908
pain and right loin pain both predict renal colic, but pain in
both loins is likelier to arise from urinary tract infection.
Results from the French collaborative study of this
approach showed a modest rise.9
Further modifications to bayesian systems might raise
their accuracy towards that of clinicians, but are unlikely to
do more. Such systems seem merely to rehash the clinicians
own opinion, losing accuracy in the process. Computers will
not become diagnosticians in their own right until they
acquire the deep knowledge of anatomy, physiology, and
pathology that underpins the simplest surgical decision.
This implies using techniques of artificial intelligence,
though these have been unpromising to date.
The present trial was potentially biased towards the
retrospective mode, as database cases were included in that
accuracy series; but in fact computer accuracy was very
similar in the two modes. Future programs can and should
therefore be tested on existing patient archives before "going
live". Retrospective trials can predict gains in prospective
accuracy through better mathematical methods, new disease
categories, and new database probabilities. They cannot
predict gains through greater user-friendliness or new
symptoms and signs not previously recorded.
The present study was not designed to assess the relative
contribution of structured forms, computer diagnosis, and
audit feedback to surgical decision making. However, it does
strongly favour the null hypothesis that the computer
diagnosis contributes precisely nothing. Only bayesian
methods have been studied, and only the acute abdomen.
Yet this is the area for which the greatest claims have been
made, and in which studies are easiest to conduct. Its failure
here must seriously undermine its credibility in other areas.
Might exposure to computer diagnosis have increased the
clinicians accuracy? A large effect is unlikely; moreover,
early trials demonstrated that structured records and audit
feedback can be implemented without computers on site.5
Though the results are negative, the implications are
considerable. Computer-aided diagnosis is not yet suitable
for clinical practice. "Live" prospective trials should be
conducted only with systems shown in retrospective
matched trials to do significantly better than clinicians. But
greatest research effort, and any government funding,
should now be devoted to the low-cost innovations of
structured forms and audit feedback.
I thank the members of the Lothian CADA group for their support during
these studies, in particular Mr A. A. Gunn (consultant at Bangour and
Chairman) and Mr I. M. C Macintyre and Dr K. Little (consultants at Leith
and RIE).
REFERENCES
1. de Dombal FT, Leaper DJ, Staniland JR, et al. Computer aided diagnosis of acute
abdominal pain. Br Med J 1972; ii 9-13.
2. de Dombal FT, Leaper DJ, Horrocks JC, et al. Human and computer aided diagnosis
of abdominal pain: further report with emphasis on performance of clinicians.
Br Med J 1974; i: 376-80.
3. Sutton GC. Computer aided diagnosis: a review. Br J Surg 1989; 76: 82-85.
4. Horrocks JC, McCann AP, Staniland JR, et al. Computer aided diagnosis: description
of an adaptable system and operational experience with 2034 cases. Br Med J 1972;
ii: 5-9.
5. Gunn AA. The diagnosis of acute abdominal pain with computer analysis. J R Coll
Surg Edin 1976; 21: 170-72.,
6. de Dombal FT. The OMGE acute abdominal pain survey. Progress report 1982.
Scand J Gastroenterol 1984; 19 (suppl 95): 28-40
7. Graham DF, Wyllie FJ. Prediction of gallstone pancreatitis by computer. Br Med J
1979; i: 515-17.
8. Adams ID, Chan M, Clifford PC, et al. Computer aided diagnosis of acute abdominal
pain: a multicentre study. Br Med J 1986; 293: 800-04.
9. Seroussi B and ARC and AURC Cooperative Group. Computer aided diagnosis of
acute abdominal pain when taking into account interactions. Meth Inf Med 1986;
25: 194-98.
