http://exhibits.library.stonybrook.edu/mfp/files/original/159923c8867e9781f49e8300e7f3e2d3.pdf 560d0723c8cbc5298ad5e04e592ff291 PDF Text Text 0 Reprinted from the A. M. A. Archives of Neurology and Psychiatry October 1952, Vol. 68, pp. 481-490 Copyright, 1952, by American Medical Association EXOSOMESTHESIA OR DISPLACEMENT OF CUTANEOUS SENSATION INTO EXTRAPERSONAL SPACE MORTIMER F. SHAPIRO, M.D. MAX FINK, MD. AND MORRIS B. BENDER, M.D. NEW YORK MONG phenomena that may be apparent during examination of patients with disease of the sensory pathways is mislocalization of a sensory stimulus. It has long been known that a person with a sensory defect, as seen in the common varieties of cerebral hemiplegia, may inaccurately localize stimuli applied on the paretic side. Such point mislocalizations are apparent in examinations using a single stimulus and have been described in detail by Head} These mislocalizations can be accentu— ated by the use of double simultaneous stimulation techniques.2 In addition, when these techniques of examination are employed, other varieties of mislocalization, such as displacement,3 become apparent. Displacement is the patterned mislocali— zation of one of two stimuli simultaneously applied to different body areas. The direction of displacement is in a definite pattern, which is dependent upon the parts of the body stimulated. Characteristic of mislocalization so far reported has been the fact that their extent was within the limits of the patient’s body. In the course of studies of cutaneous perception, we observed a new form of displacement in which the patient consistently and in a predictable fashion mislocalized stimuli into extrapersonal space. This type of displacement we have termed “exosomesthesia.” 4 Exosomesthesia is not a commonly observed phenomenon. More than 400 patients with brain disease were examined at Psychiatric Pavilion of Bellevue Aided by a Fellowship from the National Foundation for Infantile Paralysis (Dr. Fink). This investigation was supported in part by research grant #MH-139 from the United States Public Health Service, National Institutes of Health. From the Department of Neurology and Psychiatry, New York University College of Medicine, and the Neurological Service of the Mount Sinai Hospital and Bellevue Hospital Center. 1. Head, H.: Studies in Neurology, London, Oxford University Press, 1920, Vol. 2. 2. Bender, M. B.; Shapiro, M. F., and Schappell, A. W.: Extinction Phenomenon in Hemiplegia, Arch. Neurol. & Psychiat. 62:717-724 (Dec) 1949. Bender, M. B.; The Advantages of the Method of Simultaneous Stimulation in the Neurological Examination, M. Clin. North America 32:755-758 (May) 1948. 3. Bender, M. B.; The Phenomenon of Sensory Displacement, A. M. A. Arch. Neurol. & Psychiat. 65:607-621 (May) 1951. 4. The term was derived by Dr. Judah A. Joffe (Hinsie, L. E., and Shatzky, J.: Psychiatric Dictionary, New York, Oxford University Press, 1940) from the Greek 55w, out of; will“, body, and 41709710”, perception by the senses. �2 7 Hospital Center by routine and specialized sensory tests. Exosomesthesia was observed in only 15 cases, an incidence of about 3%.5 The following case reports illustrate the phenomenon and demonstrate some of the conditions under which it was observed. CASE REPORTS CASE 1.—H. M., a man aged 64, was admitted to the Psychiatric Pavilion of Bellevue Hospital with a history of progressive mental changes of six years’ duration. The first four years of illness were marked by slowly progressive impairment of memory, concentration, and other intellectual functions and by increasing apathy to his' environment. In the last two years there was rapid exacerbation of this condition, resulting in the loss of his job as a store manager. During this period his speech became increasingly garbled and stammering. He vacillated between irritability and complete apathy. He was occasionally incontinent, ceased bathing, had difficulty in dressing, and was sometimes so forgetful and confused as to wander into the street without his trousers. Routine Neurologic Examination—In walking, the trunk was tilted to the right, and there was a tendency to drag the right lower extremity. However, there was no significant motor weakness, reflex change, or tonus abnormality. Coordination tests were well performed. The cranial nerve functions were intact. Vibration sense was correctly perceived only in the clavicles and the head, while position sense was lost in the fingers, wrists, toes, and ankles bilaterally. Temperature differences were poorly perceived except in the face area. His responses to touch and pinprick stimulation will be described later. A mild degree of “mixed aphasia” was present. This speech difficulty was evident only by special testing or when the patient was fatigued by prolonged examination. There was a fluctuating dyspraxia of moderate severity. Occasionally he had difficulty in dressing, being unable to handle buttons and sleeves. However, he could perform such functions as feeding himself, combing his hair, and other routine daily tasks. He was usually unable to mimic the more complicated patterns of the hand-praxis tests. An electroencephalogram showed bilateral diffuse abnormality, with decrease in amplitude and intermittent suppression of activity over the parietal regions. A pneumoencephalogram disclosed bilaterally dilated ventricles and moderate “cortical atrophy,” particularly in the left temporal lobe. Psychiatric Status—Although the patient was oriented for place and situation, he made errors as to date and time of day. There were defects in recent memory, concentration, calculation, and ability to assume the abstract attitude. He usually sat placidly staring into space or wandered aimlessly about the ward. He did not mix with other patients. When approached by members of the staff, he was friendly and passively cooperative. Testing procedures were approached with cheerful indifference. When, however, he was pushed into test situations greater than his capacity, he reacted with increasing irritability and tension, eventually culminating in a “catastrophic reaction.” At such times he would become red in the face, shout that he knew the answers but did not want to continue, and suddenly begin to weep. Body Schema—He was able to distinguish the right side of his body from the left, but was unable to make this distinction on the examiner’s body. He had no difficulty either in locating midline structures of his body, such as the nose, mouth, chin, umbilicus, and penis, or in pointing to his eyes. With eyes open he readily found both ears; but when his eyes were closed he groped about his face for several seconds before locating them. He could point to his thighs, knees, ankles, and toes but could not point to any specific toe other than the big toe. He frequently had difliculty in locating portions of his upper extremities. If asked to point to his shoulders, he correctly located one shoulder but then groped behind his neck looking for the other. This defect was even more noticeable in trying to find the “other” elbow and wrist, and greatest in trying to find the “other” hand. His search for the “other” hand or wrist was bizarre. He would look under the pillow or rummage under the mattress, becoming tense and Fink, M.; Green, M., and Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology 2:46-58 (Jan-Feb.) 1952. 5. �3 insisting it was lost. It should be emphasized that, despite the great difficulty in locating parts of his body, the patient was able to name the body parts, except the fingers and toes. This was true whether the part pointed to was on the patient’s or on the examiner’s body. Sensory Status—(w) Single Stimulation: He had difficulty in differentiating between the sharp and the dull end of a pin. This defect was present throughout the body, although he made significantly fewer errors in the face and hands. Touch stimulation was poorly perceived. Usually he could not state whether or not he had been t0uched. Again, there seemed to be relatively better preservation of this modality in the hands and face. Except under special conditions of examination of the hands, to be described later, the patient was able to locate the site of a pinprick by pointing. However, if the pin was repetitively and rapidly applied to one region, or if the prick was steadily maintained at that one place, he could not locate the point of stimulation. He would make frantic, random searching movements over his body, and not infrequently around the bedclothes, grimacing as though in pain and exclaiming that he was trying to remove the pin. If asked where he was being pricked, he dis— regarded the question and continued to try to remove the stimulus. This phenomenon occurred on stimulation of any portion of the body but was most apparent when the hand was tested. (b) Double Simultaneous Stimulation: The phenomena of extinction and displacement were frequently observed in tests of different body areas by simultaneous tactile stimulation. On stimulation of the face and hand, stimuli to the hand were not perceived or were mislocalized to the cheek. In tests of homologous body areas (as hand-hand) extinction of one percept was common. The side on which the stimulus was not perceived fluctuated, so that at one moment only a. right—sided stimulus was perceived and a few moments later only a left-sided stimulus was perceived. Exosomesthesia—Whenever his palm was in contact with a portion of his body or any other object, and the dorsum of that hand was pricked with a pin, the patient consistently mislocalized the stimulus. This mislocalization