconclusive results. He obtained should be tested routinely. parieto-occipital alpha rhythm of higher voltage (2) Well defined extinction was observed in which was more pronounced on the right 'than cases of deep parietal lesions, encroaching on the the left. Beta waves are more prevalent on the thalamus or thalamic peduncle and in extensive or left. Alpha spindles occur on both sides. He rapid destruction of parietal lobes. In such cases suggested that in pathological disorder of the extinction was associated with parietal syndromes. left parietal lobe, the lesion causes misdirection of The superficial, benign, and less extensive lesions impulses, flowing out from the left into different showed inconstant extinction without parietal regions. Various previously used schemes overlap syndromes. the misdirected schemes, and result in various (3) Mechanisms of extinction and parietal lobes types of apraxia. syndromes have been discussed. copyright. Hans Hoff (I953) believes that the two parietal lobes have an important co-function in combining Acknowledgment frontal, temporal and occipital impulses. At the I wish to record my thanks to the physicians same time each prevents disturbing impulses and for providing facilities for the study of these concentrates as well as divides occipital, temporal cases, particularly Dr. K. A. Latter (Consulting and central functions. The right parietal, con- Physician and Neurologist, Norfolk and Norwich necting our sensation.with total function of the Hospital), Dr. W. H. Palmer (Physician, Lowestoft brain, forms the body unity. The left parietal Hospital), Dr. A. P. B. Waind (Consulting Physi- lobe has the function of highest sensory level cian, Barrow and Furness Group of Hospitals),http://pmj.bmj.com/ such as calculation, speech, reading and writing, Dr. J. K. Slater (Consultant Neurologist, Royal disruption of which leads to various parietal Infirmary, Edinburgh) for his critical review on the defects. paper, the Neurosurgical Department of Queen's Extensive disorder of function may result in Square National Hospital, London, and Man- body image disorder, which is built up of past chester for arranging angiography, etc., and and present visual, auditory, tactile, postural and supplying reports on the operative findings, Dr. sensory perception. Lesions, in the deep parietal J. E. Horrocks (Consultant Pathologist, Barrow on October 1, 2021 by guest. Protected lobe, cause corporeal agnosia by interfering with and Furness Group of Hospitals) for the patho- :synthesis of cutaneous and proprioceptive im- logical reports and helpful advice in the prepara- pulses with other sensory data. Widespread and tion of the paper, and Dr. L. Watson (Consultant, bilateral parietal lesions result in visual agnosia Pontefract and Castleford Group of Hospitals) for due to interference of connection between visual his helpful suggestions. and other association areas. Diffuse cerebral lesions of the left or left BIBLIOGRAPHY parietal angular gyrus BALINT, R. (1909), Mschr. Psychiat. Neurol., 25, 51. result in apraxia of idea. Disruption of parietal BENDER, M. B. (1945), Arch. Neurol. Psychiat., 54, I-9. (L) or L-angular gyrus with the motor cortex BENDER, M. B. (I948), M. Clin. North America, 32, 755. causes ideomotor Constructional BENDER, M. B., and DANIELS, S. F. (1952), Neurology, 2, apraxia. apraxia 195-202. results from disturbances of visual-spatial func- BENDER, M. B. (I95I), Arch. Neurol. & Psychiat., 66, 355-758. tions with kinaesthetic impulses. Probably, BORSTEIN, W. S. (I940), YaleJ. Biol. & Med., 12, 719. temporal quality also combines with it. Parietal BORSTEIN, W. S. (1940), Ibid., 13, I33. ataxia results by interference of parieto-cerebellar Bibliography continued on page 352 352 POSTGRADUATE MEDICAL JOURNAL July 1956 Postgrad Med J: first published as 10.1136/pgmj.32.369.338 on 1 July 1956. Downloaded from DR. LUMB: Could I just clarify one point for localized in bone. Occasionally, as you know, myself here,? In interpreting the flocculation examples of plasma cell leukaemia are found. tests is it true to say that any one of them may be Another site for soft tissue tumours is in the naso- raised in different cases ? pharynx. These cases most commonly pursue a PROFESSOR MACLAGAN: Yes, but those which benign course and are not associated with bony most commonly show gross abnormality are the lesion but occasional examples are recorded where zinc and ammonium sulphate tests. multiple bone deposits appear. PROFESSOR PULVERTAFT: So far we have dis- cussed tumour deposits in bone only. In what BIBLIOGRAPHY other have found ? DEUTSCH, H. F., KRATOCHVIL, C. H., and REIF, A. E. (I955), organs you personally deposits J. Biol. Chen., 216, I03. DR. LUMB: In a few cases one has seen plasma GRIFFITHS, L. L., and BREWS, V. A. L. (1953), J. Clin. Path., 6, I87. cell proliferations in liver and spleen and lymph GUTMAN, A. B., MOORE, D. H., GUTMAN, E. B., nodes. In other words when the McCLELLAN, V., and KABAT, E. A. (1941), J. Clin. Invest., proliferations 20, 765. become generalized they tend to involve the MORISON, J. E., J. Path. Bact., 53, 403. PUTNAM, F. W., and HARDY, S. (955), J. Biol. Chem., 212, reticuloendothelial system. It is my own personal 36I, 37I. view that these conditions are in fact a tumour of SMITH, E. S., BROWN, D. M., McFADDEN, M. L., BUETTNER-JANUSCH, V., and JAGER, B. V. (1955), the reticuloendothelial system most commonly Ibid., 216, 6oi. Restoration ofRepose with EQUANILE * (MEPROBAMATE) copyright. an outstanding new drug to lessen tension, reduce irritability and restlessness, and to produce more restful sleep and generalized muscular relaxation. i ,~d~ Supplies: http://pmj.bmj.com/ Bottles of2o and 250 x 400 mgm.tablets

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