http://exhibits.library.stonybrook.edu/mfp/files/original/945d2769d3cde3d546dfd13ec8bc4c04.pdf 7b68d01261bda3dea9d45000fea060a8 PDF Text Text The F ace—Hand Test as a Diagnostic Sign of Organic Mental Syndrome Max Fin/c, M.D., Martin Green, [M.D. and [Morris B. Bender, M.D. In the course of sensory studies by the method of double simultaneous stimulation, it has been observed that patients with mental changes may show perceptual errors which are not demonstrable by routine single stimulation.1 When stimuli are simultaneously applied to the cheek and the hand (the face-hand testz) , patients frequently report only one of the two stimuli, or when reporting the two stimuli mislocalize one to another part of the body or even into space. These changes in perception are seen on repeated trials of the face-hand test and seem to form a con— sistent part of the syndrome usually labelled “organic mental syndrome” or “organic psychosis.” SUBJECTS Four hundred patients, who manifested cerebral dysfunction in the form of an organic mental syndrome due to a variety of causes, were studied on the wards of the Bellevue Psychiatric Hospital.* Each patient manifested, to some degree, the following mental changes: (1) impairment of memory, for both recent and remote events; (2) confusion and disorien— tation for time, space, situation and body image; (3) errors on calculation and general information tests; (4) distractibility, poor attention span, inability to handle more than one situation at a time, concreteness and *This number represents several series of patients in whom the method of double simultaneous stimulation were applied. It includes all tests of the face and hand by touch, pin prick and combinations of touch and pin prick stimuli, as well as tests of body areas other than the face and the hand. From the department of neurology and psychiatry, New York University College of Medi— cine, and the department of neurology and psychiatry, Bellevue Hospital, New York City. This work was aided in part by a Fellowship from the National Foundation for Infantile Paralysis, and by a research grant from the United States Public Health Service, National Institutes of Health. Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 46 �4'7 ORGANIC MENTAL SYNDROIVIE rigidity in thinking; (5) perseveration of speech and behavior; (6) emo— tional liability and readily elicited “catastrophic” reaction; (7) loss of initiative and interest in the environment and indecent exposure and soiling of the clothing. The clinical diagnoses were varied, including chronic alcoholism, post-traumatic encephalopathy, hypertensive cerebro-vascular disease, diffuse arteriosclerotic softening, syphilis of the central nervous system and degenerative diseases, such as Alzheimer’s disease, Hunting— ton’s chorea or senility. Observations on the face-hand test in patients with organic brain disease were compared with previously obtained results of similar examinations in normal adults and children and in adult patients with schizophrenia”. The normal adults and children, including students, associates and patients in clinics, were without manifest disorder of the nervous system. The schizophrenic adults were patients from the wards of the Bellevue Psychiatric Hospital. No effort was made to group the patients into the various clinical types of schizophrenia. JMETHOD The face—hand test was applied to each of these subjects. During routine physical examination the patient was asked to close his eyes. One cheek and the contralateral hand were simultaneously touched or stroked by the examiner’s fingers. The patient was then asked what he had felt. The usual response was, “You touched me here,” while pointing to the cheek. After this initial application of the face-hand test, the patient was again asked to close his eyes and the contralateral cheek and hand were similarly stimulated. In the many instances when only one percept was reported, the patient was asked if he had felt anything else. Occasionally the second percept was reported after this question, but more often it was not. Thereafter the tests were applied to the face and hand and to other parts of the body. RESULTS In patients with the organic mental syndrome most responses to the initial and subsequent face-hand tests were of four types: (1) a touch on the cheek only, implying no sensation in the hand; (2) a touch on each cheek, implying a mislocalization or displacement of the percept evoked in the hand to the cheek; (3) a touch on the hand only, implying no sensation in the cheek; and (4) correct localization of the percepts evoked in the cheek and hand. Less frequently other responses were noted, as both percepts in the hand, or a percept in the cheek and homolateral hand implying a mislocalization from one hand to the opposite hand. In a few cases the �NE UROLOGY 4-8 percept in the hand was mislocalized to a part of the body upon which the hand was resting, out into space, or onto the examiner’s body. The following case illustrates the various responses of patients with an organic mental syndrome. Case admitted to the psychiatric hospital with a one year history of progressive difficulty in concentration, inability to continue work, mood disturbances, episodes of confusion, forgetfulness and occasional lapses into irrelevant speech. Later, following the death of his wife, he became depressed, cried frequently, and spent many hours talking to himself. The neurologic examination showed minimal right facial weakness and some gross tremors of the hands. On psychiatric examination the patient answered questions coherently and relevantly. He was euphoric and friendly. There was disorientation for time and place, his memory for both recent and remote events was poor, and confabulation was frequent. Calculation and general information tests were performed poorly. Judgment was poor and there was no insight into his difficulties. When left alone he carried on a conversation with himself, and when presented with a mirror he identified the image as that of his brother and conversed with the image, listening for replies and reporting them to the examiner. In addition, there were difficulties in expression, both verbal and written, with errors in reading, calculation and reporting numbers. He was able to carry out simple commands but made errors in imitating mouth and hand movements. He handled objects clumsily. There was right-left dis— orientation, and he made errors in naming body parts. Psychometric examination revealed a severe organic impairment with defects in memory, concentration, abstraction, and concrete verbalization. His performance on the Kohs block test was severely deficient, exhibiting ability to complete only the first two 1:——-A 60 year old man was figures. , 0n sensory examination by the method of single stimulation he could identify and localize pin prick and touch stimuli, except that stimuli applied to the left hand TABLE Stimulus Right cheek, left hand Left cheek, right hand Right cheek, right hand Left Cheek, left hand Right and left hand Right and left cheek Right cheek, left shoulder Left cheek, right shoulder Left foot, right hand Left hand, right foot Right and left hand Right cheek, right hand Left cheek, left hand Right and left cheek Right cheek, left hand Left cheek, right hand 1 Response Right and left cheek Right and left cheek Right cheek, right shoulder (P) Left cheek only Correct Correct Right and left cheek Left cheek, left shoulder Left foot, left hand Right and left foot Out into space* Two percepts right cheek Left cheek only Correct Right and left cheek Right and left cheek Type of Defect Displacement Displacement Displacement Extinction Displacement Displacement-allesthesia Displacement-allesthesia Displacement Exosomesthesia Displacement Extinction Displacement Displacement *Patient mislocalized these percepts into space, insisting that the stimulation had not been applied to his body. �49 ORG/1N1C .MENTAL SYNDROME were occasionally displaced to the shoulder or the face on the same side. There were no significant differences in temperature, Vibration, position sense, and two-point discrimination tests on the two sides of the body. Stereognosis was intact. Examinations by the method of double simultaneous stimulation elicited many defects in cutaneous perception. These were manifest by