was to whatever object the palmar surface of the hand was touching. For example, if the patient’s hand was resting on his thigh and the dorsum of the hand was pricked, he insisted that the thigh had been touched, and not the hand. This mislocalization —exosomesthesia—occurred to the thigh, abdomen, leg, or face and was present with stimuli to either hand. It was observed even when the patient was urged to look at the hand during the application of the pin. Exosomesthesia could not be elicited, however, by stimulation of the palm or palmar surface of the fingers when the dorsum of the hand was resting on a portion of the body. Furthermore, localization of stimuli to the dorsum of the hand was correct if the hand was held in space. Mislocalization also occurred to objects external to his body. If his palm was resting on a table or on his bed, and the dorsum of the hand was pricked with a pin, he would point to these objects and state that the pin had been applied “there.” When questioned, he stated that the hand had been touched but continued to point to the bed or table. Frequently, however, he insisted that it was the bed or table that had been touched, and not his hand. If asked how he could feel the bed being pricked with a pin, he would become tense, avoid the question, and insist, “You touched the bed, not me.” Displacement into extrapersonal space was not eliminated by simultaneous stimulation, even when extinction of one of the percepts occurred. For example, if pins were simultaneously applied to the dorsa of the hands while the palms were resting on a table, he would report feeling only one pinprick, that on the left (or right, as dominance fluctuated) and point to the place where the left hand had been resting, saying. “You touched the bed there.” This phenomenon of displacement into extrapersonal space occurred daily during a period of more than two months. C 0mment.——~In this patient a requisite to displacement into space was that the palm of the hand be in contact with an external object. In other words, there were two cutaneous stimuli simultaneously in operation, namely, the pinprick on the dorsum of the hand and the pressure of the object in contact with the palm or fingers. A single stimulus, such as pricking the dorsum of a hand held in space, did not elicit the displacement. �4 Exosomesthesia was elicited only on stimulating the hands. This occurred even though single pinprick was perceived more sharply in the hands than in any other area except the face. Although this patient showed inability to locate correctly parts of his own and the examiner’s body, it does not necessarily mean that exosomesthesia is determined by this particular type of disorder in body scheme. The following case illustrates the phenomenon of exosomesthesia in the presence of the patient’s ability to locate body parts. 2.—E. K., a woman aged 52, was admitted to the neurologic service of the Mount Sinai Hospital in August, 1950, with a history of grand mal seizures. She had been in good health until 1947, when there appeared sporadic, momentary sensations of “blacking out.” About two years before admission she began to suffer monthly grand mal seizures. There was no aura. Routine examination on admission showed that her status was within normal limits except for anosmia in the right nostril. There was no organic mental syndrome. X-ray studies revealed evidence of a subfrontal neoplasm. On August 12 a craniotomy was done, and after amputation of a portion of the right frontal lobe, a large bilateral subfrontal meningioma was excised. Her postoperative course was stormy. For two weeks she was semistuporous. She responded only to massive, painful stimulation, and these responses were limited to vague, ineffective attempts to push away the stimulus. In this period she lapsed several times into coma and showed Cheyne-Stokes respiration. The Babinski response was obtained bilaterally. Her pupils did not react to light. From about Aug. 23, 1950, the patient improved slowly and steadily. She began to respond verbally, and contact could be maintained for short periods. Vision, which had apparently been absent, began to return, although right homonymous hemianopsia remained for some time. A marked organic mental syndrome characterized by confusion, disorientation, and anosognosia, was present. Routine Neurologic Examination.——Neurologic examination in September, 1950, disclosed right homonymous hemianopsia, severe impairment of visual acuity with bilateral secondary optic nerve atrophy, nystagmus in all directions of gaze, a bilateral Babinski sign, and a mild degree of aphasia. Position sense, vibration sense, and temperature perception were unimpaired. There were difficulties in perception of touch and pinprick stimuli, as described below. Psychiatric S'tattusr—The patient was usually friendly and cooperative. However, she was frequently irritable and would not permit examination. She was disoriented as to time and occasionally to situation, but not to place. There were defects in retention and recall, covered by confabulation. She was euphoric and displayed little self-restraint or concern in social situations. Usually she would lie with her body fully exposed. Not infrequently she soiled herself or wet the bed. Anosovgnosia was prominent. Body Schema—On command, the patient was able to identify and locate correctly parts of her own and the examiner’s body, such as the ears, eyes, feet, and parts of the upper extremities. She exhibited some confusion about the right and the left side of the body. Sensory Status.—(a) Single Stimulation: The patient perceived single pinprick stimuli well, although she made occasional nonpatterned errors in localization. These errors were more frequent on the left side. (b) Double Simultaneous Stimulation: On simultaneous application of pinprick to the two sides of the body, except the hands, extinction on the left or displacement on the left toward the level of the right—sided stimulus was the usual response. Homolateral simultaneous stimulation on the right side of the body showed no extinction, but stimulation on the left side elicited frequent extinction and displacement. CASE Exosomesthesia.—Displacement into extrapersonal space occurred when the left hand was pricked at the same time that either the right hand or the right cheek was stimulated. The phenomenon could also be elicited when the left hand and any other area of the left side of the body were simultaneously stimulated. Under these conditions the patient mislocalized the stimulus to the left hand into space near that hand, or to the object on which the hand was lying. For example, if pinpricks were �5 . simultaneously applied to the right cheek and the left hand, the patient indicated she had been pricked on the right cheek and the arm of the chair on which her left hand had been resting. As a rule she answered by pointing. If asked to verbalize, she would say, “The right cheek and about here,” (pointing to the chair arm or into space near her left hand). If asked directly. “Was your hand touched?” she would avoid the question, responding only, “Here,” pointing at the same time to the left chair arm or into space. It is to be noted that, except under the special condition of simultaneous stimulation, the patient was always able to point to or to name her left hand on demand. If pricked simultaneously on the dorsa of the left and right hands, she correctly localized only the stimulus on the right, both by pointing and by stating, “My right hand.” The stimulus on the left, however, was localized only by pointing to the chair arm and saying, “Here.” If asked whether the chair arm and not her left hand, had been touched, she answered, “No, here,” pointing to the chair arm. When pinpricks were applied to the left hand and, at the same time, to another area on the left side of the body, a similar displacement into space was evident. Usually the stimulus to the left hand was mislocalized onto whatever structure the hand was resting or else 'into contiguous space. The other stimulus on the left side was usually correctly localized, though this stimulus, too, was occasionally displaced into space. When this double displacement occurred, the patient would state that she felt two stimuli and would point into space to the left of the arm, stating, “Here and here.” These mislocalizations were repeatedly observed during a period of a month and were not always limited to the left side. They were occasionally observed to occur on the right side. At these times localization on the left was always correct, as indicated by pointing and by verbalization. C omment.—Exosomesthesia was elicited in this patient only under the condition of multiple simultaneous stimulation. It could not be elicited by single—stimulation methods. Also significant is the fact that exosomesthesia was apparent even though there was no gross disorder in body scheme on routine testing. Furthermore, it is evident that her errors in localization were not simply inability to point to or identify parts of her body by name, as ordinarily she experienced no difficulty in doing this. on command. Both patients mislocalized percepts to parts of the body, to objects, or into space contiguous with the area stimulated. Occasionally, we have also observed displacement of a stimulus to the person of the examiner. Usually such percepts are mislocalized to a homologous portion of the examiner’s body; e. g., a stimulus applied to the patient’s hand is reported by him as though it had been applied to the examiner’s hand. Rarely, the mislocalization is to any part of the examiner’s body. This type of displacement is illustrated in the following case. man aged 52, was admitted to the Psychiatric Pavilion of Bellevue Hospital with the complaint that he had become confused and depressed. For about a year he had been disoriented and confused as to date and his relationship to people and had wandered about the city aimlessly. He had been admitted to the Farm Colony about a half-year before and had worked as a barber until the week before his admission to the hospital. Routine N emologic Examimtion.