Neuropsychologia,

1967,
Vol. 5, pp. 105to 117.Pergamon
PressLtd. Printedin England

IMPAIRED SELECTIVITY OF MENTAL PROCESSES IN

ASSOCIATION WITH A LESION OF THE FRONTAL LOBE

A. R. LURIA, E. D. HOMSKAYA, S. M. BLINK~V and MACDONALD CRITCHLEY*

Department of Neurposychology, Moscow University, Moscow, U.S.S.R.

(Received 26 July 1966)

Abstract-The paper deals with a special type of “frontal syndrome” resulting from lesions
deep within the mesial parts of the frontal lobes, more especially on the left. Psychological
processes lost what the authors term their “selective” character. The patient demonstrated
many instances of perseveration as well as confabulation. In this case there occurred a rapid
day-to-day deterioration, the features of which were carefully analysed. One of the interesting
points lies in the fact that the patient was a man of high intellectual as well as artistic calibre,
being both a scientist and a musician. A latent or ingravescent dysphasia steadily became more
evident as the tumour increased in size.

THE PROBLEM

[T IS well known that the frontal lobes are not to be looked upon as homogeneous structures,
for they include regions which differ considerably in structure and function. Consequently
it is not surprising that clinicians are able to isolate a number of variants of the “frontal
syndrome”. Posteriorly situated lesions of the convexity of the frontal lobes are associated
with severe motor disturbances; lesions of the basal parts of the lobes are linked with
symptoms of uninhibited behaviour and emotional instability; while deep lesions involving
connections with the limbic system and thalamic structures can result in disturbances of
vigilance, and a selectivity of psychological processes may often be a prominent symptom.
The last-named syndrome is observed most often in cases where a deeply situated lesion
of the mesial parts of the frontal lobe, particularly when it is bilateral, exists against a back-
ground of some general factor, toxic or hypertensive. In such circumstances it is often far
from easy to identify the role of the frontal component. For this reason, those cases are of
particular interest where lesions of the deeper parts of the frontal lobes without any back-
ground of vascular disease, are followed by severe disturbances of orientation in space and
time, and in a loss of selectivity of intellectual processes. Detailed analysis of such cases can
advance our assessment of the cerebral mechanisms necessary, for the preservation of a
healthy conscious state of existence.
The case we have studied during the summer of 1964 in the Bourdenko Neuro-Surgical
Institute, Moscow, affords useful information in this connection.

* National Hospital, Queen Square, London W.C.l.