extinction and displacement of percepts. The errors were persistent despite numerous examinations and over many weeks of study. Table 1 is an extract from the record of the patient’s responses to touch stimula- tion. Similar errors in localization of percepts were found when continuous and repetitive pin prick, tuning fork and temperature tube stimulations were used. 0n simultaneous stimulation of the cheek and any other region of the body, the patient correctly localized the percept in the face but seldom perceived correctly, or at all, the other stimulus. This was particularly evident when the cheek and hand were tested, especially a cheek and contralateral hand. A pneumoencephalogram revealed symmetrically dilated ventricles without displacement. A biopsy of brain tissue removed from the right cerebral hemisphere disclosed a prominence of senile plaques, Alzheimer cells and fatty pigmentation of neurons. COMMENT In this case there was no question as to the clinical diagnosis. The is of in defects not surprising. It is significant that perception presence despite the severity of the mental dysfunction the alterations in perception were consistent and patterned. Even though the patient appeared confused he never made errors in perception and localization of stimuli on the face, whereas he frequently erred in the simultaneously stimulated hand. Extinction and displacements from the hand were frequent during many examinations. These perceptual errors were conspicuous by their consistency, orderliness and predictability against a background of apparent mental confusion. These changes can be considered a prominent sign in the organic mental syndrome. DISCUSSION Incidence of errors on the face-hand test: Of 156 patients with organic mental syndrome, 91 per cent made errors on the initial trial of the face-hand test using touch stimuli. Subsequent trials revealed a similar high incidence of errors. These errors were in a definite pattern, in which the face percepts were correctly localized, and the hand percepts either not perceived or mislocalized. Displacement of percepts from the hand to the cheek was a prominent feature during the initial few trials of the test. Errors were noted on both sides of the body and occurred on tests applied to cheek and hand on the same side of the body, or on opposite sides. In 87 per cent of the patients errors were apparent through the tenth trial of the test and persisted for many more trials. Repeated testing �NE UROLOGY 50 I 100 ~ ‘~_ 60 O RESPONSES 0*.\ Responses of normal children ages 3-6 DOMINANT Responses of schizophrenic patients FACE CENT PER 1 2 3 4 NUMBER FIG. 1. Responses on 5 6 or successnve '7 8 9 TRIALS gm multiple trials of the face—hand test to touch stimuli:. on subsequent days elicited similar errors. It must be emphasized that these patients were able to correctly identify and localize single stimuli applied to the face and hands. In significant contrast to these observations on patients with organic mental syndrome are the observations on normal and schizophrenic adults.2 On the initial trial of the face- hand test to touch stimuli, '75 of normal and the adults cent per cent of the schizophrenic adults per failed to report one of the two stimuli. As the test was reapplied, the percentage of error rapidly declined until by the tenth trial of the facehand test less than 0.5 per cent of the normal adults and less than 3 per cent of the schizophrenic adults still showed omissions or mislocaliza— tions of percepts (figure 1). However, examination of children, age three to six years, with this method again showed a very high incidence of defects on face-hand tests. The curve of responses, as noted in figure 1, is parallel to the curve of responses of the patients with organic mental syndrome. The errors persisted for many trials and were observed in testing over many days. In older children, the curve of responses ap— proached that of the normal adult. A number of factors were found to influence these responses. Such elements as the type of stimulus, the conditions of the test, the part of �51 ()RGA N10 i1! ENTAL SYNDROME the body stimulated, “set” and “attention” of the patient, the type and severity of the mental changes, and the effect of drugs were considered. Timing and type of stimulus: In previous studies on normal and schizophrenic adults,2 simultaneity, similarity and equality in strength of stimuli were emphasized as essential for eliciting these responses. In the patients with mental changes, however, these factors were not as prominent since stimuli of unequal intensity or of different modalities still elicited errors in the tests. Dissimilar stimuli, as application of a touch stimulus to the cheek and a pin prick stimulus to the hand, or stimuli of unequal intensity, as a light touch to the cheek and forceful rubbing in the hand, elicited extinction and displacement of percepts. Similarly, errors in localization were elicited even if stimuli were not simultaneous, i.e. followed one another with a lapse of a moment or two. As previously reported, these errors on unequal, or dissimilar stimu— lation were not seen in the normal or schizophrenic controls. Application of the face—hand test using pin prick stimuli elicited the same pattern of responses as with touch stimuli. Eighty per cent of the patients made errors on the initial trial and such errors persisted in 60 of incidence is This defects trials. for than ten lower, cent more per however, than in the series with touch stimulations (table 2). In some of these patients it was possible to alternate touch and pin prick stimuli, and observe extinction and displacement of the touch percepts alternating with correct responses to pin prick stimuli. In a number of the more severely affected patients, extinction and displacement of percepts were also apparent on tests with temperature tubes, tuning forks and repetitive rubbing stimulations. TABLE 2 INITIAL TRIAL Organic Mental Syndrome Normal Adult Schizophrenic Adult Modality Touch Pin Prick Touch Pin Prick Touch Pin Prick Hand or Face Only Face-Face Hand-Hand Total Correct 156 50 160 68 15 10 122 35 7’7 75 15 45 ’72 50 51 24 36 13 14 5 3 3 2 2 1 2 0 1 5 0 This factor of the type of stimulus was more prominent in the normal and schizophrenic subjects. Less than 30 per cent of these made errors on the initial trial with pin prick stimuli, and the number of errors declined rapidly until by the tenth trial none of the normal subjects and only one of the schizophrenic subjects still showed errors. �NEUROLOGY of cutaneous stimuli between various body parts was apparent. lation of dissimilar body areas with the face as one locus, the the cheeks were well localized and identified, while stimuli were either not perceived or poorly localized. Combinations SQ On stimu— stimuli to elsewhere of stimuli to the face and trunk, face and foot, face and hand, etc., repeatedly showed face dominance. In contrast, in tests with the hand as one locus, the hand percept was always poorly perceived and poorly localized. This was observed in the initial trials in the normal and schizophrenic adults, but was more apparent in multiple trials in patients with organic mental changes. By repeatedly testing various combinations of other body areas, a gradient of the sensory relationships of these areas has been established. Because the face and hand regions represented the extremes in the pattern of responses, these two regions were selected as the basis of most of the tests. Therefore, this method of examination was named the face-hand test. The errors in these examinations were apparent in tests of both sides of the body without any manifest preference. In patients with hemiplegia of recent onset and associated mental changes, extinction and displacement of percepts were apparent bilaterally, but were more prominent and more persistent on the involved side of the body. In patients with long-standing hemiplegia in whom the mental syndrome was no longer apparent, the defects were limited to the involved half side of the body? The factor of mental set: The mental set or attitude often influenced the perceptual response. Once the normal adult was examined by the method of double simultaneous stimulation, subsequent tests failed to elicit a repetition of the errors which occurred on the initial face—hand