—Neurologic examination showed normal gait and station. Coordination tests were well performed. The reflexes were active bilaterally, with normal plantar and abdominal responses. Cranial nerve functions were normal. The sensory status showed changes, but only with special methods of testing. A pneumoencephalogram demonstrated moderately dilated ventricles, without shift or deformity, and some dilated cerebral sulci. Psychiatric Status—A severe organic mental syndrome was evident. In the ward he sat quietly for hours by his bedside, taking little interest in his surroundings. When approached by members of the staff, he appeared perplexed but was affable. During the testing procedures he was cooperative unless confronted by a test situation in which the examiner demanded tasks CASE 3.—-R. M., a ‘ �6 ‘ beyond his ability. At such times he showed a “catastrophic” reaction, became excited, and discontinued his efforts in the examination. He was disoriented for time, place, and situation. However, he was able to find his way about the ward, locating his bed, the nurses’ desk, the doctor’s office, and the lavatory. Severe difliculties in intellectual function were observed. He was unable to give an adequate history. He could not recall the examiner’s name or the events of several hours before but did not confabulate. Calculation and symbol—identification tests were poorly performed. Severe aphasic difficulties Were evident. He was unable to name common objects, clothing, or most parts of the body. He could not comprehend written commands, nor could he write, but he was able to follow simple verbal commands. Mild dyspraxia was demonstrated in his attempts to imitate finger and mouth movements. However, he was able to dress, feed, and otherwise care for himself. Body Image.—He had difficulty both in naming body parts and in locating them by pointing. The defects were severest in the fingers, wrists, and elbows, and occasionally the feet. There was difficulty in right-left orientation. Sensory Status—(a) Single Stimulation: Routine sensory studies of touch, pinprick, and vibration stimuli showed no consistent impairment. These stimuli were usually correctly localized and described. Occasionally a single stimulus to the hand or forearm was displaced to a contiguous object or to space about the upper extremity. (b) Double Simultaneous Stimulation: On double simultaneous [touch] stimulation the patient displayed extinction and displacement of tactile stimuli. This was most evident in trials of the face—hand test 6 but was seen in tests of other body parts as well. For example, on simultaneous stimulation of the cheek and the opposite hand, he would either report only the stimulus to the cheek (extinction of the hand stimulus) or report a stimulus to each cheek (displacement of the hand stimulus). The pattern of sensory dominance was that usually seen in diffuse cerebral disease, the face being most dominant, the hand least.5 There was no lateral dominance. Exosolm-esthesriav.—Displacement into extrapersonal space was occasionally observed on single stimulation. This displacement was from the hand, forearm, or elbow to space contiguous to the part touched. Exosomesthesia was, however, markedly exaggerated when double simul— taneous stimulation was employed. Again, the areas from which the phenomenon was most frequently observed were the hands, forearms, and elbows. For example, when stimuli were applied to the dorsa of the hands as they were lying on the patient’s lap, he pointed to space in front of his knees. If asked to state where he had been touched, he would say, “The hands,” but would continue to point to the space in front of his knees. Exosomesthesia was rarely noted when other body parts, such as the cheeks or shoulders, were simultaneously stimulated. Occasionally it was found that on tests with double simultaneous stimulation the patient mislocalized a stimulus from his body to the homologous region of the examiner’s body. For instance, when the hands were simultaneously touched, he would grasp the examiner’s hands and affirm he had been touched “there.” Despite the examiner’s insistence that the stimulus had been to the patient’s hands, the patient would persist in pointing to the examiner’s hands. When asked to name the parts touched, he would say “There, there.” The same phenomenon was occasionally observed on simultaneous stimulation of the two elbOWS or cheeks. It was significant that this mislocalization to the examiner’s body occurred even when the patient was urged to look at the stimulations. It was observed that emotional tension, increase in the rate of testing or undue prolongation of the examination increased the incidence of exosomesthesia. For example, to initial application of pinprick to the right hand and the left cheek, the patient reported only the face percept, omitting the hand stimulus. Later, he localized the two stimuli to the cheeks. As the examination progressed and the physician speeded up the testing, the patient became tenser. He then localized the face percept correctly but insisted that the hand stimulation was into space in front of the hand. Finally, both stimuli were displaced into space or to the examiner’s body. These phenomena were observed daily over a period of 2% months. . Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of Face and Hand, Tr. Am. Neurol. A. 75:250-252 (June) 1950; Patterns in Perception on Simultaneous Tests of Face and Hand, A. M. A. Arch. Neurol. & Psychiat. 66:35‘5-262 6. (Sept) 1951. �7 Comment—While single stimulation occasionally produced exosomesthesia in this patient, the phenomenon was more pronounced under conditions of double simultaneous stimulation. This patient also mislocalized stimuli to the examiner’s body. Emotional tension, prolonged examination, or increase in the rate of testing exaggerated the phenomenon of exosomesthesia. GENERAL COMMENT On consideration of these cases, it is immediately apparent that exosomesthesia is associated with a severe organic mental syndrome. Therefore, it might be argued that exosomesthesia is merely a manifestation of the patient’s mental confusion; that the patient simply points into space because he is confused. However, we have examined many severely confused patients and found exosomesthesia only rarely. Moreover, exosomesthesia is a patterned phenomenon, demonstrable in each patient under defined conditions, predictable as to the area from which it will occur and the extrapersonal spatial region to which the sensation will be projected. For example, in Case 1 exosomesthesia could be elicited only from the hand, and only when the dorsum was stimulated at the same time that the palm or fingers were in contact with another object. Displacement under these circumstances was usually not haphazard. As a rule it occurred to the object touching the palm or fingers. In Case 2 exosomesthesia could be elicited only by double simultaneous stimulation. It was seen most clearly in the hand and could be elicited only unilaterally at any one examination. Again, the displacement was not haphazard; the stimulus as a rule was localized to extrapersonal space contiguous to the area actually stimulated. In Case 3 the phenomenon was observed again under conditions of double simultaneous stimulation, and the displacements were either to space contiguous to the stimulated area or to homologous areas of the examiner’s body. It is significant that these displacements could be elicited even when the patient was urged to look at the application of the stimuli. Moreover, even when the examiner pointed out the error in localization and emphasized the implausibility of the response, the patient characteristically insisted on the correctness of the mislocalization. Factors Inflnencing Exosoimesthesiax—Many factors influence the appearance of exosomesthesia. Except in children under special conditions, it has been observed exclusively in patients with severe mental changes resulting from disease of the brain. It is influenced by the type of stimulus used and the rate of stimulation, as well as by the element of simultaneity of stimuli. Moreover, the emotional state of the patient has a significant effect on the phenomenon, as does the part of the body stimulated. In some cases exosomesthesia has been made apparent by administration of small doses of amobarbital sodium. These factors will be discussed. (a) Bilateral Cerebral Disease: The symptom background in every case of exosomesthesia is an organic mental syndrome secondary to bilateral cerebral disease. We have not been able to demonstrate exosomesthesia in an adult unless there were severe mental changes. But, as previously noted, it is a rare phenomenon, and only a few patients with severe organic mental syndrome show it. In 400 patients with organic cerebral disease, of varying severity, exosomesthesia was observed in approximately 3%.5 Even in these patients it was not manifest in every examination, and its frequency was readily altered by changes in the conditions of testing. It is therefore evident that severe bilateral cerebral