105
106 A. R. LURIA, E. D. HOMSKAYA,S. M. BLINK~Vand MACWNALD CRITCHLEY

EXPERIMENTAL
The patient, Vass., 64 years of age, was a highly qualified scientist, whose background had been
unusually versatile. He was an engineer in the oil industry, who had previously been educated in a
Musical High School. Thus he has an excellent grounding in music, literature and art.
Until May 1964 he had been in good health, and was engaged in intricate scientific work. Only
during the previous few months had be complained of headache and tiredness; sometimes he felt lethargic
and occasionally he fell asleep while at work. It was noticed that he began to talk a little louder than
usual; sometimes he seemed not to notice people nearby; and he even gave instructions to persons he
imagined to be in his presence.
During May 1964 he spent some time in the Ural mountains engaged in work upon an oil plant. On
May 12th he wrote to his wife the following letter which showed nothing unusual:
“Tomorrow will be the day of the start of a new plant. I forget whether I mentioned
that yesterday I ‘phoned Moscow and had a talk with N.A.; she told me that on Thursday
she will be flying with Lucy to S., N is leaving for the Carbon Institute, and so N.A. is not
bothering to get him to come to S. All right, let him stay . . . Today it is the first fine day
we have had. I have been talking about giving a series of lectures . . . etc.”
Up to this date his behaviour had been perfectly normal. Two days later however it began to change.
On May 15th he had a headache and vomited; his behaviour became strange, and he even spoke of
spending the day in Baku (on the Caspian Sea). He urinated in the garden in front of a lady colleague,
and he sent his wife the following letter which contained a number of confabulations:
“Hello, dear. Today is May 15th. In the morning we went hunting with Igor [i.e. his
son, who was actually then in Moscow] about 15-20 km from our place. As expected, we
got nothing. We returned home at 10 a.m., had breakfast, and went to M.A.N. He was
very busy and told us to come back at 2 p.m. We returned then with Igor and my father
[the patient’s father had died many years previously], and we had a talk. Of course we are
hunters of quite different types, and we wanted his advice about what we should do, and
we were sure that we are the finest hunters imaginable. We bought some sausage though
not to send right away to Kiev. I am sorry I didn’t know that you could post me things
from Moscow, so we asked I.P.N. to send the parcel. Yesterday N.A. and Lucy turned
up. 1 did not meet them, but I waited for them in the administrator’s office. I was very
shocked by their arrival and all day long I have had a headache. Best love, S.”
The next day Vass. was quite muddled, and when his wife turned up from Moscow, she found him in bed
surrounded by a pile of newspapers pencilled with various senseless remarks and underlinings. He asked
her not to take the papers away, because he wanted to study them. He was confused, and his sleep was
disturbed. In this state he was transferred to the Neuro-Surgical Institute in Moscow.
On admission, the patient was bemused, emotionally upset, and slow in his replies. His behaviour
was apathetic, and stereotyped movements of both hands were observed like grasping his blanket and
scratching the wall. He was incontinent of urine, and was quite uncritical about himself.
Papilloedema was observed on the right side with retinal haemorrhages. The acuity of smell was
reduced in the left nostril. Optokinetic nystagmus to the right was diminished. Ocular movements were
full. There was a paresis of the left hand; grasp reflexes were present on both sides, more so on the right.
An EEG gave an irregular tracing, with a cluster of beta waves present mostly in the anterior parts
of the left hemisphere. There were obvious abnormal features in both anterior parts of the cerebrum,
more so on the left side.
X-rays of the skull showed the sella to be somewhat decalcified. Left carotid arteriogram: sharp
deviation of the anterior cerebral artery; no contrast substance in the arteries of the left frontal lobe,
suggesting a gliomatous mass in the frontal lobe near the midline distorting the right hemisphere.
Results of a special examination made by one of us (M.C.):
Reflexes: All his tendon jerks were in abeyance. Superficial abdominal responses were unobtainable
in all quadrants, but on testing for deep abdominal reflexes by percussion a very faint response was seen
in the right upper quadrant, but not the left. Hoffmann’s sign absent right and left. Mayer’s reflex
present right, and exaggerated left. Wartenberg’s sign absent right, slightly positive left. No grasping
phenomenon on either side. Plantar responses: on the right, a normal flexor, on the left the big toe
moved down, but the little toes markedly fanned. No grasping reflex of the toes occurred on either side.
No anosmia could be demonstrated.
Conclusion: As far as this particular examination went, it suggested a right-sided frontal tumour
lying far forward, with evidence of raised intracranial pressure. Probably a malignant glioma (astrocytoma
grade III).
All the other findings, however, as well as the absence of signs of severe hypertension suggested a
rapidly growing intra-cerebral tumour of the left frontal lobe, rather than the right.
 A FRONTAL LOBE LESION 107

On June 22nd, 1964, craniotomy was performed (Dr. S. N. Fedorov). In the middle part of the left
frontal lobe, 3 cm deep to the cortex, a tumour was found. The anterior portion of the tumour was
directed towards the polar region of the left side of the ventricle while the posterior parts were close to
the anterior frontal fissure. The mesial edge of the tumour could be seen on the parasagittal surface. of
the frontal lobe.
The tumour was removed. Histological examination proved the growth to be an oligodendroblastoma.
The patient’s post-operative state showed a marked improvement in his behaviour; but on the 5th
day after operation the temperature rose and signs of meningo-encephalitis developed. On July 12th the
operative field was reopened and pumlent matter was removed. On July 19th 1964 the patient died.

NEURO-PSYCHOLOGICAL ANALYSIS OF VASS.

General data

Neuro-psychological studies 2 weeks before the operation revealed no disturbances of

an agnosic, dyspractic or dysphasic character.
The patient was able to recognize objects and pictures shown him and he evinced no
difficulty in reproducing movements on command. “Postural praxis” was intact, and no
disturbance in the spatial orientation of movements could be observed. He showed no
upset in reciprocal coordination as regards hand movements, and he could imitate any
rhythmical patterns given him. Nor was there any impairment seen when he was required
to change from one motor rhythm to another. He could easily repeat complex rhythmical
melodies, both according to acoustic patterns and to verbal command. He had no difficulty
in carrying out elaborate motor reactions when told to do so, and he could perform such
complex activities as lifting his right arm when the examiner gave one knock, and his left
arm when two knocks were given. Reverse instructions were easily performed and he made
no mistakes. He had no trouble carrying out an intricate motor programme, being able to
execute a series of drawings (such as two circles followed by a cross, and then three triangles
etc.). His performance in this respect differed markedly from the results described in patients
with massive tumours of the frontal lobes (LURIA [l]; LURIA and HOMSKAYA [2]; LURIA,
PRIBRAMand HOMSKAYA [3]).
During the first few days after admission, the patient’s speech did not show any defect.
He was easily able to repeat separate sounds and words spoken to him, and no defects could
be made out either in phonematic usage or in articulation. A series of four or five words was
readily repeated on request. He displayed no difficulty in understanding speech, or in
naming objects. Reading and writing were intact, and he had no obvious trouble with
arithmetic. The fundamental symptoms of the patient at this time consisted in a marked
upset in orientation within his immediate environment, together with an inadequate insight
into the actual situation, and a disturbance of selectivity of his intellectual processes.
Although highly cooperative and ready to carry out any instruction, the patient was
severely disorientated in space and time. To direct inquiry he stated that he was in his own
Institute on the banks of the river Dniepr within the office of the Director. He became
uncertain when asked the date, and could not say what he had been doing the previous day
or even hour. He proclaimed that he had just returned from a walk; that he had been
invited to go to the Opera that night; and so on. He was in doubt as regards the identi-
fication of persons, mixing up the physicians with his friends. Nevertheless he readily
agreed that he was in a hospital, although at a loss to say why, or when he had been brought
there.
108 A. R. LURIA, E. D. HOMSKAYA,S. M. BLINK& and MACDONALDCRITCHLEY

