Document 93dNx9yjvjBE7rqNy22MyYmmp

A?K / f y ............................ vr* . pfcum pij'ciiolo ol. 10. pp. ZS rrTeSc)^ IO J5J. persa m on Prest, Printed in E n s U M / f ^ g _ ,S^ T <5 Y R, ^AY "' rV. `.*** WRITING DISTURBANCES IN ACUTE CONFUSIONAL STATES - :*V . F ranois Chdru* and Nrman Geschwind ; Neurological Unt. Boston Qty Hospital and Department of Neurology, Harvard Medical School; : .. Aphasia Research Center, Department of Neurology, Boston University School of Medicine! *.V -....... '. - *. V; *' '* - - ' j * ; '{Received 11 April IS l) / V : ` - - Abstract--Studies of writing ability were carried out in 34 acutely confused patients. Their j performances were compared to those of 10 controls and, ! 24 of the cases, to their own - performance after recovery from confusion. - . Writing was impaired in 33 of the 34 cases. The writing disorder could involve the motor and tiic spatial aspect of writing as well as spelling and syntax. It was the most constant and the most striking linguistic disorder seen in these patients. It disappeared When the confusion . cleared. The spelling disorder had the following features: high error rate in consonants and . if 'n a i; grammettrai words in their entirety, higb rate of missiez and substiTUtirn, hijh involvement of the last letters of the words. The problem of pure agraphia is discussed in the contest of these findings. - `' *- ... . Writing disturbances in focal brain lesions are well recognized, (Marce, [I]; Benedikt, [2]). .In general, such disturbances are associated with aphasie, aiexic or apraxic signs (for a recent review,sec Leischner, [3]). In a few cases, however, writing impairment has appeared . to be isolated. This isolated defect in graphic expression has been called "pure agraphia" (P.A.). In these cases the lesion has most often been considered to be localized in the left . : frontal area, (Gordinier, [4]; H enschen, [5]). For these authors, such cases represent a confirmation of the cerebral writing center postulated by Exner, [6] to be in the foot o f the left second frontal convolution. .-.i-.V. ........... . '. Many neurologists have however been reluctant to accept the existence of such a center, (Dejerine.[7]; Wernicke,[8J; Rawak,[9]; RussELLand Hspir,[10]; Hecaen, Angelergues and Douzenis, [I JJ). The present study was in part motivated by our own skepticism con cerning the existence of pure agraphia on the basis of an isolated destructive lesion in the left frontal lobe. We had been struck first by the difficulty of finding such cases (either personal or in the literature). Secondly we had found that, in contrast to our failure to find cases of pure agraphia with focal vascular disease, we had seen many cases of agraphia, with little or no other language disorder, in patients with toxic or metabolic confusional states. Thirdly, we had noted that the cases of P.A. in the literature, although often attributed to,focal disease, frequently had tumors and were often stated to show general mental impairment. We therefore decided to explore methodically the question as to whether isolated writing disturbance could be found in cases suffering from acute confusional states (A.C.S.). *. i 'A 0j's> * Present address for reprints: Service de Neurologic et de Ncuropsychologie, Hpital de la Salpclriirc. 47, boulevard de l'Hpital, Paris ( 13o)--France. t Some of the work reported here was supported by Grant NS 06209 from the National Institutes of Health, and by fellowships to Dr. Chdru from the Eli Lilly and Fulbright Foundations. 343' b Cr 344 F ranois Chedru and Norman G eschwind For the purposes of our study, we have characterized the principal features of the A.C.S. as follows. The main characteristic is a reduction and/or a ready shifting of attention. Other symptoms, (e.g. disorientation, changes in mood, hallucinations), arc not essential for the diagnosis. A.C.S. may occur in any kind of toxic or metabolic disorder, especially of rapid onset, as well as in cases of head injury, subarachnoid hemorrhage or increased intracranial pressure, especially when of rapid onset. The type of pathogenic agent involved y appears to have little bearing on the clinical picture of the A.C.S., (Bonhoeffer, [12]). In this report we will describe the writing impairments we observed in 34 acutely .confused patients. On the basis of these observations, we will reconsider the problem of P.A. c y v II y I .