disease in itself is not sufficient to produce exosomesthesia. �8 That simultaneous stimulation may elicit sensory phenomena not apparent on single stimulation has previously been demonstrated.2 For example, a hemisensory syndrome in a hemiplegic patient may not be discernible except under conditions of double simultaneous stimulation. Thus, single stimulation may be well perceived and localized by the patient, but the addition of a second stimulus simultaneously applied may so affect integration that the phenomena of extinction, obscuration, and displacement become apparent. Similarly, simultaneous stimulation elicited exosomesthesia when it was absent on single-stimulus examination, or exaggerated it when it was occasionally manifest on routine stimulation. In Cases 1 and 2 simultaneous stimulation was a necessary condition for eliciting the phenomenon. It could not be demonstrated by single stimulation. In Case 3 exosomesthesia could occasionally be elicited on single stimulation, but with simultaneous stimulation the phenomenon was demonstrated with much greater frequency. (c) Type of Stimulus Most Effective: Of the various stimuli used in these examinations, such as single touch, single pinprick, repetitive touch, and repetitive pinprick, it was noted that repetitive touch stimuli were most effective in eliciting exosomesthesia. This was especially true on double simultaneous stimulation. (d) Effect of the Patient’s Emotional State: Exosomesthesia was exaggerated by alterations in the test situation which made performances more difficult. Increasing the rate of stimulation or unduly prolonging the examination increased the displacements to extrapersonal space. If the examiner was deliberately critical of the patient’s errors, the phenomenon also appeared with greater frequency. These factors increased the emotional tension of the patient and if carried further produced a “catastrophic” reaction. (e) Effect of Drugs: It has previously been demonstrated that difficulties in perception may be exaggerated by barbiturate intoxicants.5 Amobarbital sodium was administered intravenously in doses of 3 to 7 grains (0.2 to 0.45 gm.) to patients with diffuse cerebral disease. Prior to administration of the drug, these patients manifested the phenomena of extinction and displacement of percepts on simultaneous tests, but not exosomesthesia. While under the influence of the barbiturate, three patients showed exosomesthesia, in addition to extinction and displacement. In two other patients, in whom exosomesthesia had been elicited only after a protracted testing period, the administration of amobarbital sodium elicited exosomesthesia at the onset of testing and exaggerated the phenomena of extinction (2)) Effect of Simultaneous Stimuli: and displacement. Relation of Exo'somest‘hesia to: Extinction, Obscumtioln, and Displacement—In our experience, whenever exosomesthesia has been observed, the phenomena of extinction, obscuration, and displacement are also present. Exosomesthesia, how— ever, is a rare phenomenon, whereas extinction, obscuration, and displacement are commonly observed. Moreover, whereas extinction, obscuration, and displacement are frequently seen in adult patients with mild cerebral dysfunction,5 displacement into extrapersonal space is present only in cases of severe mental changes due to disease of the brain. It may therefore be concluded that exosomesthesia in adults represents a severer type of cerebral dysfunction than other simultaneous stimulation phenomena. �9 Relation of Exosomes'th‘esia; to Body I mage.——It might be said that exosomesthesia is a pathologic extension of the body image. The normal person is continually extending the boundaries of this image. For example, Head cites the examples of the woman with a feather in her hat who “feels” when the feather is touched, and the surgeon who handles his probe as though it were an extension. of his fingers.1 In the normal person, however, these extensions of the body image are fluid, immediately reversible, and clearly recognized by the subject as artificial. The surgeon, for example, is able at any moment to redefine correctly his body image. He “knows” that the probe is not his finger. In the group of patients described above, however, the extension of the body image seems to operate in a pathologic, rigid form. Under certain conditions these patients lose the ability to maintain a realistic definition of the limits of their body. They behave as though portions of the contiguous external world are concretely incorporated into the inner image of their body’s extent. Although we may consider exosomestheisa as a specialized body-image disturbance, it should be noted that patients who do not show difficulties in identification and location of body parts still may show mislocalization into extrapersonal space. On the other hand, patients with an inability to identify or locate their body parts on command do not necessarily manifest exosomesthesia. In similar fashion, there is no necessary relationship between exosomesthesia and position-sense difficulties. A patient (Case 3) who manifested displacement of sensation into extrapersonal space did not make errors in routine tests of position sense in the extremities. This is consistent with observations previously made by Head1 that localization of single stimuli is not functionally related to sense of position of the extremities. Role of the Hand—Although displacement into extrapersonal space has been elicited from various areas of the body, it has been observed to occur most frequently from the hand. Moreover, in no case has it been elicited from another area and been absent from the hand. This predilection for the hand is consistent with the manner in which other dysfunctions of the nervous system are reflected. As a rule, when the functioning of one side of the body is impaired through cerebral disease, the disorder is most manifest in the hand. Thus, in the usual hemiplegia resulting from a capsular lesion the paresis, body-image disturbance, and sensory loss are most prominent in the hand and fingers. In these patients, and in others with diffuse cerebral disease, the phenomena of extinction, obscuration, and displacement are also best elicited when the hand is tested. Furthermore, studies of the order of sensory dominance of various areas of the body demonstrate that the hand is in the lowest rank. This is true of the dominance order of patients with cerebral disease,5 and also of normal subjects, both adults and children.6 Similarly, when allesthesia is observed, it is seen most clearly in the hand. Bender and Nathanson 7 described a case in which the clinical course was reflected in a Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, Arch. Neurol. & Psychiat. 64:501-515 7. (Oct) 1950. ‘ �10 waxing and waning allesthesia. As this patient improved, the areas from which the phenomenon could be elicited diminished, until finally allesthesia was demonstrable only in the hand. In autotopagnosia the hands are more profoundly affected than other regions. Finger agnosia, possibly the earliest sign of body-image disturbance, is frequently seen in the absence of other gross disturbances of the body schema. Furthermore, phantom limb, anosognosia, causalgia, and synesthesia are phenomena in which the role of the hand is especially prominent. Just as these pathologic phenomena are manifest in tests of other body parts, but are most clearly demonstrable in the hand, so, too, exosomesthesia, though occasionally demonstrable elsewhere, is most apparent in examination of the functions of the hand. Exosomesthesia in the N ormal C hild.—It has been observed that sensory phenomena which occur in patients with cerebral dysfunction may be found in the nor— mal young child.6 Similarly, exosomesthesia, which we have never found in adults except when there is severe cerebral disease, can be readily observed in children up to the age of 4 years. In examination of a large series of normal children it was noted that the initial responses of children to double simultaneous stimulation fre— quently included exosomesthesia, although the commoner responses were extinction and displacement. Exosomesthesia was rare, however, after the initial few trials. The frequency with which exosomesthesia may be seen in children up to the age of 4 years suggests that it may represent, in the child, a “normal” developmental stage in the organization of perception. Its appearance in adults with severe brain disease may possibly be, as with other pathologic phenomena, a regression in function to a previous level of sensory integration. SUMMARY , The patterned mislocalization of tactile stimuli into extrapersonal space is described and termed exosomesthesia. Exosomesthesia is observed in patients with severe organic mental syndromes. It is apparent only rarely on single tactile stimulation and is more readily elicited by the technique of double simultaneous stimulation. It is exaggerated by fatigue, rapid testing, and increased emotional tension. Barbiturate intoxication also may elicit or exaggerate the phenomenon. Exosomesthesia is most apparent in stimulation of the hand but has been observed in tests of other body parts. While it may be considered a pathologic extension of the body image, it is not dependent upon concomitant body-image disturbances. Although exosomesthesia has been observed chiefly in patients with severe mental changes, it is not a manifestation of confusion, but is a patterned, predictable phenomenon. It may be a regression, in patients with cerebral dysfunction, to a previously “normal” stage in sensory development, as suggested by the fact that it is readily observed in simultaneous tactile tests of young children. Printed and Published in the United States of America �EXOBOMIBTHIBIA OR DIEPLkGIIIIT 0P OBTlfllflfls 83N3£TIOIIINQO EantuflRSOIAL BPACE‘ EV Martino:- F. Shapiro. am. an: Fink, K.D.'