As a rule he regarded himself as being quite well, but when asked why he was in bed, he
replied that probably he was ill, but he was unable to answer any question as to the nature of
his complaint. He could not give any account of his early life, and in telling his history he
mixed up happenings pertaining to different years. There was much confabulation as to his
life history, and he stated that he was a member of the orchestra attached to the Academy of
Sciences. Although seriously confused, he later became able easily to recognise his relatives
and his doctors, rarely making any mistakes in evaluating the time between their visits.
His social graces were intact, for he was polite and friendly, and showed no catastrophic
reaction even when complicated questions were put to him.
His attention was unstable, and any extraneous stimulus easily changed the content of
his talk or behaviour. Thus, if a nurse entered the room, he would stop whatever he was
saying and would either ask her a question or else bring her into his conversation. In this
way his activity lost its selective character. When during the examination the psychologist
spoke quietly some words to his colleague, the patient included the topic in his talk. The
same phenomenon occurred when the patient in the next bed said something aloud;
orientated activity was then replaced by a dialogue between the two patients, irrespective of
the presence of the physicians. When one of us (A.R.L.) whispered to his colleague (M.C.)
a few words in English, the patient stopped speaking Russian and began to talk in English,
and asked whether the translation of his manuscript was ready. Observing the notes which
were being made by the psychologist he asked questions such as “When would the report to
the Head of the Institute be ready” or “When would the paper be presented to the Board”.
The patient was unable to evaluate the nature and setting of the examination correctly,
and on being asked, replied that he was being interrogated by a Commission appointed to
assess his scientific work. As a rule he was unable to adopt any critical attitude towards
himself; he could not correlate the results of his actions with the intentions, and his affective
responses remained very diffuse; often he said that he was unable to match his actions; . . .
“everything is confused’. Sometimes his thoughts became muddled with the impressions
arising from out of an actual situation. Thus when his hand became entangled in the net
covering his bed, he remarked “They have caught the fish in the Dniepr”, and moreover that
“Everything was important for the well-being of the fish industry”.

The questions are printed in italics, the patient’s answers in ordinary print.
Where are you now?. . . Where are we now?. . . Well, in (Echolalic reproduction of
this Institute. In what Institute? In the Technological one the question)
. . , Have you already sent in a report to the Director? (Habitual stereotypies)
What about? About some important matters I must get
ready for the meeting of the Academy.
The state of confusion, with the contamination of the flow of conversation by inter-
ruptions such as would be impossible in a normal waking state, was one of the most striking
features of our patient’s behaviour, who presented no symptoms of general retardation or
torpidity; and absolutely no agnosia, apraxia or aphasia.
There existed therefore a marked dissociation between the general confusional state of
his consciousness, and well-preserved “gnosic” and “praxic” operations.

Disturbance of the patient’s selective organization of actions

We come now to the question whether it was possible to find any conditions in which
even those operations would lose their selective, organized character. Were such conditions
 A FRONTAL LOBE LESION 109