->I I % . .. . METHODS - . -1 Subjects, . * .'V , ......... ; ....... Pour groups of subjects were examined: 1. Patients presenting with "natural** A.C.S.. 2.` Patients recovering from electro-convulsive therapy, 3. Patients receiving barbiturates during the induction of general anesthesia, 4. Controls. For the pathological groups, the following requirements were set: (a) reduction and/or shifting or attention of recent onset related to a well defined toxic or metabolic *.V .. disorder. The attention disorder was evaluated on the basis of clinical examination. (b) absence of signs of focal brain lesions and of chronic intellectual deterioration. ' ' (c) age below 60 years, m w ..:..... L ... (d) ability to cany out the test battery, ' / ' / . Every patient--but 3 of group 2--demonstrated some disorientation for time and place. On another hand, every patient of groups l and 3 performed abnormally on one or both of two tests generally con- . ... sidered as "attention talcs'*: digit span and a test of auditory--motor.attention (patients of group 2 were . not submitted to these tasks)., Group I. Patients presenting with "natural" A.C.S. The eUoiogiui were: -Jcihicir: irzi::irz (10 civ'd/:. hepatic encephalopathy (6), Wemicks's encephalopathy (4), acute alcoholic intoxication (1), te r biturate intoxication (!) In several cases more than one disorder was present. Group 2. Patients undergoing electro-convulsive therapy (E.C.T.). These patients were examined during the short confusional state following E.C.T. Before E.C.T., each patient received barbiturates end th- tub'rquer.t A.C.S. r^-y have teen related both to medication and E.C.T.: 9 patients were suffering - from psychotic depression and 1 from schizophrenia. ./ '.'Table 1. Group characteristics (number of Ss, age, educational background). Educational levels were defined as follows: Level 1: s having had no high school education. Level 2: Js with more . than I year in high school, but cot graduates. Level 3: high school graduates. , Number . \ 1Age - of s (mean age and range) *Group 1 . .'* ("natural" A.CS.) ' Group 2 (E.C.T.) . Group 3 (general anesthesia) Group 4 (Controls) 22 .. io 2 . 10 44 (28-55) * *46 (24-60) 42 (37-44) 41 (24-59) - Educational background levels I23 _ H 3 ** 33 8 4 . I 1 33 J *'* v: *r; | -- fd I Group 3 of J.V. barbi surgical ane; Group 4 (d) above an The cha given n Tat 2. Procedurt The wri (a) writing/ the weather, (b) writing . sentences (**: presentation (c) writing r. fox jumps o* Self-cor block letters This sti functions in. spontaneous tions wren: r praxis. . Subject! (examinatior Writin Thohighr only one c 1. Motor i Of the a mild Ire: to an illegi perform an disorders: of strokes linked. S' graphisms' impairmer frequently Prime* switching asked or present in 2. Spatial Twciu downward p a ra b le to [14J). In c lapping th- f the .lion, 'nttal rial Iy *ased jl\ed - ( -I). ' V Jtely m of ctus in of boic Jthcr con dire WRITING DISTURBANCES IN ACUTE CONFUSIONAL STATES 345 tff. -- Croup 3. Patients undergoing general anesthesia. Two patients were studied while under the effect .of I.V. barbiturates (total doses: 400 and 500 mg of Amytal), administered as normal premeditation before 1 surgical anesthesia. They remained under the effect of Amytal throughout the interview. - Croup 4. Controls. The 5s were chosen from the medical wards. They met requirements (b), (c) and I,,"" (d) above and were not confused. No attempt was made to exclude alcoholics. ~ The characteristics of the 4 groups in regard to number of 5s, age and educational background are NT, given in Table I. -y_. v .^ ..... / \ 2. Procedure , ~y i:"'X * ' V . T h e writing tasks consisted of the following: fa) writing to command: patients were given the command to compose and write two sentences, one about the weather, another about their jobs. : * * *C. V` : . . . . . . . - .1 -(b ) writing -* sentences (" to dictation: six words (business, the boy is stealing cookies", **if he president, finishing, experience, physician, fight) is not careful the stool will fall") were presented. and two Several 'presentations were often necessary. - (c) wrif'pg to copy: the patient had to copy in script a sentence written in printed letters ("the quick brown ife ^ 'fo x jumps over the lary dog"). = .