* and Kerri: B. Bender, H.D. ., " "i 3”“ a"? ,y. Univcruity College or’ncdieiuc and tn. 3 enrol 651331 Service of thc Haunt flinfii ficlpital Ind lollcvuo fibflpitfll, I0! Yer! 0131. 'Dntdod by a flullaulhip tram thy lationnl roundntion for Infantile QJ‘ V‘W‘ , g j , ‘9ar111510. ibis investigltion in. lupportod, in partin:by a rouonroh grant stutt- Public not ammo. mum or fianlth. aun-139 tram tho unit.d Inltitutel fl �Among phenomena bbeb new be epperenb during exe-inebion or petienbe eith dieeeee or the eeneory pebbueye is nielooelisebion It individual with e eeneory defeat, on eeen in the cannon vuriebiee or cerebrel beniplegie, any looeiioe ineoonrebely ebiuuli applied on the of e eeneory etienioo. bee long been known that on ‘ perebio bide. point nielooelieebiono ere epperenb in exelinetionl ueing e eingie ebiunlue, end have been deeoribedbin detail by Hood (1). These nationalisation: can be eooentuobed/b‘e uee or double Snob einnlbeneoue obi-ulebion techniques (2).- In eddidon, when theee technique. of exeninetion Ire enployed, other veriebiee or nielooeiieetion,-euob ee diepieoenent (3). become apparent. niepleoe-nnb ie the petberned nielooelieebion or one or two ebinnli eiunlbeneouely applied to different body areas. The direction or diepleoeuent ie in e definite pattern, which is dependent upon the parts or the body Ibilnleted. choreoterietio of nieiooelieetion on for reported bee been ‘ tho fact bhet their lxtent VII uibbin the lilibl of the patient’l body. In the oouree or obodiee or outeneoue peroeption we obeerved I new torn or diepleoenent in which the patient oonoietenbiy end in e prediobeble reebion nielooelieel obi-n11 into extra-pereonei epeoe. Thin type of diepieoenont on have teamed “exoeo-oebheeie'.¢ of the derived by Dr. Judeh A. Jotte, Editor 19%0, the tron Press. Oxford Boivereity reyobietrio biotic: none", , by ”eiotheeie”, perception body; the Greek "one", out or; 139 FI?’!53'€5§E eeneee. wee ll; Exoeoleebbeeie ie not e commonly oboerved phenomenon. more than #00 patient: with brain dieeeee were examined at Bellevue Peyobietrio Hoopibel by routine end epeoielieed eeneory beete. �2. Shoeoneetheeie wee obeerved in only 15 oeeee ~ en incidence of ebout 3! (5). who following oeee reporte illustrete the phehoaenon end deoonetrete eoee o: the oonditione finder which it wee obeerved. Case 15 H.I., e 6% year old male, wee admitted to Bellevoe Peyohietrio noepitel with e hietory or progreeeive sentel cheeses or eix years doretion. The firet tour yeere or illneee were lurked by eloely progreeeive ilpeirnent of memory, oonoentretion end other intellectual funotione. end inoreeeing epeth: to hie environnent la the leet teo ii yeere thie oondition exacerbated rapidly, reeulting the lone of hie Job ee e etore neneser. During thie period hie epeeoh bean-e inoreeeingly serbled end Ito-nerihg, Be veeoilleted oolplete epethy.i. 1*: f”;irTWT€nL. he wee oooeeionelly incontinent. mm bathing; nee dittioulty in dreeeing, end wee eoneti-ee eo forgetful end oonrueed ee to wander into the etteet eithout hie troueere. Routine georologio Ian-ioetion; In welkins the trunk wee tilted to the right end there wee e tendency to drag the right, lower extreaity. However, there wee no eignitioent motor weekneee. reflex change or tonne ebnor-elity. Coordination teete were well perromned. The oreniel nerve function: were intact. Vibretion eenee wee correctly perceived only in the oleviolee end the heed, while poeition eenee wee lost in the tinsere, eriete, toee end enklee bilaterally. Temperature difference: were poorly peroeived exoept in the teoe.eree. hie reeponeee to touch end pin prick between irritebility end nild degree or “mixed epheeie" was present. This epeeoh difficulty we: evident only epeoiel testing or then the petient wee retigued by prolonged eti-uletion will exeeinetion. be deeoribed leter. A by there one e fluctuating dyeprexie of noderete eeverity. �3. Occuionally n. ma difficulty in drawing, being unable to handle button: and alaavca. however, he could partonn Inch tunaticna aa reading hinaalr, ccwbing hia hair and cthar routine daily taaka. Ha waa naually unabla to wiwic tha aura ccwplicatad pattarna of the hand~praxia tanta. licetrcancaphalcgrwa ahcwad_bilatcral dittuao abncmnality. with dacraaaa in awplituda and interwittant auppraaaion or activity ova: tha pariatal regiona. Pnauacancaphalcgranldiaclcaod bilaterally dilated vanericlna and wodarato “cortical atrophy". particularly in an ion moral lobe. szphiatric Statua; Although tha patiant waa ariantcd for place and situation, he wada crrora an to data and than or day. Thar. war. datacta in vacant unwary, concentration, calculation and ability to aaauln the abatract attituda. no uwually aat placidly ataring intc apaca or wandered aialaaaly about tha ward. Ia did hat win with cthar pationta. whcn approachad by tag atarf he waa friendly and paaaivoly cccparativa.' Tasting proceduraa ware approachad with a chaarful indittcranca. Hhan, hcwavcr, ha was panhad into Boat aituaticna :raatar than hia capacity, ha reactad with incrwaainx itvitability and tanaicn, avantually calainating in a “cataatrcphic reaction.” it such tiwna ha would baccwa rod in tho taco, about that ha know tha ahawara but didn't want to continua and mcccniy basin to map. a. waa can. to distinguish tho right aid. or his: body tro- the 1321:; but waa unable to wake can distinction on tha miner's body. 11. had no difficulty either in locating nidlinc atruccuraa or hia body, auch aa tha uoaa, heath, chin. nabilicua and pania, or in pointing to hia cyan. With oyoa cpan ha readily fauna W ' �e. hath eere, but when hie eyee were cloned he seeped ebeut hie teee for eeverel eeeende betere leeetlns then. he eeuld'belne to hie thighs, kneee, ankles end tees but could not point to any epeclrlo toe ether thin the his teen. frequently had Alrtlculty 1n locetlns port1ene or hie upper extrenltlee. It eeked to point to hle ehouldere. be correctly located one ehoulder, but then grayed behind his neck locking for the other. This defect was even more noticeable in trying tn find the ”other" elbow and wriet, and creeteet in trying to find the "other" hind. file eeereh for the ”other" hand or wrist Be bizarre. He would parts of hie body, the look under the pillow, or rummage under the nettreee becnnlng tenee and ineietius it we. lost. It should be eupheeieed that despite the great difficulty in lecetlns was petlent was able to name the body parts. except the tinseve end toee. This was true whether the pert pointed to nee on the petient'e or on the examiner'e body. 33939;; Stetueg (e) ééfifil? Btlnhletlon: He had difficulty in differentleeins between the sheep end dull end of e pin. This defeat wee preach: throughout the body, elthoush he made eignitieently fewer erreee 1n the reee end hende. Touch atlauletian was poorly perceived. Heuelly he coulé not state whether or not he had been tauched. Again, there �5. «m to be relatively better preoorvotion or this modality in ' the hand: and face. Except under opooiol oonditiono or examinotion of tho hands, to he described liter, the patient who ohle to locate the eite of it the pin on. repetitively and or it the priok woo steadily maintained a pin prick by pointing. however, rapidly applied to one rosion, at that one place, he could not looeto the point of otinmlotion. tendon scorching lav-neat: over hio body and not infrequently around the bed olotheo. srinaoing on thouah in pain and exoloinins that he one trying to renove the pin. If ookod He would make frantic, where he one being priokod, ho diorozorded the question and con» mm on tinued to try to move the stimulus. "m. phmmnon stimulation or any portion or the body, but who most apparent when the hand no tested. (h) Double SiuultOneouo ethnolotigg; Tho phone-en: or oxtinotion end dioplooo-ont were frequently ohoerved in tests or different body area- by oilultoneouo tactile otiuuli. 