Diagnosis
VISUOSPATIAL NEGLECT: UNDERLYING
FACTORS AND TEST SENSITIVITY
P. W. HALLIGAN J. C. MARSHALL
D. T. WADE
Rivermead Rehabilitation Centre and Neuropsychology Unit,
University Department of Clinical Neurology, Radcliffe Infirmary,
Oxford
Summary Visuospatial neglect, a frequent
consequence of unilateral (usually right-
hemisphere) stroke, is associated with poor functional
recovery and in many patients is resistant to remedial
treatment. Studies of the nature and prevalence of the
disorder have been hindered by problems of definition and
assessment. In this study 80 unselected stroke patients were
assessed for the presence and severity of neglect on the
behavioural inattention test. The six subtests of this battery
all intercorrelated highly, and a subsequent factor analysis
showed that all tests loaded significantly on one underlying
factor. The construct of neglect as defined by performance
on the battery is therefore robust. Nonetheless, the
individual tests differed substantially in their sensitivity.
Star cancellation was the most sensitive measure of neglect
and correctly diagnosed all patients whose aggregate score
on the full battery fell below that of the control population.
INTRODUCTION
THE term visuospatial neglect is used to describe the
behaviour of neurological patients who, after brain damage,
appear to be unaware of visual stimuli situated on the side
opposite the lesion. Although described by Zingerle in
1913,1 the disorder has remained obscure within neurology
and until lately has had little influence on
neuropsychological thought.2,3 Clinically, neglect has been
singled out as a negative prognostic variable that has
profound effects on functional rehabilitation after stroke.4,5
Accurate information on the prevalence and nature of this
common neuropsychological disorder is necessary in
planning rehabilitation facilities. However, progress
towards the effective treatment of neglect has been
hampered by problems of definition and assessment.6
Despite the expansion of work on the clinical
manifestations and underlying mechanisms of visual
neglectthere remains disagreement about the prevalence
of the disorder. Over the past decade, reported frequencies
have ranged from less than 2 % to 88 % in patients with right
unilateral stroke.8,9 These large discrepancies have been
attributed partly to variation in the number and type of tests
used to assess visual neglect.9,10 Many different
cancellation,l1 copying,12 and visual search tasks13 are
presently used in clinical practice.
The lack of consensus about the assessment of neglect has
made it difficult to compare different studies of the
disorder.9 There has been a largely unquestioned
assumption that the various assessment procedures used all
provide measures of the same underlying deficit.1O,14 Few
studies, however, have specified the degree to which the
various conventional tests of neglect correlate. 15 Many are

unstandardised and may well differ in their sensitivity to
detect visual neglect.16,17
We have examined the performance of an unselected
group of stroke patients on six traditional neglect tests.18
Each of these tests (or variants) has been used previously to
measure unilateral "visual neglect"-a conceptual construct
which refers to the deficits observed in brain-damaged
patients who fail to notice, orient, or otherwise respond to
stimuli located on one side of space. A consistent pattern of
impairment across these tests would provide evidence
supporting the underlying construct and the implicit
assumption that such tests are measuring aspects of the same
underlying deficit.
PATIENTS AND METHODS
80 patients with a diagnosis of unilateral stroke were recruited
from admissions to Rivermead Rehabilitation Centre, Oxford.
Patients (54 with right and 26 with left brain damage) were
diagnosed according to physical signs and history; all were right
handed and capable of understanding the task requirements. The
mean time since the onset of stroke was 85-5 (SD 740; range
12-366) days. On admission each patient underwent a complete
neurological examination.
A comprehensive visual neglect battery of six pencil and paper
tests from the behavioural inattention test (BIT)1$was administered
to all patients. Eye and head movements were not restricted during
testing, but moving the stimulus paper was not permitted; test
material was centred on the patients midsagittal plane.
The first test, line crossing, adapted from Albert," consists of 40
short lines randomly positioned over the page. The patient is asked
to cross out all the lines; the maximum score is 36 (the four central
lines are not scored).
In the letter cancellation test 170 upper-case letters arranged in
five rows are presented. 40 letter targets comprising 40% of the total
stimuli are positioned so that approximately equal numbers appear
on either side of the midplane. The patient is instructed to cross out
all the target stimuli; the maximum score is 40.