* v.*-* ; Self-correction was discouraged but could not always be prevented. Occasionally the 5s were given block letters and asked to compose 2 of the words that had been dictated. No time limit was set. ' t: This study was carried out within the framework of a larger study on disorders of higher cortical functions in A.C.S. (ChWruand Geschwind, in preparation). Other language tests were thus given including *v-.spontaneous speech, naming, compreheciion, spelling, repetition, and a word-list test. In addition, evalua- tions were made of behavior, affect, attention, the other components of the Gerstmann syndrome and ^ ^ `.ptaxa. 7 -- Subjects of group? 2 and 3, as well as 12 subjects of groro 1 were tested '.wire, " re - d 'jrirt i>.~?_'.C.S. ,,i. A), a:iL a wr.sii confusion ejearoi (cxaminacion B). -. . * - . .: ' : - data '..%%C .*;*.. -* r- ' Writing was frequently impaired in regard to its motor, spatial and linguistic aspects. ics), .rate The high rate of writing impairment is shown by the fact that, of the 34 confused patients, only one did not demonstrate any abnormality in writing while in A.C.S. . ncil ates ring 1. Motor impairment. 1":-Si ' A - 1'- .7 y f l-.V ''; > ...` Of the 34 subjects with A.C.S., there were 10 who wrote the letters normally but with iJ&Va tremor (e.g.: cases 4 and 20--see Figs. 1 and 2). In 5 cases, writing was reduced . to an illegible scribble (e.g.: cases 6 and 8--see Fig. I). In the remaining 19 cases, writing V-v 'performance fell between these two extremes and manifested some or all of the following . disorders: letters clumsily drawn; absence of loops of the I, f, g, and o; reduplication f strokes in letters such as m, n, w, and u ; no dots on the i's ; letters overlapped or not linked. Sometimes contamination from a neighboring letter produced curious "neo~ graphisms" (e.g.: case 22--see Fig. 1). To be noted is the absence even in the severest " impairments seen by us, of reiterated drawing of curves, loops and circles, such as is ~l~r. frequently reported in cases of P.A., (Gordinier, [4]; Campbell, [13]). .. j/j'. Printed letters appeared to be easier to write. In some cases, the 5s improved when switching from script to print. In 6 cases, the 5s either could not switch to script when asked or mixed script and printed letters (e.g.: case 4--see Fig. 2). Micrographia was i; .; present in 3 cases. In most of the performances do punctuation marks were used. 2. Spatial disorders Twenty-three 5s could not align letters properly and oriented the lines upward or downward. Some wrote close to the margin of the sheet, demonstrating something com parable to the "fear of emptiness" mentioned in focal parietal brain lesions, (Critchley, [14]). in copying words, 4 patients wrote in close proximity to the model, sometimes over f v lapping their letters with those of the model. jt"-* 346 F ranois Chdru and Norman G eschwino 3. Reluctance to write 19 of the confused Ss consistently demonstrated reluctance to write, alleging: "I never could write well, you know __ ", "X am not much of a writer", "without the proper glasses, it's difficult__ 4. Syntactical disorders ' ' Fourteen Ss, although having been asked repeatedly to write in fu ll sentences, and apparently having understood what the examiner meant, wrote "headline" type sentences .such as "weather fair"; " making rugs", "sell T.V." . . " Such agrammatic answers were in striking contrast to the normal grammatical structure of the oral expression of the same patients, `f z IffX S Z . ~ v-"' ' *"v ;":`VA similar discrepancy between oral and written grammar has been described by H hcaen et al. [11] tn conduction aphasia. - , 5. Spelling and other'linguistic errors . ;'/ v -'.-T h e se were found in most cases even when there was no motor or spatial difficulty .(e.g.: cases 4 and 20--see figures). r!V iA* A "J, , >-?