discernable, we would have gained important insight into the analysis of the mechanisms
leading to the loss of selectivity of the patient’s mental processes.
We began with a series of tests directed towards a search for limitations in the patient’s
selective organization of actions. The patient was able to reproduce to command all move-
ments carried out by the physician. No difficulty was observed in changing from one complex
of motility to another. There were two sets of circumstances which could possibly impair
the execution of actions requested. First of all, an impairment was observed when a series of
successive movements was demanded. Secondly, difficulty was experienced when a re-coding
of the given pattern was required. In both cases the patient’s movement had to follow a
complex pattern, and it was then found that his movements or actions readily lost their
selective structure, and became perseveratory or echopractic in character.
The patient’s actions were obviously adequate when it was merely a question of an
immediate reproduction of a pattern or an instruction, but they lost their selective character
as soon as the pattern became more complicated and whenever actions entailed a series of
linkages within the given pattern. In such cases correct reponses were replaced by meaning-
less stereotypies, or by contaminations. Such a loss of selectivity of actions could be seen
whenever the task came into conflict with the direct influence of the stimulus. The behaviour
of the patient remained correct so long as stimuli evoked an immediate response, but the
selectivity of the action would become lost as soon as it was ordained by the memory-traces
of a complex instruction. At such times the traces of the command would be too weak to
produce a specific dominant reaction. To put this assumption to the test it was necessary
to turn to special studies of the selectivity of the patient’s memory.

Disturbances in selectivity in memorization

The problem then arose whether, in the absence of agnosic, apractic or dysphasic
defects, any defects in memory-processes existed, and also whether there was any upset in
the selectivity of the storage and reproduction of memory-traces ?
The patient was able to retain isolated words and phrases, and also to reproduce them
after short intervals. At times he could even retain a series of four or five words, and recall
them after 20 or 30 sec. Further testing revealed that this retention was inconsistent, and if
the same task was repeated under more complex conditions, a loss of selectivity of memory-
traces might be observed, and the patient would begin to display associated linkages of a
non-selective character. Such a defect in selectivity was readily seen whenever the interval
between the storage and the reproduction of a series was increased, as well as in tests where
the subject had to recall a series of two or more words, each series having an inhibitory
influence upon the other.

(12/VI/64)

A group of four or five words was presented orally, and the patient was told to repeat
back these words after a short interval. In the first test he had to reproduce the series
immediately; in the second, after an interval of 1S-20 set; and in the third, after an interval
of 15-20 set which had been occupied by interpolated conversation.
The patient evinced no difficulty in immediate or even in delayed recall ; but an interval
occupied by irrelevant talk showed that the traces were insecure, and that they were easily
replaced by contaminations (cat-cattle), or even by unselective associations (cattle-bull).
110 A. R. LURIA, E. D. HOMSKAYA, S. M. BLINK& and MACDONALD CRITCHLEY

Whenever verbal processes are probed more exhaustively in patients with deep lesions
of the left frontal lobe, certain “pre-aphasic” signs can occasionally be recognised, as indeed
in our patient when tested for the retention of a series of five words.
Here again, selective reproduction of a word-series was replaced by the intervention of
additional associations, and the selectivity of the series became lost.
Comparable data could be obtained in special test-situations when the patient was
instructed to retain a group of two or three words (group A) followed by a second group of
two or three words (group B). After this second test he was then told to reproduce group A.
Here, as before, a selective reproduction of a verbal series, given in an orderly fashion,
loses its selectivity when the conditions are more complicated, and are replaced by non-
selective alternatives due to a retro-active inhibition. The loss of selectivity became even
more obvious when the retention and reproduction of complex verbal material was specific-
ally tested. A sentence was given to the patient, and he was told to repeat it after an interval.
It was easily seen that whenever the patient was fatigued or drowsy, the selective reproduc-
tion of the phrase in question was replaced by a number of extra-associations, which the
patient was unable to inhibit.
The verbal traces were obvious, and even on immediate repetition, extra-associations
were added. After a “filled pause” the selective reproduction of the sentence was replaced
by uncontrolled associations. The question arises whether this loss of selectivity was due
merely to an instability of memory-traces, or whether in addition it was the result of a loss
of the function of control; in other words, a loss of matching of relevant and irrelevant
associations which is so important a component of any selective process of memorization.
To answer this question a special test was devised. The patient, when unable to reproduce a
given verbal series, was asked to pick out the words he needed from a list put before him.
This test, which entailed recognition rather than recall, demonstrated not only the presence
of unstable traces, but also an impairment of matching-process underlying the defects which
have been described. To begin with, Vass. used only occasionally a matching of the words
given with the traces of the previously given series, but after a few attempts he replaced this
matching with an inapt repetition of the answer already given. Only a special analysis of
the latencies of his answers made it possible to determine whether traces of the former series
remained in his memory or not.

Disturbance in the selective reproduction of texts

The same disturbances of selectivity as were observed in the patient’s verbal memoriza-
tion could also be discerned in the reproduction of complicated paragraphs.
The patient was quite unable to preserve a selective system of association which form a
basis of the story, and the fundamentals were soon muddled up with extraneous associations.
The confusion of selected systems can be seen in special circumstances, when the content of
one become confused with the content of a totally different one. These facts can be illustrated
by special tests, in which the patient was given two successive tasks.