0n etinnletins tho race and hand. otinuli to the hand we». not perceived, or nioloooliaod to the cheek. In touting honolosoue bod: stone (on hondvhond) extinction of one poroept III col-on. The side on which the stimulus III not pcrooivod fluctuated, no that at one uooont only a right-sided stimulus one perceived and o for momentleter, only a lott~oided etinnloo not perceived. Exooonootheoio; Whenever his pal: who in oontoot with a portion or his body or any other ohJeot, and the dorouh of that hand In: prioked with o pin, the patient oonoiotently nioloohliaod the �6. ottuulun. this nialooaiisation who to whatever object the phi-tr tartan! of the hand was touching. For txlhplc, 1f the pntioht'l hand was routing on his thigh and the doroun of tho hand VII priokod, he insisted that tho thigh had boon touched, and not the hand. Th1: ninlootlisntion ~ oxooonoothooio - occurrod to the thigh, obdonnn, 105 or (too, had who present with stimuli to oithor hind. It Ill observed even when the patient who urged to look 1t tho hlhdt durtng the application or the pin. nah-anesthesia could not be elicited, however, by otinulhtion of tho pnln or polmar curtuoes of tho ringer! uhnn the aorta: of tho hhné ill rooting on a portion or the My, runner-more. ionization or dorul hand amnion um correct 1! the hind III hold in space. Iloloooltsntion also ooourrod to abduct: external to hit body. It h1o pal: ill rooting on I tabla or on his bad. and the doroun of tho hand It; prioknd with I pin, ho would point to those ohjooto and 091th thlt tho pin had been $991106 "thmru." Whoa quantionod. ho hinted thlt tho hand had huen touched, but continued to point to tho bid or table. Proquontly. however. ho'inntotod thht it on. tho bod or tohlo that hon boon touohnd thdhnntphhohhnnd. Ir alkod how he could too;_tho bod being priokod with a pin he would booonn ton... avoid the queut1on and inliot ”you touohod the bed, not In". III not ell-inatod by Itlhltanooun stimulution, oven whnn extinction of one of tho parocpto occurred. for 03:391., 1! pins hero oinulthnoouoly applied to the aorta of both hands Ihllo tho pal-n wore resting on o table, he would report fetish; only on. p1n prick, that on tho loft (or right, a: dominance fluctuhtod) and point to thn plloo whore the loft hind huh boon rooting. saying ”you touohod the bed thoro.” Displheonont into outrouporoonnl than. �this phone-enon or dilplucancnt into cxtra~peroonal tpnoe occurrcd daily during e period or over two nonthn. Commont: In this paticnt a rccuicitc to dimplecenmnt into space was that the pmlm or the hand be in contact with an external object. In other words. then. were two cutaneooo stimuli limnltcnecully in operation, nemoly the pin prick on the doreun or the hand and tho pro-lure or the object in contact with the palm or ringcro. A single nti-nluc. eooh II pricking the dornun or e hand held in upeoe. did not elicit the dicplnccmnnt. luoeomeutholih III elicited only on otimullting the hands. mu oocumd am though Ilmle pin print as: perceived me cum: in the hand: than in any other areo. excepting the thee. Although thin potient showed In lnability to oorroctly locate phrte or his own and tho esnminor's body, it doc: not necoecnrily amen that exolcnelthscic in dutenmined by thie particular type of disorder in body ache-n. the following case illustrate. the phenomenon or exoocmeetheaiu in the preeonce or to. patient'n some: to locate body pam. can. 23 l.l., a 52 your old woman, III edmitted to the. Neurolosio Service of the flaunt Sinai hoeoitdl in August 1950 with I history of grand hnl eelxuroo. She had been in good honlth until 1937 uhcn there appeared sporadio, noncntnry ecnuutione of "blacking out." About two year: before hdniehion she began to suffer Ionthly ' Ill leisurel. There was no euro. Routino exeminntion on admiulion III within normal limits, oxoept for dnolmia in tho right nontril. there one no organio honthl cyndromo. apocinl x~rcy studiel reveoled evidonoo or a oohfronthl grand necplcen. an August 19th a oreniotoly mm: done and following amputation of e portion or the right frontal lobe, a large bilateral �8. ‘tub-troattl III umniaginnn was axcitcd. nor pout~opcrutive courts an; stormy. For tut lacks an. saui~stup¢rann.r 3h. raupondod anly ta lassive, painful stimu— than: renpanuaa flirt limited to vague ineffective nttenpta ta.punh Quay tat stimulun. In this pcriod the lnpuod uovcral tin»: latian, irate and om um: "sputum um chem-Magma did not Bar rttpannoa rare pruatnt. pupil: mutem ublmkl retot to light. tn. pltiint inproved slowly and steadily. an. hogan to rtlpond vcrbtlly and contact could be maintained far short poriodn. Vinita, union and apparently been absent, begin Frau about Augunt 23, 1950 to rcturn, tlthough a right unnonyloul halinntpuia tiltinofi for Dunn tino. A Iarkod orgtnic nanttl syndrtlo characterised by confusion. disorientation and nuouognusin was prcnant. Routine laurolggic xxnlinntion: laurtlosit exnuination in aoptonbor 1950 diteltuoa a right honcnynnun honiunopnil, asthma impairment of vilual Inuit: with bilatorul nocondnry Optic atraphy, urttaslnl in all directions or ante, bilaterally patitiv. nabintki night. and a nild dogree or uphatin. Position nan... vibration and tonporntur. porcuptian wire unimpairtd. Thor. were difficulties in perceptien or touch Ind pin prick stimuli at anacribod belwu. Puzehiutric Status: The patient was usually friendly and cooperative. Bouvver, the III frequtntly irritable 1nd unuld not pomnit culmination. an: an. dilaritnt-d II to tins and notational: to situation, but not to placa. Thar: var. defeat: in retention Ind maul covered by contabulatian. am am euphoric and 41:91:,“ littlc self restraint er aoneern in social oituatiana. Usatlly uh: would lie with her body fully oxpoaod. not intrtqunntly she toiled �bereelt or wet the bed. Anaeognoein In: prominent. Bod: Scheme: 0n contend the petient we: able to identity lbette correctly parts of her can and the examiner's body, such In ears, eyee, feet and parts of the upper extremities. She exhibited name oenfueion about the right and left eidee a! the bady. end Season; statues] (a) siggie atiuulntian: The patient perceived single pin prick cumin mi, eitheugh m undo 0003:1011“ nompntterned em» in localisation. Theta errors were more frequent on the left side. (b) Double ginniteheaue stimuletion: 0n sinulteneouu epplicetion of pin prick: ta both tides or the body (excluding the hands) extinction on the left, or dieplaceaent on the left toward the level at the right-aided stimulus were the usual reepaneee. amneleterll linulteneaus etimuletion on the right side or the body shaved no extinction, but ntinuiatian on the left side elicited frequent extinetian and displacement. Runneleetheeieg Dieplaeenent lute extra—portend! space either occur-m than the lettihahdawn pridked at the me time the right hand or right cheek were stimulated. The phenamenon could u ' ulna be elieited then the left hand and day other are: or the left side or the body were simultAneeualy etimnleted. Under theee conditions the patient nislocelixed the stimulus to the left bend.inte evade near that hand, or to the object on whieh the mind was lying. For example. it pin pricku were e’imltehemu applied to m right cheek and the 1m; tune, the patient indicated she had been pricked on the right cheek and the are or the chair on Ihich her left bend had been renting; As 1 rule ehe answered by pointing. I: neked to verbelise the ebuld any, “the right cheek end about here,“ (painting to the their emu er into space near be: lett �10. hand). 1! ssksd dirsotiy, “was year hsnd touched,” sh. sauld avoid the gunmen mymzug can; "use," pointing st m um em to tbs 10ft oasis sun at ta spans. It is to be netsd that oxespt undsr the spssisl condition at sinultsnsaus stimulation tbs patient was always sbls to point tu as to ash. hsr‘istt hand on dsssnd. 1r prieksd silnltsnsuusiy an tho dorss or was isrt sud right hands. shs carrots}: localissd only tbs stimulus an tbs right, been by painting sad ststins. “I: right hand.” 2h! stilnlus an the new-y». m 190311104me by painting to m chair s:- and saying, “asrs.* 'It ssksd lasthsr the «hair sun. sud not but 10!: hand use issn toushsd, shs snsssrsd. ”as. hs:s’ pointing to tbs chair an, sun. Inna pin prints ssrs spplisd to tho lsrt hand. sad It the suns «ins, to snethsr sass on the 1st: sids or any baay,s 51-11.: dispisosssus into spsos III status. Ususlly tbs stisulus to tbs lift hand was sislosslissd onto Instsvsr structurs the hsnd sss rusting at else t9 contiguous spsos. tbs uthsr‘stflsuius an tbs 10ft sids was ususiiy oarssotly locslissd, though this stimulus too It: onessionsiiy displaced into spans. when this doubis displsosssnt oocurrsd, tho psiisnt.soula stats sh. rsit eve stimuli and staid paint inte space to tbs lots sf tbs ans. stating "bars and have”. !hsss saslosslisstiens ssrs rspsstsdiy ohssrvsa during s period or s.smnth, sad wars not sissys limited to tbs 1st: lids. tbs: ssrs ecossionslly obssrssd to scan: on sh. right sins. At an... c1... localisation on tho lots its slings aorrsot ss indiestsd by pointing and vsrbslisstion. . siioitsd in this pstisnu only the oenditian or Imitiplo smsuitsnsaus sci-ulstian. It scald can-snsz Ixososssthssis was ' under not be sliaitsd by .1331. summon isthmus. mo signifiosnt :- �11. that oxooonoothooid Ill appoxont ovoa though thoro In. no gross diuordor in body ooh... on routine touting. rurthonuoro, it is evident that bar errors in localisation not» not oi-ply on inabiiiiy to point to or identity park: or her body by nine. ll ordinarily the exporidaood no difficulty in doing this on oonldad. In hoth onto. paranoia word nioiooolinod to part. or the body, to abstain. or into npnoe contiguous with tho tron stinulotod. ooouoiondliy. we have nine observed dilpldodnant or a stimulus to the pardon or the can-inor; Usually ouch percent: art nioloodlilcd to o homologous portion of tho cal-inor'o body, 0.3., a otilniud appliod to tho potiont'u hand in reportod by hin.oo if it had been oppiiod to tho tau-inor'o hand. 'narolr, tho nioioodlizntion ll to any part? of the oxaniner'o body.‘ this §ypo or dioplaoonont is illuotmttod in the following on... also 3; 1.1., o 52 your old male, to: aduittod to Boliovuo Payohiltrio Hoopitll with the oonplnint that ha pad hood-o oontuoed and doprooood. for about a yetr ho had boon disoriented, oootnsod on to date dud rolutionohipo of pooyIi, and had uialdred ubout the 01¢: dill-nix. a. and been to um um colony about a mu “ you: beforo, and had uorkod no d harbor until tho rook before his mum“ to the hupiui. mum ' Slowing shouod non-o1 tomnod. lm;gio fixation! leurologiool examination gait and Itation. coordination Scots our. '01: per- lagrrotioxoo wore doiive bilaterally with normal plantar and undo-inol.rolponnoo. Cranial norvo runoiiono ward now-n1. otltuo thouud Ohtnxil, but only by opooidi nothodo or testing. A pnou-oonoophalogrnu dononotrutod nodordtoly dilated ventrioloo "ith°“t '31" 0’ def°flitia Ind ton. dilated cerebral ouloi. 098.1110 mu} Indra. Status I donoory Militia 3 m “. �12. evident. 