The stimuli in the star cancellation test are 52 large stars, 13
letters, 10 short words, interspersed with 56 smaller stars. The
patient is instructed to cross out all the small stars. Two of the
central small stars are used for demonstration, and the maximum
score is thus 54.
For figure and shape copying the patient copies three outline
drawings of a four-pointed star, a cube, a daisy, and a group of three
simple geometric shapes presented on a separate stimulus sheet.
TABLE I-DISTRIBUTION OF NEGLECT AMONG 80 STROKE PATIENTS
I I
I I
TABLE II—CORRELATION MATRIX
909
TABLE III-VARIMAX ROTATED FACTOR MATRIX
TABLE IV-TEST SENSITIVITY
*Defined by aggregate score from all six tests < 130/146; n = 30.
The presence of neglect is defined as the omission of any major
part of a lateralised subcomponent of the figures; the maximum
score is 4.
In the line bisection test patients are presented with three
horizontal (204 mm) black lines in a stepwise arrangement across
the page. The test is scored by measuring the extent to which the
patients bisection mark deviates from true centre on each line; the
maximum score is 9.
For the representational drawing test the patient draws, from
memory, a clock-face, a man or woman, and a butterfly. Scoring is
the same as for figure copying, with a maximum of 3.
The diagnosis of visual neglect was calculated from normative
data on 50 age-matched control subjects. 1.8 The presence of neglect
on each of the six tests was defined as the score 1 point or more
below the lowest score achieved by any normal control subject.
Aggregate performance on the six tests was used to assess the
presence and extent of visual neglect; the cutoff for normality was
130/146. Patients characteristics are given in table 1.
The method of analysis used was principal components analysis.
This process involved the examination of a correlation matrix to
determine which variables co-vary and the subsequent combination
of these variables into meaningful factors or traits. In this way,
evidence for a hierarchical factor structure can be used to support
the case for a robust measure of the constructs being tested. Pearson
product moment correlations were calculated for all six test
measures. The resulting correlation matrix, and correlations with
age and days since onset of stroke, are given in table u.
RESULTS
Because of the large number of comparisons, the
significance level was set at 0 001. All correlations between
tests were positive and significant; performance on all the
neglect tests was statistically independent of age and time
since onset (although the values were, as expected, all
negative). By means of the BMDP computer package, a
principal component factor analysis was carried out on the
data. The analysis extracts the orthogonal linear
combinations that account for the largest proportion of the
total variance. The rotated factor matrix showed a single
factor that accounted for 72 6% of the total variance
explained (table m). No other factor accounted for any
significant proportion of variance. This single factor had
substantial loadings from all six neglect tests. The results of
the principal components analysis thus provide evidence for
the homogeneity of these visual neglect tests. In other
words, patient performance on the set of six visuospatial
910
Star cancellation test (BIT).
Dimensions of original are 298 x 208 mm. Reproduced by permission of
Thames Valley Test Company.
tasks clearly shows that all the tests are measuring aspects of
the same construct, clinically described as visual neglect.
Nonetheless, there were some discrepancies in the
homogeneity of the tests (table m). Representational
drawing loaded only 0-75, whereas figure copying had the
highest loading of 0-92.
The reason for including all 80 patients in the factor
analysis is that visual neglect is not an all or none
phenomenon.l9 Although some of the stroke patients scored
as well as the controls, the scores of the majority, though
above the designated cutoff, showed omissions on some
tests. For the purpose of examining the relative sensitivities
of the six tests, only the 30 patients who were classified as
showing neglect by the operational definition of an aggregate
score less than 130/146 were included.
Using the respective cutoff score for each individual test
we compared detection performance on each test with that
of the diagnosis achieved with the six-test aggregate cutoff
score. There was substantial variation in sensitivity (table
iv). Star cancellation (see accompanying figure) was the
most sensitive test, eliciting evidence of visual neglect in all
cases diagnosed on the basis of aggregate score. Drawing
from memory (representational drawing test), although
popular as a clinical bedside test, failed to identify a
substantial majority (63%) of neglect patients in our
(non-acute) sample. In groups including acute patients,
drawing from memory may be a more sensitive measures
Likewise, line crossing (Alberts test) and line bisection were
insensitive tests that correctly diagnosed little more than half
of the patients.