test. It was as if these subjects had “learned” the set of “two-ness.” Moreover, when normal subjects were tested with face-face stimuli, the responses were correct, and then all subsequent face-hand tests were also correct. When face-face tests were interposed among trials of the face— hand test in the patients with mental changes, they continued to make errors on tests of face and hand, even though they were correct on the face-face trial. Such errors persisted for days. Evidently mental set and learning did not alter the pattern of response. The factoq' of attention: It is well known that attention can influence 4 perception.2' In a series of 30 normal adults who were told that two stimuli were to be applied, none made errors on the initial trial of the face-hand test. However, patients with severe mental changes, who were �53 ORGANIC MENTAL SYNDROME told either before the initial trial or on subsequent trials that there would be two stimuli, still showed extinction and displacement of percepts. It was possible to have the patient, with eyes open, observe the application of two stimuli and report them correctly. Then, with eyes closed, and the stimuli applied to the same or homologous areas, the patient would report the stimuli incorrectly. The effect of fatigue on the performance of the patient has already been mentioned. It is possible to increase the errors of the patient by administering the stimuli more frequently, or by making him aware of his errors and thereby increasing his anxiety. With mounting anxiety, errors increase until culminated by a catastrophic reaction and withdrawal from the examination. A similar effect of anxiety on performance was manifest in the normal subjects. The adults with manifest severe anxiety required more trials of the face—hand test to perceive the percepts correctly than adults without manifest anxiety. Degree of mental changes: We found a definite relationship between the severity of the mental changes and the frequency of errors in perception in the patients with an organic mental syndrome. The patients varied in their mental status from mild memory disturbances and alteration in intellectual ability, to severe psychomotor retardation, amnesia, aphasia and somnolence. The responses to the face-hand test varied from occasional extinction of percepts seen in the mild cases, to con— sistent, bilateral displacement of percepts to other parts of the body, the examiner’s body, or into space in the subjects more severely affected. In a number of patients with severe head trauma or following cerebral in mental functioning was acthe improvement progressive surgery, companied by a change in response to repeated trials of the face-hand test. The responses changed from bilateral displacement and allesthesia when damage was most severe, to extinction in decreasing frequency and finally consistently correct responses as the subject improved. Perceptual errors were greatest in subjects in whom nervous system dysfunction was acute in its course with rapid onset and short duration. Patients with severe head trauma, infections of the nervous system, vascular accidents and neoplasms were more likely to show extensive changes on double simultaneous stimulation than patients with chronic alcoholism or senility. It was in these last two groups that there were a number of subjects with organic mental changes who consistently per— ceived the two stimuli of the face—hand test correctly on the initial and on multiple trials. Type of mental defect: There was no obvious correlation of the freface—hand with of in of the the single test errors symptom any quency �NEUROLOGY 54 organic mental syndrome as in patterns of thinking, spatial or body orientation, memory or calculation. Errors in perception were most apparent when disturbances in function were most widespread. A good correlation existed, however, between the patient’s alertness and the responses on the face-hand test. In patients who were apathetic or lethargic, errors on double simultaneous stimulation were most promi— nent. This was apparent in many subjects who made errors occasionally during the initial trials of the face-hand test, but in Whom errors became more frequent and changed from extinction to displacement responses as the examination continued. Similarly, in testing patients with fluctuating states of consciousness, there was a good correlation between the degree of alertness and the responses on multiple trials of the face— hand test. Some of the patients were unable to carry out tasks which had two different aspects. But despite this inability to do two things at once they were able to perceive the two stimuli applied to the sides of the face. Therefore, it could not be said that the inability to correctly perceive one of the two stimuli applied to the face and hand was due to a defect in the ability to perform a task with two different components. The factor of aphasia: Aphasia is sometimes considered a defect in mentation. Such a defect, Where severe or associated with mental changes characteristic of the organic mental syndrome, yields a picture of the pa— tient as confused. For instance, a patient with aphasia may also have a loss of memory and an inability to recall or recognize situations even after they are described to him. In order to determine whether aphasia per se will produce errors in the, face-hand test, aphasic patients, with or without such mental changes, were studied. Patients with aphasia but without mental changes did not make errors on the face—hand test, while patients with aphasia and mental changes made repeated and consistent errors on multiple trials of the test (figure 1) . Organic mental syndrome with normal responses on the face-hand test: As already noted, not all patients with an organic mental syndrome make errors in tests by the method of double simultaneous stimulation. In a series of 271 patients in whom various combinations of these tests were applied, there were 228 patients who made errors and 43 patients who gave correct responses on initial trials. Of these latter, however, there were 22 who made errors after the initial trial. The remaining 21 were correct throughout multiple trials. Of the 228 patients who made errors on the initial trial there were 28 who were subsequently correct and yielded responses similar to the normal as carried out in one series of tests. In of found 49 it the 271 patients with mental changes that was summary, �55 ORGANIC MENTAL SYNDROME yielded normal reactions. All of these 49 patients had an organic mental syndrome but in general the mental changes were not severe. lVIemory loss was spotty and the degree of orientation varied, Apathy was seldom marked. There were fluctuations in performances. At times there were long intervals, minutes to hours, during which the patient showed no apparent mental changes. Examinations during those symptom—free intervals showed the face—hand test to be normal. In several instances it was learned that the defects in memory or indifference in answering questions pertaining to orientation were‘due to an emotional depression or to a phlegmatic premorbid personality. Their organic mental syndrome was only apparent and not real. There were, however, 11 patients with severe mental changes who reported correct responses on repeated face—hand tests. Eflect of drugs: From the foregoing studies it is clear that patients with organic mental syndrome make errors in perception in double simul— taneous stimulation tests. Consequently it was thought that the mental changes induced by drugs should yield similar errors. To test this theory, normal adults were subjected to intravenous injections of 7 to 10 ml. of a 5 per cent solution of sodium Amytal administered slowly. This drug produced the usual nystagmus, dysarthric speech and drowsiness. In addi— tion, normal adults, who made no errors on the face—hand test prior to the injection, now made consistent bilateral errors. Within 5 minutes after the injection errors were apparent on many repeated trials of the test and these persisted during the period the drug action was effective. The more drowsy or intoxicated the subject became the greater the tend— ency to make errors in perception. At the onset, displacements of hand percepts were frequent, but as the drug effect diminished, displacements diminished