0n the word he eet quietly for boure by hie bedside taking little interest in hie surroundinge. 'Ihen opproeched by the eterr he eppeered perplexed but one erreble. During the teeting procedures be one cooperative unleee confronted by e teet eitoetion in which the emeniner demanded teeke beyond hie ebility. At theee ti-ee he showed e ”ceteetrophic' reeotion, bece-e excited end diecontinued the exeeinetion. Re wee dieoriented for time. place, end eituetion. However, he nee eble to find hie Hey about the nerd, looeting hie bed, the nnreee deek, the dootore office end the lavatory. severe ditticultiee in intellectual function were obeerved. He nee oneble to give en edeqnete bietcry. fie could not recell the examiner's none nor the evente or several houre before, but did not contehulete. Celculetion end eyebol identification teete were poorly performed. severe epheeic difficultiee were evident. Re nee uneble to none cannon objecte, clothing or moat body perte. He could not colorehend written collende nor could he write, but he wee able to einple verbal cannon. lilo dreorexie nee demonstreted in hie ettenpte to imitate ringer end mouth novenente. nouever, he lee able to drone, feed, end otherwise cere for hinoelt. Bod: gaggeg He bed difficulty both in neling body perte, end in locating the: by pointing. the defect: were Imet eevere in the fingers, wriete end elbows, and ooceeionlly feet. There nee difficulty mm ‘ ' in right-10ft orientetlan. age-or: Statue; (e) giggle Stinuletionx Routine eon-cry etudiee or touch, pin prick and vibration eboeed no ooneietent inpeinlent. Theee �13. correctly looalieed and deaoribed. Oooaaiohally a eihgle stimulue to the hand or toreahn wee dieplaoed to a contiguous object, or to apaee about the upper extremity. (h) Double Simultaneoae stimulation: 0n double aiaultaneoua touch atinolation the patient dieplayed extinction and dieplaoaleht atianli or were ueually tactile etinali. lhie he would trials or the teoemhand teete or other body parte as well. to: on ai-nltaneouely etindlating the cheek end the oppoeite hand either report only the etioulue to the cheek (extinction of text (6), hot example, nae moat evident on nae eeen in the hand etianlua) or would report e etmlulue to eeoh oheek (displacement or the hand stimulus). The pattern or seneory doainanoe wee that oeoally eeen in ditruae cerebral dieeaee, the race being aoet dominant. the hand leaet (5). There nae no lateral doaihanoe. Rho-oaeetheeia; Dieplaoeeent into extra-pereonal apece eaa oceaaionelly ohaerved on single etiaulation. This displaoeaent vae fro- the hand, forearm. or the elbow to apaoe oontiguoue to the part touched. lxoaoaeetheeia was however aarkedly exaggerated when double einultaneoua atuuuuon was employed. Again the am. from which the phenomenon was noet frequently dheerved were the hands. toreeraa and elbovl. tor ext-pie, when etieuli were applied to the dorae or both hande ae they were lying on the patieht'e lap he pointed to epeoe in front of his kneea. It aaked to etate where he had been touched he uould say. "the hande" but would continue to point to the epaoe in front or hie knees. laoeo-eetheeie nae rarely noted when other body parta. euoh ae oheeke or ehouldere were simultaneoualy stimulated. Occasionally it one found that on teete with double allula taneoue atinulation the patient nielooeliued a etihnlue tron hie body to the hoaologoue region or the exeeiner'e body. For inetanoe, when both hand: were oinultaheoualy touched he would grasp the exauiner'e �1%. binds and strin- ho had boon touched “there.” Dsopito tho sxosinor's insiotsnoo thst tho stinnlu: hsd boon to tho outiont'o hoods, tho pstiont would persist in pointing to tho oxouinsr's hands. When asked to noon the ports touched, he would on: 'thsro. thorc." The fill. phonononon Isl occasionally observed on liltltsnoons sti-nlotions or both elbows or ohooko. It was signirioont that this nislooslisotion to tho oxosinor's body occurred oven thou tho potiont urgod to look ot tho otinnlotiono. It III observed that onotionsl tension, inoresoing tho rot. or touting or unduly prolonging the oxasinotion, inorossod tho inoidonoo of oxosolosthosis. ror ext-910, to initisl sppliostion was of pin priok to the right hand and loft chock, tho pstiont reportsd only tho the. psrospt, quitting tho hsnd stimulus. Lstor, ho localised the two othnulino tho ohooks. As tho sxoninotion pro« groslod sad the phyoioion opsodod up the testing. tho patient boot-o sore tohss. no thin looslisod tho toos pore-pt correctly, but innistsd thst the hand otimlntion as into upon. in front at the hand. tinslly both stimuli our. displaced into spooo or to tho oxaninor's body. those phononons wort obsorvod dsily over s period of two and a half unhthl. Coulent: Hhilo single stimulation occasionally produced oxooolnlthosio in this individual, tho phenomenon Ill note pronounced under conditions of double oi-ultonoouo Iti-nlstion. this ntiont sloo lioloooliood stilnli to tho oxsninor's body. lhotionol tonoion, prolonged canninstion, or inorossing tho onto or touting exaggerated the phone-anon or ozosonosthosin. Bisousoion; In oonoidoring thou. ossoo it is illodistoly opporont thst oxooolosthosis is osoooiotod with o savor. orgsnio �sentsl syhdrose. therefore, it night he ersued thst exoscseethesis ‘is sorely e ssniteststiou of the petient's sentsl contusion; thst 15. the petient sisply points into spsce becsuse he is confused. However, we hsve eyesined sssy severely confused pstieuts end found exososesthesis only rarely. moreover, exososestheeie is e petterned phenomenon. desonetrstle in eschvpstieat under defined conditions, predicteble ss to the eree tron which it will occur end the extra» personel spetisl region to which the sensation will be projected. For exemple, in Case I, exoscsssthesie could be elicited only from the head end only when the dorsus use etisuleted st the sese tine es the psls or fingers were in contsct with smother object. Displscesent under these circusstsuoes use ususlly not hephsssrd. sis s rule it occurred to the object touchins.the palm or fingers. In exososesthesis could be elicited only by double silulteneous stteulstion. It see seen most clearly in the head end could be elicited only unileterslly st say one exesinetion. Again the Case 2, displace-eat use not hspheesrd; the stimulus es s rule use locslised to extre-pereonsl speoe contiguous to the eree sctuelly stilulsted. In Cece 3 the phenosenon use observed sgsin under conditions or double sinnltsneous stimulation. end the displsceseuts were either to spece contiguous to the stisnlsted eree, or to honologous srees of the exsliner'e body. It is signifiosnt thst these displscesente could be elicited even when the or the stimuli. pstients to look st the epplicstion the ensuiner pointed out the error were urged noreover, even when in looelisstion end esphssised the i-plsusebility or their response. the pstiente chsrecteristioelly insisted on the correctness of the nislooslistion. rectors Influencing lxososesthesisa There ere esny rectors which influence the sppesrsnce of exoeosesthesis. Except under specisl conditions in children, it �16. has been obeerved exclueively in patiente uith severe mental chensee reeulting true dieeeee or the brein. It ie influenaed by the type of etianlue need. the rate or etiluletion. ee veil an by the elelent of einnlteneity or eti-mli. loreover, the e-otianel etete at the petient nee e eignificent effect the phenuuenon ee doee the pert or the body etinnleted. In ease oeeee exoeaneetheeie nee been nude epperent by edeinietretion at eeell doeee or enoberbitei eodiun. :heee feature will be diecueeed. (e) Bilateral Cerebrel Dieeeee; the emlptae beekground in every eeee or exoealnetheeie ie en arsenic uentel eyndraee eeoondery to bilateral ceretrel dieeeee. we have not been eble to denonetrute exeealeetheeie in en adult unleee there «ere eevere neutel thengee. But,ee previouely noted,it ie e rare phenonenou end only few or the individuele vith eevere arseniereentel eyndruee show it. In boo patiente with arsenic brain dieeeee at verging eeverity, exoeaneetheeie ee- obeerved in ephroxintely as or the one: (5 ). Even in then patiente, it wee not leniteet in every exeeinetion. end it: frequency vee reedily eltered by «bungee in the oonditione of teeting. It ie therefore evident that eevere bileterel oerebrel dieeeee, in iteelr, ie not sufficient to produce exoeoleetheeie. (b) Irrect or Binnlteneaue atiunli: whet einnlteneoue eti-uletion nay elicit eeneory phenaleue not epperent on eingle eti-nletion nee been previouely denonetreted (2). tor exllple, e henieeneorw eyndrtne in e heeiplegia petient he: not be diecernihle except under eonditione or double ei-nlteneuue etinuletion. Tune. single etilnietion may be well perceived end latelieed by the petient. but the eddition at e eecond etinulue einulteneouely applied .1: no effect integration thet the phenomene of extination, obecuretion end diepleaeeent become epperent. on �17. ‘ m ‘sullarly, “alumnus “mutton elicited “comma 1: an aunt an angle annulus umlnulon. or magnum 11: when 'oun 1 n In Manama: mun: and 2. man. stimulation. In ulmltmem «mung» am a menu»: “mum on for aligning the phonon-anon. It could not be amount-um by tingle uttunlatlan. In am 3, ant-tumult could “nationally onum on .112ng stimulation. but annulment “mutton dmmtum flu. inhuman run much water frequency. b0 (a) :12! a! gtggglu! Inst lrtbotgvug or tub vurioua Uzi-”11 and in that Manama. mix as final. when. :5.le pin prick, ripotltlvc tauch and rlpctltlvc pin prick. it It: noted that mutt" tmh "man mm was: «1'00th 1!: allowing cucum- thuu. m. m «mull: two on double almlum Itimlltion. (a) gram o: t! "time's an»! momentum-la anal um amt-mud hr 31%.!!qu in th- m: “mum which and» mum“. not. difficult. lama tbs n“ of “hunting, artho unduly prolonging mn~m~ml Imo. tantalum 1mm“ Alta, 11‘ the the Multan-nt- to twin" was deliberately critical or the mtlmt'o 0mm, tho phonmmm appomd with 5mm futon mam-d an. action“ switch at tho Imam”. patient, and 1t amt-d mun-r. prom.