DISCUSSION
This analysis suggests that visuospatial neglect is, to a
large extent, a single phenomenon, and that different tests of
it have differing sensitivities. In the absence of any widely
accepted operational definition, reports of the frequency of
visual neglect must be considered within the context of the
particular criteria and tests used. The most important factor
that has contributed to the variation reported is the range of
different tests used to assess neglect.9,14,21 For example, Hier
and colleagues21 reported a frequency of 85 % in 41 patients
with right-hemisphere brain damage seen within 7 days of
stroke based on omissions in copying the complex Rey
figure. Vallar and Perani,22 studying 110 patients with
right-hemisphere damage of equivalent aetiology, found a
prevalence of 43% based on a simple cancellation task in
patients seen within a mean of 6 7 days since onset.
The subject is further complicated by the fact that some
behavioural neurologists advocate the use of visual double
simultaneous stimulation (in the absence of primary sensory
loss) as a clinically useful method for diagnosing visual
neglect.23,24 Yet the relation between the elicited response of
extinction and the more flagrant symptoms of visual neglect
is unclear, so the equivalence of these measures remains
open to question.2s In extinction, failure to detect a stimulus
depends on the simultaneous presentation of a second
competing stimulus, whereas visual neglect occurs with a
full range of head and eye movements and does not require
competing stimuli or fixation of gaze. Unlike florid visual
neglect, extinction is not readily apparent in spontaneous
behaviour.26 It is associated with damage of both left and
right hemispheres, whereas neglect of the left side of space
after right brain damage is very much more common than
the opposite. Reports of double dissociations suggest
caution in equating the two disorders.14,27
Since the manifestation of neglect is variable, many
investigators have thought that more than one test should be
used; several tests are more likely to uncover evidence of
neglect than a single test. Our study shows that, if only one
test is used, star cancellation from the BIT is an extremely
sensitive measure of neglect. It lends itself to very detailed
experimental analysis28 and is well-adapted to rapid,
accurate diagnosis. Nonetheless, 1 of the patients within our
large sample had a perfect performance on star cancellation
(54/54), but a score of only 30/40 on letter cancellation; the
worst control scored 33/40 on that test. A full examination of
any patient with suspected visual neglect must accordingly
use a wide range of different tests.
This work was supported by grants from the Chest, Heart, and Stroke
Association, and the Medical Research Council.
Correspondence should be addressed to P. W. H., Rivermead
Rehabilitation Centre, Abingdon Road, Oxford OX1 4XD.
REFERENCES
1. Zingerle H. Ueber Storrungen der Wahrnemung de eigenen Koerpers be: organischen
Gehirnerkrankungen. Monatsch Psychiatrie Neuro 1913; 34: 13-36.
2. De Renzi E. Disorders of space exploration and cognition. New York: Wiley, 1982.
3. Bisiach E, Berti A. Dyschiria: an attempt at its systematic explanation. In. Jeannerod
M, ed. Neurophysiological and neuropsychological aspects of spatial neglect
Amsterdam: Elsevier, 1987: 183-201.
4. Adams GF, Hurwitz LJ. Mental barriers to recovery from stroke. Lancet 1963; ii
533-37.
5. Wade DT, Langton Hewer R, Skilbeck CE, David RM. Stroke: a critical approach to
diagnosis, treatment and management. London: Chapman and Hall, 1985.
6. Caplan B. Stimulus effects in unilateral neglect? Cortex 1985; 21: 69-80.
7. Jeannerod M, ed. Neurophysiological and neuropsychological aspects of spatial
neglect. Amsterdam: Elsevier, 1987.
8. Prescott RJ, Garraway WM, Akhtar AJ. Predicting functional outcome following
acute stroke using a standard clinical examination. Stroke 1982; 13: 641-47.