and extinction of hand percepts became prominent—only to disappear as the subject became more alert. Similar effects have been observed in the patients with a mild mental syndrome. Where only extinction of hand percepts was apparent prior to the Amytal injection, displacement of percepts became frequent and persisted for the duration of the examination. The effect of the drug persisted for longer periods in patients with organic mental changes than in normal adults, so that displacement of percepts was manifest hours after the injection in the patient group. Similar observations on the effect of anesthetics on central nervous system function have been made in a study of normal adults subjected to varying periods of anesthesia.5 These subjects with no demonstrable disease of the brain, who made no errors on double simultaneous stimulation tests prior to anesthesia, manifested extinction and displacement of �NEUROLOGY 56 percepts in either hand on multiple trials of the face-hand test during recovery from anesthesia. When these subjects regained consciousness from a general anesthetic, they were disoriented and confused. There was a manifest correlation between the duration of the perceptual errors and the period of confusion, lethargy and apathy that followed the anes— thetic administration. Efleet of convulsions: During post—convulsive states patients frequently show confusion and other symptoms of the organic mental syndrome. Since persistent errors on the face—hand test were found in patients with mental changes due to disease of the brain or due to drug intoxication, it was thought that any one who has an organic mental syndrome, of whatever cause, should show these errors. F or this reason, groups of patients were studied in whom convulsion were induced electrically for treatment of depressions. Patients who were given intravenous barbiturate prelimi— nary to electric stimulation were not included in this group. It was found that if the post-convulsive confusional state was severe, these patients showed a high incidence of errors on the face-hand test. As soon as the confusional state cleared, the incidence of errors in the facehand test decreased. Value of the face—hand test as a diagnostic sign: In order to determine the value of the face-hand test as a diagnostic sign of severe mental changes, a series of patients were examined in the admission ward of Bellevue Psychiatric Hospital. This examination was carried out by simultaneous stimulation of the face and hand. Each patient was given a series of 10 tests. N 0 history was taken nor were other clues used to make a diagnosis. Using this method it was found that in all cases in which the face—hand test showed errors on repeated trials, subsequent psychiatric examinations disclosed the presence of an organic mental syndrome. CONCLUSIONS From the foregoing observations it is apparent that subjects with the organic mental syndrome showed persistent errors on face—hand tests. It is significant, however, that the same confused and disoriented patients did not err in a haphazard fashion. An analysis of their responses based on numerous tests showed that the errors were made in a predictable pattern. There were consistent errors in the hand percepts, whereas there were very few errors in response to the simultaneous stimulations applied to the face. Another significant point is that this pattern was found not only in patients with cerebral dysfunction, whether it was due to structural or chemical changes in the brain, but also in normal children. This was found in children in whom the brain was not altered in any manner. The latter �57 , ORGANIC MENTAL SYNDROME observation indicates that this pattern is not the result of disease of the brain, and conversely, that it is inherently organized. Moreover, it indicates that this pattern is acquired early in life. N o explanation is offered as to why these patterns are so organized, namely, face dominance and hand “extinction.” The rostral dominance theory proposed by Cohn6 cannot be supported by these observations, inasmuch as it was found that the foot dominates over the hand. This fact automatically precludes the factor of rostral dominance. Moreover, the authors do not wish to agree or disagree with the well known theories proposed by Goldstein.7 Still another point is that reactions of the child are similar to those of the senile individual with mental changes. One might draw an analogy to the Babinski sign, which is considered normal in the developing infant and abnormal in the adult. From this analogy, it might be inferred that the presence of persistent errors on the face-hand test in the adult indicates a regression to the infantile level. However, we do not wish to convey the idea that we concur with such a theory. Finally, it might be concluded that what is seen in patients with dis— ease are normal patterns of function which appear to be grossly exag— gerated. As noted, repeated errors on face-hand tests may be found in the normal adult under certain conditions, particularly when there is altered brain function. Based on this hypothesis it is felt that a good deal of information about normal function can be obtained from patients with dysfunction as a result of altered structure. Aside from the theoretical considerations it must be concluded that the face—hand test has clinical value. It is a diagnostic sign of the organic mental syndrome. The persistence of errors on face-hand tests in an adult strongly suggest an organic mental syndrome. SUMMARY Patients with an organic mental syndrome make persistent errors in tests by double simultaneous stimulation of the face and hand. The errors are usually made in the hand. These errors are made on multiple trials of the face—hand test and on subsequent examinations on repeated days. The normal and the schizophrenic adults, however, do not make persistent errors. This difference in response between these groups is so striking as to have diagnostic value. Errors of extinction and / or displacement on multiple trials of the facehand test by touch stimulation are indicative of the organic mental syndrome. In a series of patients examined in the admitting room of the Bellevue Psychiatric Hospital, these tests were applied to patients as the �NEUROLOGY 58 first questions of the interview. The diagnosis of an organic mental syn— drome was confirmed by subsequent interview in every case. The significance of these findings is discussed. REFERENCES 1. (a) BENDER, M. B., and NATHANSON, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena, Arch. Neural. & Psychiat. 642501, 1950. (b) BENDE‘R, M. B., and WORTIS, S. B.; Patterns in perceptual, motor and intellectual functions in organic brain disease, Tr. Am. Neural. A. 72:31. 1947. (C) BENDER, M. B.; WORTIS, S. B., and CRAMER, J,: Organic mental syndrome with phenomena of extinction and allesthesia. Arch. Neural. & Psychiat. 59:273. 1948. (d) BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disorder of the body scheme, Tr. Am. Neural. A. 73:170, 1948. (e) SHAPIRO, M. F.; TEUBER, H. L., and BENDER. M. B.; Disturbance of body image and allesthesia. J. New. & illent. Dis. 108:253, 1948. (0 BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disturbance of the body scheme, Arch. Neural. 10 . . & Psychiat. 62:222. 1949. BENDER. M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Tr. Am. Neural. A. 75:250, 1950. (b) BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neural. &: Psychiat, 66:35.5, 1951. BENDER, M. B.; SHAPIRO. M. F., and SCHAPPELL, A. W.: Extinction phenomenon in hemiplegia, Arch. Neural. & Psychiat. 62:717. (a) 1949. The phenomenon of tactile inattention with special reference to parietal lesions, Brain 72:538. 1949. 5. JAFFE. J., and BENDER, M. B.; Perceptual patterns following general anesthesia. J. Neurol.. Neurosurg. & Psychiat.. in press. . COHN, K.: On certain aspects of the sensory organization of the human brain: 11. A study of rostral dominance in children, Neurology 1:119, 1951. GOLDSTEIN, K.: The Organism. New York, American Book Co., 1939. 