Disturbance of selectivity in the naming of objects

It has already been stressed that no symptoms of aphasia were observable in this patient,
but in some conditions the same disturbance of selectivity could be observed even in
elementary forms of speech, suggesting a kind of “pre-aphasic” state, This was demonstrable
in special tests, and after a time, when Vass.‘s general state worsened, it could even be
 A FRONTAL LOBE LESION 111

detected in his ordinary verbal behaviour. As already mentioned, the patient did not display
any difficulty in understanding speech, or in naming objects. He could easily identify
isolated articles, but when he was asked to name two simultaneously presented objects,
perseverative mistakes could be observed; after the patient became tired, this symptom
would become very obvious.

Still more obvious errors could be observed in tests dealing with the naming of objects
It is well-known that the naming of an object is a complex process, which includes singling
out some leading features of the article, and also its assignment to a certain category. This
process necessarily includes the suppression of inappropriate alternatives, and a selective
choice of proper designations. In a normal waking state this process does not occasion any
difficulty, but, as is well known, when the subject is drowsy it can become diffuse, and various
designations can be confused. In our patient we were able to discern evidences of a loss of
selectivity in our tests which concerned the naming of objects. Often this symptom showed
itself in a certain excess of detail in the replies, indicating an impairment of inhibition of
extraneous associations. Such symptoms were very obvious when the patient was asked to
name two or three objects; in this case symptoms of a pathological inertia were observable,
and the normal transition from one term to the other became severly impaired.

The naming of two simultaneously presented objects becomes a sensitive index of

disturbed selectivity of intellectual processes, and the observer can thus observe a certain
amount of new and unexpected data. The following examples may be given in illustration:

(18/W/64)

Pairs of objects, (or pictures) or groups of three were shown to the patient and he was
told to name them.

(a mushroom and a goose) (a beetle and an elephant)

. . . “a duck” (he pointed to the goose) “ . . a disease . . . and an elephant”
“and a red duck” (he pointed to the mush-
room)

(a globe and a watch) (a goose, a beetle and a mushroom)

“a world . . . a globe . . . and a globe “a duck . . . a disease . . . and a duck” (the
experimenter here whispered to his col-
leagues : “these are dynamic symptoms”)
. . . a globe” “Of course, dynamic!”

dis . . . a. . . cancer”

Examples such as these indicate certain pre-aphasic symptoms observable in special

conditions. The difficulty in naming objects is clearly connected with disturbed inhibition
of extra-associations and of pathological perseveration. Inertia so typical of the frontal lobe
syndrome, became well-marked when a transition from one type of naming to another was
added, rendering this process impossible. This pre-aphasic disorder symptomatic of a
disturbance of the left frontal lobe, illustrated the influence upon processes of verbalization.
112 A. R.LuIuA,E.D.HoMsKAYA,S.M. B~r~~bvand MACDONALD CIWCHLEY

Disturbance of the selectivity of intellectual processes

Consequent upon the foregoing data, the intellectual activities of our patient could be
expected to show a disturbance of selectivity similar to those in his memory-processes. That
his formal intellectual operations did not show any marked impairment could be observed
only when relatively simple and familiar intellectual operations were concerned. But when
in order to solve a problem the patient had to make a choice from several alternatives of
equal probability, his mental activity would become considerably disturbed. In such cases
we were able to observe defects of selectivity similar to those already mentioned.
This fact could be shown by tests where a logical operation preserved in one condition
(i.e. when the necessity of choice from many alternatives was reduced) faltered when the
same problem required a selection out of many alternatives. Such a complication came to
light when we requested the patient to solve a logical problem in two different sets of
circumstances.
So far we have analysed certain logical codes which were well preserved in our patient,
and which would become disturbed only in circumstances entailing a choice. We might
expect tbat the same type of disturbances would be much more marked whenever such highly
automatized logical codes were inaccessible and where the alternatives before the patient
were of a higher level of certitude. Such are the typical features of all operations which entail
transfer of meanings, and assessment of the meaning of complex pictures. It is for this reason
that both operations proved to be very imperfect in our patient.
The main defect in the patient’s thinking clearly lay in the fact that Vass. was unable to
suppress irrelevant associations which were provoked by the situation. Any analysis of the
meaning of the proverb was replaced by unselected statements arising from attempts to
compare the basic difference between two countries irrespective of the problem which the
patient was asked to solve.
The same type of disturbance was seen in tests which entailed an analysis of the meaning
of complicated pictures. A fragmentary perception of the elements included in a picture led
to a whole medley of associations; the patient proved to be unable to make the necessary
choice from all these, and instead of an organized analysis of the content of the picture, a
flow of unihibited interpretations of isolated details took place.
The case-notes made it clear that in our patient, organized intellectual processes linked
by a programme were very unstable. Selective analysis of the meaning of the set of pictures
as a whole, was readily replaced by numerous immediate associations evoked by the patient’s
irrelevant impressions. When his mental process had no fixed logical lines, and when he was
faced with a choice out of a number of possible alternatives, his intellectual activity lost its
linked, organized character. This could be demonstrated by special control tests. When this
factor of incertitude as between multiple alternatives was eliminated, the whole intellectual
activity being now dominated by a single logico-grammatical context, all difficulties would
disappear, and the patient proved able to solve the set problem. This was shown by the use
of Ebbinghaus’ tests, where the patient was shown a text with various words omitted. When
the probability of filling the gap with a particular word was high, the patient’s intellectual
operations became normal. For instance, when one reduced the uncertainty of extra-
associations, they could be inhibited so that the patient was able to use the necessary intel-
lectual operations. All our findings warranted the assumption that more complex forms of
discursive thinking would be impaired in our patient, as a result of a loss of selective, well-
programmed intellectual processes.
 A FRONTAL LOBE LESION 113