9. Fullerton KJ, McSherry D, Stout RW. Alberts test: a neglected test of perceptual
neglect. Lancet 1986; i: 430-32.
10. Ogden JA. The neglected left hemisphere and its contribution to visuospatial neglect.
In: Jeannerod M, ed. Neurophysiological and neuropsychological aspects of spatial
neglect. Amsterdam: Elsevier, 1987: 215-33.
11. Albert M. A simple test of visual neglect. Neurology 1973; 23: 658-64.
12. Oxbury JM, Campbell DC, Oxbury SM. Unilateral spatial neglect and impairment of
spatial analysis and visual perception. Brain 1974; 97: 551-64.
13. Gainotti G, DErme P, Monteleone D, Silveri MC. Mechanisms of unilateral neglect
in relation to laterality of cerebral lesions. Brain 1986; 109: 599-612
14. Vallar G, Perani D. The anatomy of spatial neglect in humans. In: Jeannerod M, ed.
Neurophysiological and neuropsychological aspects of spatial neglect. Amsterdam:
Elsevier, 1987: 235-58.
15. Sunderland A. Cognitive aspects of visual neglect. Doctoral thesis, Brunel University,
1984.
16. Colombo A, De Renzi E, Faglioni O. The occurrence of visual neglect in patients with
unilateral cerebral disease. Cortex 1976; 12: 221-31.
17. Sunderland A, Wade DT, Langton Hewer R. The natural history of visual neglect
after stroke. Int Disability Studies 1987; 9: 60-65.
18. Wilson B, Cockbum J, Halligan PW Behavioural inattention test. Titchfield, Hants
Thames Valley Test Company, 1987
19. Weinstein EA, Friedland RP, eds. Hemi-inattention and hemispheric specialisation
New York: Raven Press, 1977.

Point of View
THE RELIEF OF COMMUNICATION
WILLIAM G. PICKERING
7 Moor Place, Gosforth, Newcastle upon Tyne NE3 4AL
WHY aregeneral practitioners attending to the
populations personal problems and anxieties in ever
increasing numbers,l when a stringent financial climate
suggests that their resources would be better channelled to
medical need? There is not a shred of evidence that doctors
are more able at handling non-medical problems than
laymen. Part of the reason lies in the escape of "hands-on"
medicine to hospitals, the resolve of GPs to retreat
therefrom, and the numerical growth of GPs. Thus
disburdened, GPs are available to tackle a wider range of
human need. At the same time, traditional fountains of
succour have decayed or been switched off. Religion is out of
vogue; families, wisdom, and generations are wont to
scatter; there exists a cult of the individual, not of the
community. These are ideal ambient conditions for the
sickness born of isolation to flourish nicely; and, with the
current fashion of seeking counsel at the surgery, the
National Health Service is fast becoming an integral part of
the populations modus vivendi rather than a service
primarily reserved for those requiring a medical opinion.
The old idea of medical omnipotence, not always
discouraged by the profession, is only part of the story. The
public are ducking the needs of their fellows. Rather than
receive a proposed confidence from friend or associate, how
often people interpose hastily, "Oughtnt you to see
someone?"-a thin euphemism for "Get thee to a doctor".
Do such persons deem it unseemly to listen? Are they
indifferent? Or do they truly believe that doctors alone hold
the sovereign remedies? We cannot exactly know; but it is
simple to divine that they are of no earthly use to a friend ill
with the need to unburden the heart.
So, propelled by a desperate urge to communicate, they
try the National Health Service. A common ploy is to
camouflage the complaint with the decorations of sickness.
Another is the frequent involuntary elevation of a minor
medical trouble to one of extravagant urgency and
importance which, had it occurred in a composed
individual, might scarcely have been noticed.
How often are the simplest things in life the most essential
and the most easily overlooked. Without communication
how "imprisoned and tortured"2 may the heart become. Yet
confidants do not abound and communication starvation is
indiscriminate: it is found in the young and old, the single
1. Morbidity statistics from general practice; third national study. London: HM
Stationery Office, 1986.