4. CRITCHLEY, M.: In order to conceive a clear idea of the pathology, we have only to imagine the physiological phenomena, already noticed, assuming a pathological character. Now, the force of these phenomena may be augmented, diminished, or annihilated. In regard to the cerebral functions, we have, in the sentient nerves, pains or insensibility; in the cerebrum itself erroneous perceptions, judgments, and colitions, or delirium; or a total deficiency of these faculties, or come; in the motor nerves continual voluntary actions; or paralysis. Hall in Lectures on the Nervous System and Its Dis-eases, published in 1876. -——Marshall �The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome 31am Fink, M .D., 111a7'tin Green», M.D., and NI 0772's B. B ender, M.D. Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY �NEW YORK SOCIETY FOR CLINICAL PSYCHIATRY The 116th Regular Meeting oI the Society WILL BE HELD AT THE BELLEVUE PSYCHIATRIC HOSPITAL LEWIS I. SHARP. M.D.. Direcior 30”! STREET AND FIRST AVENUE THURSDAY, NOVEMBER 9th, 1950 AT 8:30 P.M. PROGRAMME I. TWELVE YEAR FOLLOW-UP STUDY ON METRAZOL TREATED CHILDREN AND ADOLESCENT SCHIZOPHRENICS . LAURETTA BENDER. MD. and S’raff 2. THE FACE-HAND TEST IN ORGANIC MENTAL DISEASE M. FINK, M.D.. MORRIS B. M. GREEN. MD. BENDER. and M.D. NOLAN D. C. LEWIS. M.D. MORRIS HERMAN. M.D. Prosideni Secrefary Staff invited — Dr. Herman �4/,q/, . 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Most often the mislocslisstion or displacement occurs to another part or the subject's body but occasionally there is displacement into extrspersonsl space or onto the examiner (exosomesthesis) (8). Displacement of stimuli �2. across the mldllno of the body (alleatheala) is another form of displaoomont Normal adults initial trials orrots that may show of the among occur (9). errors in perception teat. characteristically of face dominance). all subjects correctly - be those is perceivod correctly As correct (phen- additional tests are tho errors disappear so that by the.tenth to on the oonaiot of extinction of the stimulus on the hnhd wheroao the face stimulus - may done trial noarly porcolvo both stimuli and continue 0o subsoQuent trials. has been tarmod a ”negatlvo faoe~hand This type of response test." lt oocura not only with normal gdulto but also in patients wito nohlzophronla, depression, or oovoro anxiety{ In contrast to the preceding groups, patient tith' an organic mental tyhoromo show extinction‘and diaplaoef want not only during the initial trials or the ‘tost but ’ after 10 total: of testing or as long on testing is continued. Such a rooponse is termed a ”positive taco—hand �3f test.” -by A normal "positite fees-hand test“ is also manifested ohildren, normal aged persons. fectives asvwell as syndrmhe. by patients with and mental de- an organic mental ~ Because of the differentiel_response or these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it hes been noted thst patients with an organic mental syndrone vary ' greatly in the type and frequency of peroeptuel errors. Also, subjects without organic brain disease ‘ occasionally manifest a positive faoefhend test. The questions thieh arose from these observations are: 1) Is it . poeeiole to classify or standardize the different types of errons ooeuring in subjects with e positive race-hand test? 3 2) Gen these different types of response he corb related with the several groups or subjects previously mentioned?; 3) In there e type of response which can be �llld to ooour absolutely only in notiente with eeyere 4 dieeeee of the brain? 'The present study ie an attempt to enerer these questions.‘ ~ “ ‘ . lethod end Resultez. We test reviewed our previous records of the face-hand done in almost syndrome, normal 1000 adulte, patients with organic mental and schizophrenia adults, as well an in lesser numbere~of normal children, normal aged persons, and subjects with mental defioienoy, depression or severe anxiety. Additional groups or some of theee subjects were aleoteeted in different types of stimuli. e systematic manner with The criteria ueed‘to form- ulate a standardization of the race-hand test were: 1) ‘type of perceptual errorx'a) frequency or the variOue type: or error: with different types of stimuli (touch, rubbing, scratching, or pinprick); quency of errors when 3) effect on the fre~ the Subject ere-witnesses the applio' cation of the stimuli (factor of attention). Fifteen to thirty trials ' or the test were usually done for each eubjeet. �5. Based on theoe criteria, it was possible to divide oeticnte showing a poeitive race-hand test into four groups. The oheracterietio reeponeee for each group are V ' in Teble I. summarized Qheee reeponeee with examples are described more fully in the following peregraphe. mm I Features of the Different Type: of Positive Face-Hand Test \ One-glue Extinction only with , a touch stimuli, Two-Blue Three—glue Extinction Extinction ~pinprick placement with touch, rubbing with touch, rubbing, and and deep ~ stimuli die- and pinprick ’stimull Four-Rina Same as three-plus with at least one or the following feeturoe: e) exosomeetheeie b) alleetheeie c) frequent pereervetion d) occurrence of errors while subject eye— witnesses the areas stim- ulated. One~Plue Face-fiend show These Test: errors only of extinction The subjecte in this gnoup~ and not of displacement. errors occur only with touch stimuli. When pinprick �6. in need, both stimuli are perceived correctly, although errors will again uppeer when touch stimuli are reintro- duoed. A 6h year old because of a 1% men with mild diabetes was admitted year history or difficulty in walking. For at leeet the same period of time the patient had been depressed, The elept and ate poorly. and wee impotent. only neurological finding was a elow, heeitent, shuffling gait. There vascular dieeaee. payohomotor was The peripheral patient appeared depressed. showed retardation, and cried readily. Senecrium intact. Spinal fluid, eere normal. The was no evidence of The EEG, and X—reya of the spine diagnoeie wee involutional psychosis. gait difficultiea were thought to be secondary to the depression. this patient hand test. A shoeed a onesplue response on the raoe~ sample of his response: rollove: �7. ' com stinging touch: right chcokolort hand' right cheek touch loft chock—right hand touch right check—right hand '“touch loft chockwlcft hand touch right check-loft chock touch right hand-loft hand touch right chock—loft hand touch lelt chock-right hand touch loft check-right hand ' left cheek right cheek left cheek T222 of Error extinction extinction oxtinction extinction correct correct right chock‘ extinction correct correct touch right check-right hand 'right cheek touch left chock—loft hand left cheek extinction extinction pinprick right chock—left hand correct pinprick loft chock-right hand oorncct pinprick right chook-right_hand correct pinprick loft chock-left hand corrcct touch right cheek-loft hand correct touch loft check~right hand loft chock extinction ' adamant: Although this type patients with cerebral disease, it Or response occurs in is not alwaya charac{'5 w (M . [cal/ca toriatic for this group. It is also seen in caciiihf defrlswod’ a; MAJ (as: t/(O‘fili‘d 4"/ Mo, fitter (a! amt/11:5 Skits} .(achizophrcnia, and, occasionalgy, in normal adults. �8. Two-Plus Paoe~fiand Test: In this group extinction ' occurs with pinpriok and rubbing stimuli as well as with These errors.may be touch stimuli. just as frequent with both types of etimhli or may be more conspicuous with touch than sith pinpriok is not present, but or rubbing. may ooour on an A.72 year old man had a 5 weeks and Displacement occasional trial. history of mental. behavioral changes. This. consisted of disorientation, confused behavior, and internittent autism. thero was an examination organic mental syndrome characterized by partial disorientation, defects in recent and oiroumlooutions illnoss, On in answering questions, denial of and pain asymbolia. logical disabilities. l-raye were normal. memory, evasione The A There were no other neuro~ spinal fluid, and EEG, pneumoenoephalogram showed skull diffuse ,oerebral atrophy. This patient's responses on the face-hand characterise the two-plus type or response. A test sample �of these responses followc: Stimulfis touch touch touch touch touch touch lett cheek~right hand right cheek-left hand left chock-left hand right cheek—right hand right chookéleft cheek right hund~1ert hand touch right cheek~left hand I . Roseanne ngo of Error left extinction extinction extinction extinction cheek right cheek left cheek right cheek