An analysis of the processes of problem-solving behaviour, confirmed this view, where

an inability to suppress extraneous factors might result in an upset in the whole intellectual
operation.

MODIFICATION OF THE NEUROPSYCHOLOGICAL SYMPTOMS

FOLLOWING OPERATION

As emphasized, the patient’s basic symptom entailed an impaired selectivity of his

intellectual processes, which contrasted with well-preserved “gnosic”, “praxic” and verbal
functions, as well as with the more highly automatised mental codes. What were the changes
observable in Vass. after his operation ? To begin with a reduction occurred in some of the
symptoms, but after a week a meningo-encephalitis complicated convalescence. Accordingly,
three stages within the post-operative state can be described: (1) a period of post-operative
oedema; (2) reduction of symptoms; and (3) a stage during which general cerebral
symptoms complicated the focal disturbances. Specific studies clearly reflected correspond-
ing neuropsychological changes observable during these three periods.

During the first of these phases no marked changes in the patient’s mental state as
already described could be seen. He was confused; believed that he was in “some hospital
or other”; was hazily orientated in time; and he showed confabulation. A general irritative
state occurred in which motor perseveration was seen. When told to squeeze the physician’s
hand two or three times, he continued to go on squeezing many times on end, repeating
meanwhile one-two, one-two, etc. The same inability to stop was observed in the rhythmical
tapping test: he reproduced the rhythm given, but continued it for an inordinately long
time. Throughout this period he was unaware of his errors. Defects in conditional motor
responses became greater; after the instruction “when you see my fist, show me your
finger; and vice versa”, he gave a confused verbal reply : “I am showing you a finger which
becomes a fist and which shows my disdain”. Or else he answered in an echolalic manner:
“When you show me your finger, I shall show you my finger” and so on. Considerable
changes were to be seen in his drawings which offered abundant evidence both of his
irritability and of the motor perseverations (Fig. I).

All these symptoms were observable during the first three days after operation, but dis-
appeared after the fifth day.

The patient’s speech during this time remained unchanged, and only in the repetition of
strings of words were perseverations and contaminations detectable. When told to repeat
the two sentences: “On the edge of a forest a hunter killed a wolf” and “In the garden
apple trees were in bloom” he repeated “In the garden . . . on the edge of a forest apple trees
were growing . . . and a hunter went and killed . . . a rabbit”. In putting a name to some
objects he often evinced perseveration and unsuppressed extraneous associations : thus
trying to name “a beetle”, he said: “It is . . . lapis . . . l’apis . . . with an apostrophe . . .
apis . . . place . . . That thing can bring to a man . . . a name. . . and a family name . , . ”
and so on, showing a total loss of selectivity.

Similar features were seen in the reproduction of paragraphs, and he repeated the story
The jackdaw and the Dove in a very confused manner; “You told me all about the victory
of a white colour as a colour of progress over a black colour as representing a colour of
114 A.R.LuRIA,E.D.HoMsKAYA,S.M.BLINK~V~~~ MACDONALD CRITCHLEY