2. Thackeray WM. Vanity fair. London: Bradbury and Evans, 1848.
20. Schenkenberg T, Bradford DC, Ajax ET. Line bisection and visual neglect in patients
with neurological impairment. Neurology 1980; 30: 509-17.
21. Hier DB, Mondlock J, Caplan LR. Behavioural abnormalities after right hemisphere
stroke. Neurology 1983; 33: 337-34.
22 Vallar G, Perani D. The anatomy of unilateral neglect after
right hemisphere stroke
lesions: a clinical/CT scan correlation study m man. Neuropsychologia 1986; 24:
609-22.
23. Mesulam M-M Principles of behavioral neurology. Philadelphia: FA Davis
Company, 1985.
911
and married, the solitary and the gregarious, those in
humble or abject conditions, and those in apparently
buoyant or agreeable ones. "Is there a single person to whom
you can openly confide?" If the armour of stoicism and pride
be gently removed, comes the quiet and sorrowful reply
"No". Let there be no confusion. This is not a medical
problem but a human one with a human solution. The
requirements for a confidant are availability and empathy.
When depth answers resonatingly unto depth, the relief is
sublime and restorative. The quality is instinctive rather
than teachable and, in my judgment, as likely to be found in a
hairdresser or shopkeeper as in a doctor.
The new tendency to employ "counsellors" in general
practice suggests that doctors are either experiencing
self-doubt about their skills in dealing with non-medical
need or are being asked to do more than they can cope with.
Even for the doctor with special empathy a ten-minute
consultation is scant time for heart-felt deliverances to be
decently handled. One thing that distinguishes him or her
from non-medical confidants is the possession of blunt and
expensive instruments to terminate the consultation. Even
those doctors best equipped to soothe turbulent souls may,
for lack of time and energy, reach for the pen. The resultant
prescriptions, investigations, and referrals carry the tacit
message "I see, I feel, I care, but I cant help: please go".
Normal people with normal worries that have no outlet are
thus transmuted, at some expense, into patients.
The essential difference between non-medical problems
and medical problems is that thorough ventilation heals the
former but not the latter; and medical intervention is
indicated in the latter and contraindicated in the former. We
general practitioners should consistently rebut rather than
reinforce the notion that non-medical need is part of our
domain. The sage who declared that a trouble shared is a
trouble halved had ordinary people in mind as sharers. If
disused, the thousand natural healing influences of
instinctive, unwitting, and everyday counsellors will remain
wastefully inactive, eventually to disappear.
Round the World
From our Correspondents
New Zealand
PATIENT ADVOCATE AT AUCKLANDS NATIONAL
WOMENS HOSPITAL
THE first patient advocate appointed under the
recommendations of the Report of the Cervical Cancer Inquiryl
began work at Aucklands National Womens Hospital in mid-
September. Judge Dame Silvia Cartwright, who led the inquiry,
1. Committee of Inquiry into Allegations Concerning the Treatment of Cervical Cancer
at National Womens Hospital and into Other Related Matters. Report of the
cervical cancer inquiry. Auckland, 1988.
24. Heilman KM, Watson RT, Valenstein E. Neglect and related disorders. In: Heilman
KM, Valenstein E, eds. Clinical neuropsychology. 2nd ed. New York: Oxford
University Press, 1985: 243-93.
25. Schwartz AS, Marchok PL, Kreinick GJ, Flynn RE. The asymmetric lateralization of
tactile extinction in patients with unilateral cerebral dysfunction Brain 1979; 102:
669-84.
26. Critchley M. The parietal lobes. New York: Haffner, 1953.
27. Barbieri C, De Renzi E. Patterns of neglect dissociation. Behav Neurol (in press).
28. Marshall JC, Halligan PW. Does the midsagittal plane play any privileged role in left
neglect? Cogn Neuropsychol 1989; 6: 403-22.