correct correct right cheek pinpriok left cheek-right hand left cheek pinpriok right cheek-left hand oorrect’ pinprick loft cheek~lort hand left.choek pinpriok right cheek-right hand right cheek pinprick left cheek-right hand left cheek Gonncnt: extinction. extinction extinction , extinction extinction This roaponco occurs most often in patientcv with cerebral disease although patients with anxiety state, I depression or schizophrenia may also exhibit it. It is not seen in normal adults. Three-Plus Paco—Hand Test: This group is characterised by the Occurrence of displacement as well as with both touch and pinprick stimuli. The extinction frequency of �10; extinction and displaoomont may be aqual or unequal and, likewise, the number of errors with touch and pinprick otimuli will be variable. A 57 year old chronic alcoholic was found in the in a stuporous condition. Hia Itroot. breath had an alcoholic odor and there oas a laceration over his right foroooad. There here no hospitol focal neurological signs. During the doy the patient graduolly Spooch woo rambling and was was and skull had savoro memory defects There were no X~ru§a were fialluoinationsti' nofonl. The diagnosis ocuto and chronic alcoholism with deterioration; A hand fluid And 35‘ expressed taranoid ideas aod was He hoatilo'hnd asafiultivo. ISpihal fully oooacioualgii. at timeo almost incoherent! oomplotoly‘diooriontod with confahulation. become first sample of this pationt'a toot, indicative of fallout: responooa on the race- a throe—plgo rooponao. in go ‘ �114‘ szg Rcaponso Stimulus of Error right chcck~left hand right chock-left hand displacement touch loft check~right hand right hand—left hand displacement touch right cheek-right hand right cheek extinction Touch touch touch loft loft cheokfiloft hand Correct cheekoright hand. left chock extinction touch right chock-loft hand right check—left check diaplacomont touch right hand-left hand .correct pinprick right chock~1c£t hand‘ right-choek-lcft chock displccomcnt pinprikk loft chock-right hand loft chock-right cheek displacement ‘ pinprick right chock—right hand right cheek left check pinprlck left chock-loft hand FourvPlus Facc~Hand Test: extinction cxtincticn This group shows the. sovercat porcoptual errors. In addition to frequent extinction and displaccment ac scan group. one or . all in the threc~pluc of the following phononcna may be sccn' with touch andfilr pinprick stimuli: 1) oxoaomcsthesia; 2) allcsthosic; 3) frequent pcrservation of responses; h) the occurrence of perceptual errors even while the subject keeps his apes open and eye witnesses tho arcas' stimulated. �12. A 60 year old man had a oriéntation, torgetfulness, examination he ShOfiBd a three year history of interest. and loan of On sovare organic mantal syndrome manifested by cemplete digorientation. marked -d6fect3, and inability to calculate. 'oodperativo. d18~ He was mamary alert There were no other neurological Spinal fluid and skull x-raya were normal. EEG and signs.' showed modernta, diffuse biaynohronoua slaving with slow alpha. A diffuse curcbral atrophy. pneumoogoephalograg disclosed A sample of the patient's roaponsee; 1ndlogt1ng a' fqur-plua face-hand tagt, is as fellows: Stimulus touch right cheek~ left hand touch left cheek» hand right aheek sonal spaco~ , v‘ right.oheok oxosomosthaaia extinction , _ oheek— lart left hand 10ft hand extinction , touch touch right hand- ‘ left-hhook-oxtrlporu , touch right cheekhand . , right right ‘, ‘ of Errér Tzfio Haazonse right cheek , oorrhot perseveration ' ' �13. touch right ohook- right chook~loft left hand touch left oheok¢ hand right pinpriok right hand loft ohook- loft right hand 'pinpriok right cheek- right right hand pinpriok loft ’lort hand loft chaok— pinpriok (eyes open) right cheek-left adamant: hand cheek—loft hand right ohook-lott left pinpriok loft chaak~ ohook ohook allosthosia displaoomont extinction _ cheek~oxtrnporaonnl apnoo displacement extinction cheek oxoaomeathosia right cheek—extrAporaonal oxosomosthoain space Throo~plua and four-plus responses invariably indicate disoaae of the brain. normal chock They are never found 1o adult: or in patients with psychiatric disorders. In oddition to tho difforont groups of subject: diaounsod above, the responses of normal children above fears 0! ago, normal hove ngod also been studiod. 3 persons, and montal defectives The distribution or the responses, or the children and aged poraooa are related moinly to age. The youngest children and the oldest adults show threo-plus and four—plus reopensoa. With changes in �age away from thine extremes, one-plus and two~plus re- spouses become more frequent. or the subjects with mentel deficiency, those with fiho lowest mental age have throe- plua and four—plus responses while one-plus and two-plus in subjects with higher mental 33035 'neoponses predominate Table II summarizes the distribution or the four different tfpes of responsesamong the various groups of subjects. ShOfl Only three-plus may be patients with and four-plus roséonses._ Such responses considered diagnostic of an organic mental syndrbme. TABLE ‘ an organic mental syndrome I; Frequency of One-Plus to Four~P1us Positive Pacerfiend Test in Different Groups of Subjects Negative Ono~ F5H.test Pius organio nental Syndrome 10% 7% 1% Normal Adults (below 60’ 99% year: or age) “yachixophrenio Adults nearly noooae- Two~ Plan Patients with anxiety nearly occae~ states all ionelly Petients with paycho~ neerly genie depression all‘ Four~ Plus Plue_ 25% 335- o o ' 25% o _ ' ' all ionally Three» rare neVer never more never never �15;- Discussion: In answer to the questions raised in the intreduetlon, our results indicate that four general types of positibe Itsce-hsnd test occur and that these different types can be correlated with different groups of subjests (Table Our attentien there was a was ii). focused mainly on the question of whether type sf response which occurred only in pamienss with severe disease of the brain. All cases with a threeplus or foursplus response have organic brain disease. Suoh'responses are never seen in nermel adults or patients- Iith psychoaenic disorders, even theugh these groups occasionally show one~plus may or two-plus responses. Patients with oerehral disease manifesting s four~ plus response invsrihbly show vsneed foam or mental changes. the severest or most adOtherwise there is no correlations between the type.n! positive faoeahand test and the severity of she senserisl defense. Same good istients with severe mental changes may have only a twenplus �» response; In addition, 10% of patieoie with an ofganio mental syndrome hove a negative face~hand ereelized that the use of ‘fov the groups 16. teet.’ It is to four ~plus nomenclature a one implies an increasing degree of cerebral ‘. -dyafunntion. This nomenclature ‘ was used because of con(1 lenience and much an implication is not intended; . We? This classification of a positiiefiface-haod should ‘ be useful clinically. In feeting neurological patients, the exect type of positive face-hand -corded, was will test should be re- rather than the deeignetion "the taceuhend test positive" as has been make it easier to of politifie faoe«hand done until now; Judge whether the Such a prooeedure particular type test manifested; indieatee definite cerebral disease or whethef‘it may not be a mnnifestatioh of anxiety or depression.‘ The use or such a classification will also make it easier to compare the response of patients at different times during their illnees. In addition. . , it should be valuable in clinical experimental work,'euoh an the reopen-e or patients to drugs. eleetroehock trentmont; ate. �17o Ema 1“,? : .A stanfiardization of the dittorgnt face-hand responses is prgsented. A fiypea of positive one-pins face—hand that consists of gxfiinotion only with'touoh stimuli. Itwo~plus reapgnsg 1a charactfigixéd by A extinction with pinprick and rubbing gtimfiix,‘gs.wéll as with touéh stim- uli? A three~plu3xfesponés consists cf extinction plus diapfiacafiont with touch, rubbing, #nd pinprick stimuli. A four—plus rggpénso has all tha charactériatics of a ‘ é three-plus rgaponsa and in addition at least one of tbs following features: a) exo§bmeathesia; b)_allesthesia;. c) pérseveration of respongea;'d) occurrenoa of evbn while the errors subject aypeyitneéaas tha Afifilication of fha stimuli. ‘Three—plfis éfidttour«plua responses invaritbly M-rindictte_¢1aeaaé of Fhé braig. One-plus and two~plua rdaponaea ocgur in patient; with brain disease but are alab maniteated by a hmélllfiumber of normal alulta and . patients with psychogenic disorders. Pationts with a; r �183 four-plus response the Invarest mental changes but show otherwise there is no correlation betwoon-tho aovopgyy' of the montql changes and the . 