regress . . . . Please forgive me . . . (looking at M.C. at this point) but that was a text about
the significance of the colour white” etc.
Similar manifestations appeared when Vass. was asked to analyse a picture illustrating
the broken window (see Fig. 2) “That is a strange story” he said “ . . . I didn’t quite grasp its
meaning. There were two girls . . . They went to a market . . . and windows in their flat
were broken (at this point the nurse gave some water from a bottle to another patient in the
side-ward) . . . They broke a bottle instead of a window (Vass. here looked around at his
fellow patients in the ward) . . . They broke . . . some chaps who are sitting there . . . ” etc.
Signs of confusion were noticeable even in his immediate orientation. Thus, on the 4th
day after the operation, he started the conversation by saying: “Well, what have you done
with our manuscript? Have you already had it typed? We must show the manuscript to the
Head of our Department . . . ” When asked why his arms were fastened to the bed, he
replied : “That’s because I am all the time working with my hands . . . I have to write my
manuscript . . . and this gentleman (indicating his own head) has to write this message”.
(These words probably represent a confusion of the actual situation with the famous picture
by Repin “The Head of the Cossack writing a message”.)
Thus, during this period his confusion was far more gross than before operation.
The second phase showed a marked regression of these symptoms. On the 8th day after
his operation he still imagined that he was in a Technological Institute, but for a short while
he became critical, complaining that his speech had “lost its precision”; that his “left side
would say one thing while thinking about another” . . . “there is some rupture”. At this
time only isolated evidences of perseveration could be noted, and an inertia of motor
activity was seen only when the patient became tired. He could repeat a series of four words,
and the naming of pairs of objects became possible.
The disturbance of selectivity in his intellectual processes continued, and on the 7th
post-operative day he repeated the tale about the Jackdaw and the Dove as follows: “A
jackdaw (there was a noise outside of an axe chopping wood) went to cut the black spots
but. . . without any result . . . have you really studied the whole literature concerning this
problem?. . . ” He tried to find the crux of the fable, saying “The jackdaw went to the
jackdaw’s house hoping to find better food . . . but the doves discovered it was from another
tribe...oh...no!...Ihavelostitall...”. The same impairment of selectivity could be
seen in his repetition of the next fable, which concerned the Ant and the Dove: “The ant
went to a stream . . . and it met a jackdaw . . . and a crow . . . and a crow is not so clever as
an ant, and a fox . . . “. The same sort of confusion could be observed in the patient’s other
intellectual activities during this period of time.
The third phase, when symptoms of a purulent infection were present, brought about an
increasing confusion, and the symptoms of mental deficit became very marked. During the
last period (i.e. the 3rd and 4th weeks after operation) psychological examination became
impossible, and the patient died 4 weeks after operation.

POST-MORTEM FINDJNGS

A post-operative defect in the left hemisphere involving the cortical tissue of the first and
second frontal convolutions, was seen lying close to the convexity of the frontal pole, and
occupying a part of the limbic gyrus anterior to the rostrum of the corpus callosum. The
surgical track implicated the region of the tumour. The cortex of the anterior parts of the
 A FRONTAL LORE LESION 115

first and second frontal convolutions and of the limbic gyrus close to the genu of the corpus
callosum was destroyed, as well as the dorsal part of the white matter of the frontal lobe in
its polar region, and its zone beneath the medial surface of the hemisphere in the limbic lobe
as well as below the genu of the corpus callosum. The defect involved the left side of the
genu. The walls of the cavity showed a purulent pachymeningitis.
Histological examination showed it to be an oligodendroglioblastoma.
After the operation a purulent meningo-encephalitis supervened. That is why it was
impossible to define precisely the limits of the tumour. We can be sure that the growth did
not spread to the areas which remained intact, as histological analysis revealed.
The post-mortem diagnosis may therefore be stated as an oligodendroglioblastoma of
the upper and middle parts of the left frontal lobe, occupying the region between the frontal
pole and the anterior horn of the left lateral ventricle.

CONCLUSIONS

A neuro-psychological analysis is presented of a patient with a deep-seated tumour of

the mesial parts of the left frontal lobe, with extension to the right frontal lobe.
The syndrome in question had some of the features of the “frontal lobe syndrome” as
described elsewhere (LURIA [l]; LURIA and HOMSKAYA[2]); but there were also some
additional features peculiar to our patient.
The patient showed a lack of spontaneity; an inadequate critical attitude towards his
own state; and a pathological degree of inertia in complex actions and intellectual processes.
He differed from most other “frontal” patients in possessing well-preserved motor activity,
a feature which contrasted markedly with his confused state and his loss of selectivity in
intellectual processes.
No symptoms of an agnosic, apractic or aphasic character were observed. The patient
was able to imitate given movements to command, and no defect was observed in tapping
tests. He carried out with ease a transition from one rhythm to another, and he could
perform a short series of motor actions to command. He could readily repeat chains of
words and phrases; there was no defect in the understanding of speech, nor in the decoding
of logico-grammatical structures.
All these points contrasted with his severe state of confusion. The initial symptomatology
consisted in disorientation in space and time, and this disorder remained as a central
manifestation of the whole syndrome.
To analyse some of the mechanisms underlying this state of confusion, a number of
test-procedures was devised.
It was found that the motor activity of our patient, which was ordinarily well-preserved,
lost their selectivity when it was necessary for them to be determined by means of traces of
a certain verbal programme which included several alternatives. In such circumstances, the
patient’s pathological inertia interfered with his normal activities, and signs of contamination
could be observed.
The same defects could be seen when the patient had to re-encode some immediate
impression, and whenever his activities had to follow a programme which conflicted with
immediate impressions.
116 A. R. LURIA, E. D. HOMSKAYA,S. M. BLINK& and MACDONALDCRITCHLEY