“ I "ututmphlo" mctlan. m man of m: It In» boon pmlmly dmtnm that arugula» in pomcpucm my be magnum by mum-ac. (0) nous-mu: team an administered lutnvmmly la 400.30! or 3 to 7 srllnl tn pltlonta Ilth altrus. ctrohwll distant. Prior to am “nutrition. thou patent! mnltum the phone-on. at «amulet: and dllplumt at pump” on ““1”me tutu, but lntuloanta not. (5) . alumnus“. m1 lo under the lntlmmc or the Whitman �18. three pationta ahovad oxoaoneatheaia. in addition to extinction and displacement. In two other patienta. in whoa axoooaootheaia has boon alioited only after a protraoted taating period. the administration or anoharbital aodiua elicited exoaoaeatheaia at the onset or teating and exaggerated the phone-one of extinction and displace-ant. Relation of lxoaoleotheaie to Extinction, Ottonretion and Diaplaoalent: In our experience. whenever exoooaeatheaia haa been observed. phonon-nu of extinction, obeouration and displacement are alao preaent. lxoaoaoathaeia, hou‘var. ia a rare phone-anon, whereae extinction, ohaouration and diaplaoolent are eon-only ohaerved. loreover. ahareaa extinction, otaouration end diaplaoaaont ere treouontly aeon in coult patient: with lilo cerebral dyoronotion (5). diapleoelent into extranperooael opeoe 1a only preaont in oaaaa or severe aental ohangea due to diaeaae ot-the brain. It may therefore he oonoluded that exoeolootheaia in adult: repreaenta a aora severe type or oarebrel dratunotion than other oiaultenaoua m otiaulation phone-one. nalation of Ixoaoleatheaia to gag: logger It night he aeid that exoaoaaatheaia ia a pathologio extenaion or the body image. The normal individual is continually extending the boundariea or thia image. For example, need oitae the eta-plea of tho lolan with a teeter in her hat who “real!" when the feather ie tonohod, and the aurgeon who handlea hia probe as though it were an axtanaion or hia tingera (1). In the normal individual, holever, theae extension. of the body 1-130 art fluid, illediately raveruibla and clearly recognised by the individual aa artificial. the surgeon for example, ia able at any'nolent to redefine correctly hia body Liege. no “known" that the prob. it not his finger. In the group or petionta ’ �19. described above. hosover. the extension of tho body isage scans to operate in a pathologio, rigid tons. under certain conditions these patients lose the ability to ssintain a realistic definition of tho lisits of their body. The: behave as though portions or the contiguous external world are concrsteix incorporated into tho inner image of their body's extent. Although say oonsider exosoaesthesis- a spooiaiiaed body ilage disturbance it should ho noted that patients who do not show we diftionlties in identifioation location of body parts still us: show aisiocaiisstion into estrsapersonsl space. Convorsely, patients with so atolhility to identity or locate their body parts on oosssnd. do not neoessariiy sanirest eaosoassthesis. In similar fashion, thers is no necessary relationship between ascsoaoothsais and position sense difficulties. A patient (Case 3) who manifested displacessnt of sensation into extrs~personai space, did not asks errors in routine tests a: position sense in” tho extresitiee. this it oonsistent sith observations previously ssdc by Head that localiation of single stilnli is not functionally roleted to senss of position or the extrusities (1). non or the land: Although displsoelont into extrs~persona1 space has been elioited tron various areas or the body, it has been observed to ooouh lost frocoentiy tron the hand. loreover. in no ossc hoe it been elicited from another area and been absent tron and 1 the hand. this oredileotion tor the hand is consistent with the ssnncr in shioh other dysfunctions of the nervous system are reflected. As a role when tho functioning of one side of tho body is impaired through cerebral disease the pathology is soot saniast in the hand. �20. lhne 1n the annex heuiplegit reeultina tram e capeulur leeion the pereeie, body image diuturhenoe end eeneory late ere use: pruexnene 1n the hind Ind (insert. In the-e petaente end in other. eleh dzrruee cerebral dieelee the phennlenl a: extinction. eheourltion end diepleoenent Ire elee beet e11¢18ed when the head in teeeed. lurthenlore. etufliee at eh. order at eeneory dullnenee or verioau ereee or the had: Genoa-trite the hand in the lowest hunk. thie in true in the eminence order or petunia with cox-em), dieeue (5). and mm nor-e1 eubjeete, both edulte and children (6). stallerly, then elleetheaie 1: oheerved, 1% 1e eeen she: olenrlr 1n khe head. Bender tad lethnneon (it) deeovihed e «nee 1n ehioh'the clinical courae III reflected in e waxing end unnans alleetheexe. Ae than petient inpraved, the trees from ehseh the phenunmaen oould be elicited amniniehed. ale delohetreble only in the hand. until finally alleethneie In entotopegneeie the hands hre ante proraundly effected thin other regiane. ringer Isnneie. paneibly the enrlieet etsn or body image dieturbenee, 1- trequentlr eeen 1n the eheenae or other groee dieeurbanaee or the bed: eehnne. Furthemeore, phantom 11gb, tnoeosnoeia. cluellsxn and eyneetheeie Ire phenalnne in which the role a: the hand 1e eepectclly praninent. Just an en». ”811010310 puma-em uniteet in tests or other body parte. but 3:. that aleerly delonetrehle 1n the hand. so the. exoealeetheete, though nonunionnlly delanetrnhle eleevhere, layman: apparent in exnlihntion of the function! at an. hand. 14: It hne been observed that luaealeytheele 1n the ham-e1 eeneory pheno-mne which aoeur 1n pettente with cerebral dylrunction m �.1 {{{{{ 21. h any bu fauna in tho annual young child (6). Similarly. have unvor fauna in adult: nxecpt than QSOOGIOIthlltl, thick I. that. in lirkod cornbrnl Ginsu... nun b0 roadily obnorvod in childrcu up to in. ago or tour. In urn-ining a 13:30 302103 of norm. chiidm it u. now that the initial mpm or ohildron to iambic ninnitunooal Itinuiation fruqunatly incinnnd' axoianucthnuia. nithough tho nor. can-an rosponnos In». «xtinctian and dispinou-ont. lionenusthonia was IIrO. havuvor. utter tho initili til trinis. In» truqunaa: with union uaonalusthnain.nnw he noon in children up to tho as. or tour insanity that it an: roprouont. in thy child, 3 ”annual" dovelopnuntai Itsse in on: ergnnisation of perception. It: uppourunan in uduits with novor. brain €110.30 any possibly ha. I. with aunt: pathologio phauulcnu, a rungIIion in function to a pruvioul iovvi at ntnnory integration. aBIIiII; lillooIIilation of tnotil. Itflluli into axtrn~poruuna1 space is dcnarihad tad tar-pd alone-cathonii. Bantu-nathnlil 1' aha-trod in pationta with saver. organic unntal lynarunon. It in apnaront only very rural: on tingle tactilu Itilnintion and in not. readily elicitdd by tho t'ahnituo of Gambia lilnltnnsoul atiunlntian. It is exaggcrntod by fatigue, rigid touting find incrOIlld unotional tonlian. lurhitnrttc intaxiention also may elicit or uxnggorlto the phauuncnon. Eh. pattoraod linsannathnuin in swat apparnnt in Itinniutian of the hand, but his bOCn obsorVCd in tiatl of othnr body part0. flail. it an: be canaidorod t pathologio axttntian of an. bad: image, it is act dopondcnt upan othcr ¢on¢anitunt body inns. disturbanotl. �nelmthOllt Mu bola observed chltfly 1n gamma nth nun natal chanson, u 1: not a manna» or contusion, but a patterned pnucun- phonmnm. It may be a "mum,“ patient: win: Mum}, animation. to I 93110th “new” was. in smear «alumna, u mated by the rut Although that 1t 1. «mum. "Ian: abut-"d in cinnamon- men. tut: 91‘ mg �1. 2. 1mm, 3.: Studies London, 1920. (a) £3. &1mm in lourolcgy, Vol. II, Oxford Univ. Prom, ammo, Id. lad wanna, Mm: Extinction mu, inILL, humans“. mu.xm1.unzuhut., g2; 717-725 phenomenon member, 19%. m, m. as: Itnuutien (b) r advantage. or the method at unannounthe neurological omimtion. monument: Anal-1c... 11.3.: 12.; 755-458. 1n V was. mm: he pheamnm or union unplacuo‘nt. mm, Awhmmelwr .. u. 9 607-621, lay, 1951. (I) MIR, LB... SWIM), IJ‘. lad gutuiugggo: the body team. W Arcth m fl.gm1.uq¢nug., a 1 m 3.1“: - ind anaemia §£L tea-am. Jeannine” ‘ (b) LB. and “We! 11.: Pattern: in alumni: their unfit»: to disorder of find: when and other unto” phone-m. 5. vm, I... film, I. Ind g5; 501615, October, m and 1950. tun-mm tut mm, Maximum sign or untrue heatnmiymejnmlm, 3!. £6.58, 1952. 6. (I) and mm, In Datum 1n perception I... rm,atII.no. on IMltlmm 0! Ind land. I I 250-»252, June, 1950. aura“) LBJ m, (2:) an , 809mb“, 1951. 0. . . 111.8. mm, I. and 11.: mm, mm, {out or and hand. “autumn no. §§: 355-362. £8 Patterns 11: . ”nation mammobgguglg8%.. � 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 Exosomesthesia; the displacement of cutaneous sensation into extra-personal space. Trans Am Neurol Assoc. 1952; 56 (77th Meeting): 260-2. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-6a-008 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 Shapiro, Mortimer F.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Bender, Morris B 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 [Preprint] and reprint. Reprint from the A.M.A. Archives of Neurology and Psychiatry, October 1952, Vol. 68, pp. 481-490 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