Higher Cortical Functions in Man PDF
Preview Higher Cortical Functions in Man
HIGHER CORTICAL FUNCTIONS IN MAN PREFACES TO THE ENGLISH EDITION BY HANS-LUKAS TEUBER and KARL H. PRIBRAM AUTHORIZED TRANSLATION FROM THE RUSSIAN by BASIL HAIGH HIGHER CORTICAL FUNCTIONS IN MAN ALEKSANDR ROMANOVICH LURIA BASIC BOOKS, INC., PUBLISHERS CONSULTANTS BUREAU New York 1966 First Printing-March 1966 Second Printing-May 1967 Third Printing-September 1970 Fourth Printing-May 1973 The original Russian text was published by Moscow University Press in 1962. AJIEKCAH.ll.P POMAHOBHtI JIYPI151 BblCWHE KOPKOBblE 4»YHKUHH '1EJlOBEKA Library of Congress Catalog Card Number 65-11340 SBN 306-10740-6 ISBN-13: 978-1-4684-7743-6 e-ISBN-13: 978-1-4684-7741-2 DOl: 10.1007/978-1-4684-7741-2 © 1966 Consuliants Bureau Enterprises, Inc., and Basic Books, Inc. Softcover reprint oft he hardcover 1st edition 1966m All rights reserued. No part of this publication may be reproduced in any form without written permission from the publishers. Manu factured in the United States of America. Drawing by Lec,;tardo da Vinci illustrating the Renaissance view of the structure of the brain and of the three cerebral ventricles Preface This full-length translation of Professor Luria's book introduces to the English speaking world a major document in neuropsychology, summarizing Professor Luria's earlier contributions to that area for nearly a third of a century. It is a monumental contribution. Nothing of this scope exists in the Western literature of this field, with the possible exception of Ajuriaguerra and Hecaen's book (in French) on the cerebral cortex. Professor Luria's book thus marks a further and decisive step toward the eventual coalescence of neurology and psychology, a goal to which only a few laboratories in the East and West have been devoted over the last decades. The book is unique in its organization. The first half deals with observations and interpretations concerning the major syndromes of man's left cerebral hemisphere: those grievous distortions of higher functions traditionally described as aphasia, agnosia, and apraxia. There is also a detailed and brilliant analysis of the syndrome of massive frontal-lobe involvement. The entire second half of the book is given over to a painstaking description of Professor Luria's tests, many of them introduced by himself, and set out in such detail that anyone could repeat them and thus verify Professor Luria's interpretations. The two halves of the book are equally challenging and original. In the first, more theoretical, section, Professor Luria gives an account of the major syndromes in terms that reject with the same force the traditionallocalizationist view-the notion of discrete centers for different aspects of language, of calculation or writing-and the opposite view of holistic function of the cerebral hemisphere, a view clearly incompatible with clinical and experi mental fact. In a similar way, Professor Luria's re-analysis of agnosia and apraxia reveals inadequacies of these clinical shorthand expressions; he points out that more elementary sensory and motor changes shade into the allegedly isolated aspects of distorted "higher" function, whether of recognition or skilled movement. As a result of this balanced approach, a further traditional distinction falls by the wayside-the traditional opposition in the description of aphasia between the "instrumental" and "noetic" views, that is, between vii those who believe that language is merely disturbed as a tool, with intel ligence essentially intact, and those who believe that the trouble with language is simply one of several manifestations of an underlying change of intelligence. The theoretical position adopted by Professor Luria himself in the face of these incredibly perplexing syndromes is most intriguing. He invokes cerebral reflexes as the basic elements of behavior. Yet careful reading reveals a remarkable restraint in the postulation of specific interruption of normal connections between different brain regions as the origin of major syndromes. In point of fact, he rejects the concept of conduction aphasia, preferring instead a carefully descriptive approach. Yet there is boldness too, as Professor Pribram stresses in his companion preface to this remarkable book: Professor Luria invokes again and again a principle of re-afference, in the tradition of Orbeli and Anokhin, and-Dne might add-Df von Holst, modifying tra ditional reflex views and emphasizing the all-pervasive influence of self produced stimulation (such as proprioceptive feedback) which the organism must compare continuously with its intended output in order to assess the success of its own movements. This sort of approach to sensorimotor co ordination requires a new way of looking at the major brain syndromes in man. It becomes particularly fruitful in dealing with the baffiing changes in human behavior after lesions of the frontal lobes, an area of furious contro versy where Professor Luria reaches conclusions (he claims there is an essential disturbance of "intention") which are identical with those reached in our own laboratory on the basis of quite different clinical and experimental data. The second half of the book with its rich descriptions of tests will be at least as influential as the first. Here one is struck primarily by the disarming simplicity of methods, nearly all suitable for bedside conditions, few requiring more than the examiner's voice, a few blocks, or paper and pencil. If one has had the privilege of observing Professor Luria and his staff in action at the Burdenko Institute in Moscow, one doubly appreciates the choice of his tasks, because he deals with large numbers of brain tumor cases, week after week; his assessment of these cases-the "neuropsychological" report-goes onto their clinical charts, together with other diagnostic techniques such as X-ray evaluations and electroencephalograms. Where the situation demands it, Professor Luria