7- test manifested. - . face-handV.‘ typo-of'politivo (J ’ " . , 'w L �19. REFERENCES 1. BENDER, u.a., PINK; 3. and GREEN, n. - Puttarnn 1n paficegtiun on simultawawus fiesta a: face and hand. Arch.Neurol.&Pq1chiat., fig: 355—362, September, 1951. 2. M.B., and PINK, M. ~ Tactile perceptual tests in the differential diagnosis or psychiatric disorders. J.Hillaido 3032., A: 21-31, Jlnunry, 1952. 3. FINK, M., GREEN, M., and BENDER, M.B. BENDER, tastNo.an dia'noatlo 1, ‘g: h'ar8, - The raoa4hand Sign or disease or the Jan~Feb., 1952. brain. Nburolo . FINE, H. and BENDER, M.B. - Dovelopmunt of perception 9f simultaneous tnctile'stimull in normal children. 2 27-3L, January, Neurolo 1953. JAFFE, J. and BENDER, M.B. ~ Barceptual patterns fol— lowing general anesthesia. J.Nouro.Neurosurg.&Psychiat., gg: 316-321, Hovombor, 1951. and BENDER, M.B. ~ Cutaneous perception in the aged. Aroh.Neurol.&ngphint. fig: 577. 1953. g. BENDER, fl.B. - The phenomenon of sensory displacement. GREEN, M.A. ,Armh.Neurol.&Pq;oh1at., 95: 607-621 May. 1951. 8. SHAPIRO,.M.F., PINK, m. and BENDER, v.3. ~ Exosomesthesia or displacement of cutaneous sensation into extruporsonnl space. Aroh.Rouvol.8:Psgchi-.at., 9. gag: 1.81-1.93, Oct. 1952. Patterns in allasthosia body scheme 3:: other g4: 501~515, Arch.Neurol.&Pa;chiat., aensorysphohamena. Oct. 19 2. BENDER, and M.B. and NATHANSON, H. — their relaticu ta disorder or 3 �3?}!DAMIM’1'IM 63‘ m FAW $33!? a, mu: 1. Green, 3. 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I mI Immu- mu mm a: mmmd‘ «gammy. adult?!» ‘Ia-I um: roux-III �13* ”I’m: slaw in mt. ”van“ yum ohms” ‘bat a» mum um. man 1: ma autumn” Miami: m “writ: the m: to“ Wand» autumn“ of thin that and of mm mm uni t1» tarp". an» 1. Italy at isthmus clinically Match or with. rut-had unnatural“: in magma-u work ��I 3"? ’ flu-h'S-S.%F#M ___________Z;#__~__'——_ ��15 November 50 Dear Dr. Bender, of outline the studies in which Following is an I an participating under your supervision: a. Being prepared for presentation: i. Patterns in perception in simultaneous tests of the face and the hand 2. The Face-Hand test in the Organic Eental Syndrome 3. Patterns in perception in simultaneous tests of parts of the body other than the face and the hand 4. Caee report- Ethel Beckhorn Nos. 1-4 with‘Dr. Green. 5. Dyecheirie (with Dr. Shapiro) i" i‘b. Under study: 1. 08? changes following arteriography 2. Gomplicatione of arteriography; evaluation of the indications for the use of arteriogrefihy and the diagnostic value of the technic // Both of these studies with Dr. Stein. c. Proposed for study under grant by Rational Foundation > ~ for Infantile Paralysis: ',// n, , 1. Relation of sdaptation time, D. S. S. and threshold stimuli in hemiplegia 2. Patterns and factors in the responses of children to D.S.S.; comparison with patients with organic mental changes 5. Gen extinction and displacement be observed in normal subjects using threshold etimnli ? ��S.R. 5004-590M-701102(50) . Q.CITY OF 114 NEW YORK—DEPARTMENT OF HOSPITALS ....................................................................................HOSPITAL CaseNo..._....__.._____ PROGRESS RECORD Name...”...................................................................................... Admitted........................................................................ 19 .......... Ward ....................... Observations and Opinions of Visitings, Consultants and House Stafi. A Final Discharge Note Must Be Entered on This Sheet. Sign and Date Every Entry. .1 e . @an A ‘ I PM ‘ - "Wx. Ei‘f~ “. is _ \ [and V5“;- R‘- j "” r 4 iLIJJzJOU» SMCJE , A ' ""19“...“ '>. - Binding for Blank Leave _____________________———_———————-———————————— Continue Notes on Other Side �....................................... Division -_ ___.____________.____.______.~________. Name__________._____.____—____________ Admitted_____.______19___ Ward__.______ HISTORY Case No...........-.--..._.......... �Prev /‘ M. ‘ .‘2. fir M/- > mmf‘ég: WW “W $79“me w /W Cm _ " '2) 05/- m [4 W.“ 4.xMWafl- Y.‘ET>:0<I!WI.’:.6-m¢ 3. ‘ , m “V x-‘6 ' /MM 7 5% Wxép (a; £44, flZZp/raa ‘ ' 414w" ' *W V » dpg, fast/aw. . ." ~ , ‘ ‘ ” WW w 44}, W flm J‘ ' %¢ ./ Wugfiéfly‘é {It/*4: ‘7' ' £4cfl/r/ofl / ‘ (a) c“: M 447‘ 014M; .— . W M¢W7 (a) flfl ‘ lg‘ :11 I " 'I Cc) .A ”..th M 71 M 06‘,” f dams. M @5447 {a} )Lgpi ' ‘ CW “(:1 ‘ . 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V ' I ' - MMWQ M(M)/Zm i M NK‘Z me/W 5' Wbfi-gc % '4’ [find/ff IV ,7/C/Wfl7 MKLKKWWL) Wot/Logbook, ‘ ,t, 611%11f3/144». ”fa/two! 4/1“ 7- (WW) AL 14mg Ego; Kilo/offéfi: 354‘: J)»; 4995] 27134 2 WWW/4i lnfi w. M Karo-4L _ ‘4 ...mo �.i M’m a??? MM Mpg mdM gm» 9' %%-Q zf/Zex/L "0 §. ‘ 7. 'C'meioo 0 - ,'. :_ ‘ , V I‘ f 2 w"ww-wrr‘rvmrg'm'rfl’wm .‘ ‘ va ~— 4”“) A.“ I —W"%*“W, .M'MJ’ %{d’ #Cnfiwwfiu '> -- iT do n- u ,7 ��' a: @729; :x/Ma. 0W Aw, I M» WWW; cm, ”MM” zz Aggy”: —G/2/m a. V'aéém , �Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION SEVENTY-FOURTH ANNUAL MEETING, JUNE 13-15, 1949 OBSERVATIONS ON THE EXTINCTION PHENOMENON IN HEMIPLEGIA MORRIS B. BENDER MORTIMER F. SHAPIRO AND A. W. SCHAPPELL NEW YORK Routine sensory examinations are usually carried out with the method of single stimulation. This method appears to be adequate, but it does not always disclose existing defects in sensibility. For example, in a patient with a right cerebral lesion the left side of the body may be sentient to a single stimulus. However, the sensation evoked at this very point may no longer be apparent as soon as another stimulation is made elsewhere, such as on the opposite side of the body. The same change in sensation may be elicited with the method of double simultaneous stimulation. This disappearance or extinction of a sensation is not always complete. At times the patient reports a dulling or obscuration rather than extinction. Extinction and obscuration have been found in tests of all types of sensation. They may be observed in patients with lesions implicating the sensory pathways of the brain or spinal cord. The object of this study was to determine: (a) the method which is most successful in eliciting the phenomenon of extinction, (b) the pattern in which extinction manifests itself on the paretic side in cases of cerebral hemiplegia and (C) the frequency with which extinction of cutaneous pin prick sensation occurs in patients with hemiplegia. Fifty patients with hemiplegia were selected at random from the medical and psychiatric wards of Bellevue Hospital. Patients with aphasia or psychosis were included in the series only when their responses in sensory tests were consistent in one respect or another. In this study the cutaneous sensory status of patients with hemiplegia were first estimated by the customary method of single stimulation with the prick of a pin. The patient was asked to report whether he felt a sharp or dull sensation. Various regions of the body were thus tested and compared for degree of sensibility. The same patient was then examined with the method of double simultaneous stimulation. Three variations of the method were employed: (A) simultaneous stimulation of points in homologous regions on the two sides of the body, such as the right and left hand, the right and left side of face, etc.; (B) simultaneous stimulation of points in non-homologous regions on the two sides 160 �Bender, et al.