Features indicating a loss of selectivity could be observed in the patient’s verbal activity.
Repetition of a word-series showed that traces of some earlier associations would influence
the reproduction of the words actually presented, and signs of contamination occurred in the
verbal sphere.
It is noteworthy that the greater the number of alternatives included in the programme
of verbal activities, the greater was the confusion. Thus, the loss of selectivity could be
observed in tests requiring the factor of choice, the defect increasing directly with the degree
of uncertainty between several possible alternatives.
As a rule the patient could not correct deviations from the programme observed in his
actions; matching their effect with the intention was not possible. He was unable to control
his extraneous associations or to compensate for the loss of selectivity.
The underlying neuro-psychological mechanism of these symptoms is still unknown,
but it seems possible that they result from a low potential of cortical excitation which
equalizes the intensity of different traces, and disturbs the dominant dynamic foci. This
hypothesis would account for the disturbance of organized activities, the shift from the
linked, programmed processes to perseveration, and the contamination with associated
ideas. It was significant that the loss of selectivity mostly affected the verbal and intellectual
activities, and was scarcely demonstrable in the motor sphere.
The localization of the tumour within the medial parts of the left frontal lobe, and the
possible implication of the right frontal lobe, and of paths ascending from the reticular
formation might be responsible in part for the syndrome described. Disturbance of the
normal relations of the left frontal cortex with the “speech area” could be responsible for
the “pre-aphasic” syndrome and for the disturbances of intellectual processes.
The fact that the convex parts of the frontal lobe remained intact might explain the
relative integrity of motor functions.
The absence of hydrocephalus and of hypertension permits this case to be regarded as
the clinical expression of a circumscribed focal lesion of the deep medial parts of the frontal
lobes.

REFERENCES

1. LURIA, A. R. Higher Cortical Functions in Man, Moscow University Press, (Russian), 1962. (Trans-
lated into English. Tavistock Publications, London, 1966).
2. LURIA, A. R. and HOMSKAYA,E. D. Le trouble du rBle rtgulateur du langage au tours des l&ions
du lobe frontal. Neuropsychologia 1,

LURIA, A. R., PRIBRAM, K. H. and HOMSKAYA, E. D. An exprimental analysis of the behavioral

disturbance produced by a left frontal arachnoldal endothelioma (meningioma). Neuropsychologia 2,
257, 1964.

Resum&-Ce travail a pour objet un type spkial de “syndrome frontal” rt%ultant de l&ions
profondes situ&es dans les parties frontales internes surtout du c8tB gauche. Les processus
psychologiques avaient perdu ce que les auteurs appellent leur caractere sblectif. Per&&a-
tions et confabulations &aient frkquentes chez ce malade. Une dCtCrioration rapide, de jour
en jour se produisit et ses caract&es en son analysCs soigneusement. Un fait inGressant est
que le malade &ait un sujet de haut niveau artistique et intellectuel, Ctant B la fois un scien-
tifique et un musicien. Une dysphasie latente se manifesta avec l’accroissement de volume
de la tumeur.
 A FRONTAL LOBE LESION 117

Zusammenfassung-Die Arbeit befat3t sich mit einer besonderen“ Stirnhirnsymptomatik”; sie

entwickelte sich auf dem Boden einer tiefsitzenden L&ion in beiden Frontallappen unter
stlrkerer Beteiligung der linken Hemisphare. Das, was dem seelischen Geschehen fehlte,
bezeichnen die Autoren als (selektive) auswlhlende Funktion. Die in diesem Fall auftretende
rapide, von Tag zu Tag fortschreitende Verschlechterung wurde in ihrer Besonderheit genau-
estens analysiert. Was den Fall u.a. interessant machte, war die Tatsache, da8 es sich urn
einen Mann handelte, der iiber auljergewiihnliche intellektuelle und ktinstlerische Fahigkeiten
verfiigte. Er war zugleich Wissenschaftler und Musiker. Eine zunachst latente, aber rasch
zunehmende dysphasische Sprachstiirung verstlrkte sich konstant im gleichen MaRe, wie der
Tumor an GroiBe zunahm.