is quite willing to employ more elaborate experimental techniques, such as the recording of eye move ments, especially in cases of frontal-lobe involvement. Yet the emphasis remains on bedside tests, and a great many of them. It is here that the Western reader will be impressed by a difference in approach: neuropsychological laboratories in the West tend to be more quantitative. The contrast is instructive, since one of the liberating effects of scientific exchange is to make one look at one's own work in a new and different way, as if one were permitted to look at it for a moment from the outside. Quantifi cation is a major strength of the British and American tradition in psychology. If a book like Professor Luria's had been written here, it would teem with viii means and standard deviations, not to speak of analyses of variance and covariance. Yet the sobering fact is that most of Professor Luria's conclusions would not be changed if he had chosen to use these refinements. His own enormous clinical experience and his intuitive sense for what are reasonable interpretations are playing for him the role of large-sample statistics. But there is a further and more important aspect to the difference in style of work: Much analysis in current neuropsychology in the United States (though much less in England and France) makes large-scale use of standard tests of intelligence, often at the expense of more versatile, qualitative tasks of the kind employed by Professor Luria. Here is a serious danger. By relying on routine psychometrics, one often loses crucial opportunities for the analysis of altered performance in the presence of brain lesions. Professor Luria's restraint in the use of psychometrics seems to me a major strength in his approach. One of the most serious indictments of such psychometric tests comes from studies that permitted direct comparison of intelligence test scores obtained before, and again, in the same subjects, after a penetrating brain injury. In our own experience with such comparisons, two-thirds of an unselected group of brain-injured men have improved their scores from test to retest, even though the brain injury had intervened. Many of these patients increased their scores just as much as their controls. Yet most of the patients would have done poorly on a number of Professor Luria's informal, qualitative tasks, which are directly geared to the detection of specific change after cerebral lesions, while routine tests of intelligence are not. The ingenious and abundant "little" tests employed by Professor Luria will undoubtedly find their uses here, and norms will be obtained in a number of laboratories. It will be of particular interest to see how his interpretations will hold up on cross-validation to other populations of patients, particularly those with selective removals of cortex for relief of epilepsy, or to those who have penetrating trauma in the absence of other complicating factors. Principal reliance on tumor cases, as in Professor Luria's work, entails certain risks of which, Professor Luria is quite aware. His patients, on the whole, are more gravely ill than those studied in the neuropsychological program of, say, the Montreal Neurological Institute, where behavioral analyses are concentrated on cases of selective cortical removals for treatment of epilepsy, or in our own laboratory, with its major emphasis on the studies of late aftereffects of penetrating missile wounds of the brain. The more serious involvement in brain tumor cases is particularly apparent in patients with frontal-lobe tumors, since these tumors often grow undetected for considerable periods, as compared with those in other regions of the brain, where specific symptoms are more rapidly evident. Yet Professor Luria makes the point that certain essential local symptoms are often brought out best against the background of more general changes in the brain, those due to pressure, vascular disturbance, or diffuse toxic effects ix The touchstone will be cross-validation and, as regards frontal syndromes, the agreement between his conclusion and ours is simply astonishing, considering the vast difference in patients and in methods. In this connection, a last word of caution, not so much to the physicians who will read and use this book, but to the psychologists, who will receive it with equal eagerness: Professor Luria's techniques, in their intent and in their application, are extensions of the classical neurological examination-major extensions, to be sure, but extensions nevertheless. This means that we must use his techniques just as he does-in conjunction with the standard neurologic examination, and not in its stead. In this way, the maximal benefit will accrue to the diagnosis of the patient's condition, and to an understanding of the roots of his difficulties. For it should be remembered that the central task of neuropsychology is always twofold: to help the patient by understanding his disease, and to understand the disease, in turn, as an experiment of nature, an experiment that, if properly used, may provide us with essential insights into the physiologic basis of normal function. In that sense, any contribution to neuropsychology attempts to tell us how the brain does work-by carefully observing how it sometimes does not. Here then is the book, written by a master in his chosen field. Its translation marks a further step in the mutual recognition of common values in the scientific endeavors of East and West, a recognition which has at times been easier in the physical than in the behavioral and medical sciences, but is needed in every respect. And since it is the rapid development of physics that has made us so dangerous to one another, is it not fitting that we should get together over the great problem of detecting what makes us so frail and to join hands in the healing of the sick? Hans-Lukas Teuber Cambridge, Massachusetts June, 1965 x
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