—Extinction Phenomenon in Hennplegia 161 of the body, such as the right face and left hand, the right shoulder and left face, etc.; (C) simultaneous stimulation of points in two different regions on the ipsilateral side of the body, such as the right face and right hand, the right hand and right foot. On each test the patient was asked to report the location and quality of sensations. When the patient reported only one sensation, he was asked if he felt another in any other region .of the body. If he felt two sensations evoked by the simultaneous method, he was asked to compare them. RESULTS The most effective technique for eliciting the phenomenon of extinction was found to be Method B, or the simultaneous stimulation of non-homologous regions on the two sides of the body, such as the face on the healthy side and the hand on the hemiplegic side. The next most effective was Method C, or the simultaneous stimulation of two regions on the hemiplegic side, as for example, the face and hand on the affected side. Method A, or the simultaneous stimulation of homologous areas on the two sides of the body, did not reveal sensory defects as frequently as did Methods B or C. Although we have been stressing the phenomenon of extinction or the disappearance or decrease of a sensation, we have not overlooked the other aspect of the situation obtained on double simultaneous stimulation, namely, the retention of a sensation. We shall refer to the sensation which is retained as “dominant” and the one which disappears as “extinct”. Examina— tions with the various methods of double simultaneous stimulation showed existence of gradients of sensibility throughout the body. One sensory region was dominant to another. Further studies showed that these gradients were patterned. The pattern on the hemiplegic side revealed sensory dominance greatest in the face and less in descending order in the following regions— face, thigh, shoulder, foot and hand. In other words, when the face and any other part of the body on the hemiplegic side were simultaneously tested, as a rule the sensation in the face was perceived while sensation in any other one part was reported as diminished or absent (extinct). A phenomenon which appeared directly related to sensory dominance was that of “displacement”. In some instances when non—homologous regions on both sides of the body were tested simultaneously, the patient reported he felt two sensations of equal intensity, there being no extinction. The sensation was localized correctly on the normal side. However, the sensation evoked by the stimulus applied to the affected side was incorrectly localized. There was an ipsilateral displacement of the sensation toward a region homologous to the point of stimulation on the normal side. The displacement was usually toward dominant sensory regions. Thus when the patient was pricked simultaneously on the face on the normal side and the hand on the hemiplegic side, he reported that both sides of the face had �162 Bender, et (LL—Extinction Phenomenon in H emiplegia been stimulated; or if the hand on the normal side and the face on the paretic side were simultaneously tested, he claimed that both hands had been pricked. In some cases of disease of the brain the displacement phe— nomenon was the earliest indication of sensory impairment. As the disease progressed, displacement was replaced by obscuration and eventually by extinction. One of the significant findings of this study was the demonstration of sensory deficits in patients with a severe psychosis or aphasia. Usually such patients are considered incapable of giving coherent or consistent answers in routine sensory examinations. The psychotic or aphasic individual has trouble in expressing comparisons between two successively induced sensa— tions. He has less trouble when the stimuli are applied simultaneously. With this technique the psychotic or aphasic patient usually responds by pointing to the sentient or “dominant” region and he repeatedly ignores the region which is apparently “extinct”. In summary, it was found that a sensation in one region of the body is readily influenced by a sensation evoked in another area. This influence is most apparent with the methods of double simultaneous stimulation. Using these methods in patients with hemiplegia it was found that extinction occurred in 44 of the 50 patients, whereas routine single stimulus examination ’disclosed defective sensation in only 29 cases. Furthermore in 28 of the latter 29 cases the sensory defects became more conspicuous with these techniques. ����.flmwéfl nMMflL—{A‘ay /m4_g. fa/A/uc/WIZMM g/éé,‘M/£¢M �����, .p~.., ��' ‘D’Mwnrw hvflfl :- f/‘f/f’l a, am» , . MW Wm V“ ‘ “Mm ,¢__,-m..‘ w ngvm’regfiww .5 w (V) (:3) gfl/hflflflh " M 7% rfii. flé’i flmw ’2 mm //M I.“ _ ‘ ‘ ‘ . ; . \n ��wiffimfi’fi; ’ ����������51$“ “<4 3 “it wfiéu'wéi 3‘” van ���. hi illanh. ‘ , ‘ .A $1.1Hnawwlllflsfalz ”436,... 13.36 Tamrgwuau .-1...i1w.uiu.«ni.1> 53.53.», . �7,) 3“, Wu 3. ' * - “aim/ad. 4.54.wa 975‘; ‘au ) «,2; MMM) LC“ 962.7 ‘@ dflaficfi . *3 SI �����5.9.50 Sensory Studies In a discussion with Dr Bender today he made the following suggestions: 1. That studies of the face— hand, face - penis as carried out in the normal could be extended in the pattern of shoulder - foot, hand - thigh etc. This will give an outline of a homonculus of sensory dominance in the normal-2. The studies of the reaction in the normal on the abnormal in the penis and breast tests two directions: the influence of amytal might on the normal response and the responses to the test in severe the test and initial be extended in anxiety states (hysterias . . .). 3. It would be an error at the present time to describe the testing as a definite aid in the diagnosis of the organic mental syndrome. With such a figure, the physiological implications of the testing would be pushed to the background. But that if the studies can be verified as valid in OMS, then it might later be described in that condition as another test like orientation, patterns be 4. A memory, etc. special study in normal children of these undertaken. 5. The problem of Beckhorn be presented as an example of a hemisensory syndrome that appears to D83 and SS upon proper stimulation; and the effect of intersensory testing. 6. In the writing of the definitive paper on the face - hand test, the following subjects must be covered: a discussion of the various theories behind dominance as the rostral idea, medial over lateral structures (concentric), importance of sexual symbols, skin sensitivity, etc.; the possibility that the disturbance is related to the state of consciousness and not the state of the reverbalization processes (aphasia, apraxia, etc.); order of dominance; 7. fl“: 4 6) m—NMWYWKwh./Lu&m" “mu—~15 4/444./GLL; » (afldiiaruiuiii7é«vl» «Ajfaa ��w' -——-- -—-\P,K.. -7. ”w“ , -..~ » ‘ . w... «kw, - , 2"” “av 7“,:'71,~',Izfiivm"’">:_’r W."'etrwwgu—cvrw"'_nWWW'-W‘4~‘Xmu_t7$m,va'fi«mv-JzT’n-VH—W-jw ���:5,“ .p �n. amm.m,mumaamfummmmm WWIIWWthflph man. «mmmmmmmmmmw sun-1m. mmflumuhmmmamtmmmw} “mummummummmmum. 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A and «rind "am. mo na- tartan an intact. him). mad, thotvmmmlom ma xnms at that ‘91:» mm,~pm31. m umu- in imam-v uma panama... damned typo. in» we annulus... an “to tho «ya-alum 69 In this 9131.!“ that«I I out-91m mum» on the {WW Ian." A awn»a! nu 'WOPW“ Yemen: a: , W ‘Wt I ' “wt touch an ' touch tumult tench Chow-loft hm right than! loft ma~n§z was fight hm tough touch tough. ; . may“ Alma-10“. rum 13.31:! i maintain-fl cum: right hum-Mu an Mi: mam: ma «Musician ,. unnatfin utimtion mot it“ in.“ 00m." animation ' com“ dwt Bulk-tilt; land ”at; . chm-k - «tintim � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The face-hand test as a diagnostic sign of organic mental syndrome. Neurology. 1952 Jan-Feb; 2(1): 46-58. And, Observations on the Extinction Phenomenon in Hemiplegia Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-3-005 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin; Bender, Morris B.; Schappell, A. W. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 15 items, each with various amounts of pages. 1: Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 2: Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY. 3: New York Society for Clinical Psychiatry: The 116th Regular Meeting of the Society. 4: [Preprint]. 5: list of publications by Fink. 6 and 7: Drafts. 8: handwritten notes. 9: Letter to Dr. Bender from Fink. 10: handwritten note. 11: City of New York - Department of Hospitals/ Progress Record. 12: Handwritten notes. 13: Reprint from Transactions of the American Neurological Association 74th Annual Meeting, June 13-15, 1949; Observations on the Extinction Phenomenon in Hemiplegia (not written by Fink). 14: Handwritten notes. 15: typed pages. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published