- % EP rp #SP ri CASE 32 Fjg. L Samples of writing performances of acutely confused subjects. - Case 6: "finishing" (dictation). Case 8: "president" (dictation), (a) first attempt; (b) second attempt;, the patient had been told at this time that he could write in print if he ' wished. Case 22: description of the patient'sjob (to command). Case 11: "if he is not careful, the stool will fall" (dictation). Two attempts were necessary because the subject was writing too close to the margin of the sheet. Case 20: (a)--description of the job (to command): (b)--"if he is not careful. . . " (dictation). Writing to command means the composition by the patient of a sentence on a specific subject set by the examiner. The samples of this picture have been redrawn with India Ink for purposes of reproduc tion.'' va WE % *- ' -F "' . 1 2 Co carried com pai time? s the thr errors i W1 in spell articles' speliti^ ending: -substiri highly : well kn Err word tc omis.\io. for " Va word eas well is"). T or won Thi the nan  WRITING DISTURBANCES IN' ACUTE CONFUSIONAL STATES /A.:.-;-' ' a /.-y/ _ C u t ` ' t > ^ .*. : .,-> . A . .*.'V-- - v. -'L ^ 'V 'y . . ' ..-- ' 1' *^*.* e* "7 7 ' US* sir'5 / .f y-(/ f . Dcjmo ' " 7*/ / ^ iV * ^ . B'OH"M . -.Z. j.*;- /<* .4 ' ' 347 -i-7a ' .Vi--, toicanoi A **"'VttA# '*7-* '^`s b art at * -- fi't y' _y,*V . **p~i*^f -.. .**--*yr-* .*a* _V Fig. 2. Samples of the writing performances of a patient (case 4) during (left of illustration-- ' 21 January 1970) and out of (right of illustration--2S January 1970) an acute confusional state. ' Comparisons of the written spelling performances during and after A.C.S. were carried out for 21 5s (10 i s of group I, 9 of group 2 and the 2 subjects of group 3). These comparisons are summarized in tables 2 and 3. During A.C_S. 5s made about three times as many errors as they did after A.C.S. .An increase in errors occurred in each of the three writing'tasks':" writing' " to" command", dictation and copying. .The increase in errors in writing " to command'*.is not, however, statistically significant. v ' -7 .:\ . When we turn to the grammatical category of the misspelled word, we find an increase in spelling errors mainly in verbs and small grammatical words (prepositions; pronouns; articles), designated in the table as "other words" , and, to a lesser degree, nouns. Mis spelling of verbs often consisted in the modification o f auxiliary verbs or of the grammatical, endings of regular verbs (e.g.: -ed, -s). Smalt grammatical words were cither omitted or substituted for by other words. On the whole, grammatical words and endings, though highly familiar, appeared to be very fragile. . Difficulties in these categories are, of course, well known in some varieties of aphasics. \ Errors were also analyzed according to the "transformation^ leading from the target word to the word actually written. We adopted the following classification of misspelling: omission ("clar" for "clear*'), addition ("carefull" for ' `careful"), substitution (" Ian lin" for "Van Line") and inversion (" Hbrety" for "liberty") (Lecours [15]). Often, an erroneous, word contained more than one type of error. Such errors could involve isolated letters, as well as groups of letters ("arearea" for "area") and whole words (" if it is" for "if he is"). The nature of the "transformation", the element involved (consonant, vowel, syllable or word) and the location of the misspelling in the word were noted. The data pertaining to this part of the study arc reported in Table 3. When we consider the nature of the "transformations", we find that the increase of written misspelling during 3 34S F ranois Chdru and Norman G eschwind . Tabic 2. Written spelling errors in controls, in 21 patients in A.C.S. (examination A) and in the same patients out of A.C.S. (examination B). Comparison of the mean values. During - A.CS. Controls exam. A ; (10 Ss) (21 Ss) Post A.C S. exam. B (21 Ss) / (A/B) r (B/Q * -T* - Total spelling errors : . .. _ - . --Writing to command 5-10 3 1.10 Writing to dictation *" `:v`*>. : 8.00 ' 15.00 f /. - ^5.5' jo.45 ''***: ..3 ; 19.83 ; . " ' 9 . 9 8 - . 3.15** ; J.71 Ns ' " 3.94** 0.42 Ns 0.51 Ns 0.42 Ns ' Copying : - V**Nouns - -;v. ;.: /;o.oo . 3 : 3 7 . 8 6 .V? ^ 3 3 Z I v " :' '_ 2.14- , 0.99 Ns *'14.00 ': 20.95 / 3 3 .10.98 2.29" V . 0.37 Ns Verbs ` V " ..'"2.00 '.ri9 .3 8 4.71 - '3 J 8 - " ,, , 1.00 Ns : f. . Adjectives i-'Other words ; 5 .0 0 3^0.00 .15.62 .3 Vw . . 7.38 , 1.74 Ns ... 0.54 Ns . - 2.88*** i- -1.25 N s" ; v. (1) total percentage of misspelled words (expressed in per cent of the total number of written wordsV .".'..(2) percentage according to the writing task (in per cent of the number of words of the task considered)- - - _> (3) percentage according to the grammatical form class (in per cent of the number of words from the - considered form-class). ;*-*/: ;.-v* : : t - ~., ~y> "Writing to command" means the composition by the patient of a sentence on a specific subject. : , ;'The A/B comparison was made by a Mcst for paired data; the B/C comparison by a regular /-test. : * / x O . Q S ; *" /< 0 .0 l. - .- i- . .- . . . = - . . *- . . . t.lil; 7 J ; !# : ; I Jw i* . . ..11 l - j X . . 't G tl: element and the location of the error in the word (see text) , Lew iIiVOjVeG 1 ' . During Post - --- Controls A.C.S. A.C^. -- - ; . (Q . - exam. A ; exam. B (10 As) (21 Ss) ' (21 Ss) . r (A/B) " / (B/C) . -'.-rtsL Omission : . \ ~S}.60 ^..3.10 ;; .0.75 Ns Addition ;X \- Substitution A. Inversion. 1 "Consonants Vowels " ' 15.43 3.74 :.r ;; 0.81 Ns 'W . .1.08 Ns 3 <................ , V'*, **;; 1-70 . 4.90 , . { - v. 3.44- >. 0.02 Ns i. S'. 0.40 .-Y-' 0J6 .0.76 1.09 Ns 0.72 Ns ' r * -V(VV v rV ^ri.90 y-V-l".: 10.30 ^ ^ 2 S 2 ` " . ` 2.30 " * . 4.74 " 1 2.48 3.0I-- " 0.72 Ns 1.63 Ns * 0.10 Ns .-sireAf*.; Syllables -- 0.40 1.74 0.81 1.17 Ns '0.68 Ns Whole words :S i 0.20 . . .,.;:.3J6 *-' . 0.62 : ' 3.48' ' 0.69 Ns First 2 letters " . '.-`.ro.oo - -:.y;o.97 ... y 0.33 ; Last 2 letters ' * . ' 0.90 ; " ...* 3.97 . ..'.--.1.85 . 1.06 Ns ;"'-" -Ns * " 2.56V ... " 1.49 Ns i Middle of u ord ,* . MO " ; ;V / 7.87 .4.79 1.69 Ns *. M 6N s A .C .S .; and inv duplicat of who! disorder o f invert (L ecour The sonants for constypes of t which re. in the te. The words hi first Iette errors in' did not. - The \ B), were minor sp; 6. Writin any othc: difficultie: spontanec ficantly b studied, v better tha block Jett-~ composin tasks and * Durin ' m otor difi - . drawing* t . tion B) we spelling sc backerour These less of (he Errors arc expressed in percentages of the total number of written words. */><o.o5; p < a o i. ii'.-W. .'f? Motor two indepem .^ v 'A .C S . appears to be related to an increase in omission and substitution errors. Addition anc* inversion errors did riot change significantly. There was,' however, a trend to re- duplication o f the last letters of the word (e.g.: "falll", " businesss" ) or to reduplication of whole w-ords (e.g.: "if if he is"). An increase in omission errors is not surprising in a disorder the main feature of which is an attention defect.' Less expected is the stability of inversion errors.' Our patients are thus different from cases of developmental dysgraphia K ^ " ;( L ecours [15]). V '.' : '; - / The study o f the transformed elements revealed a high degree of involvement of con sonants and of whole words (generally small grammatical words). The high error score Cv* , for consonants reflects particularly an increase in omissions, and to a lesser degree, other *.; ,types of transformation. It is in striking contrast to the low error rate for vowels, a difference fsC ^c': which remains even when we balance for the unequal distribution of vowels and consonants in the test material. -i. *.-A&vSvi.-.-' './.'-'..The location of the " transformation" .was studied only for errors in single letters in words having five letters or more. Wc computed the number of errors involving the two :fn il letters, the two last letters" and the middle of the word./As demonsir-lcJ in Tabic 3, errors involving the last two letters increased significantly while errors in the other categories did oof. . The written spelling errors of the subjects seen after recovery from A.C.S. (examination `B), were, similar in every respect "to those of th control group (see Tables 2 and 3); some `minor spatial or motor errors were found in only 3 patients of group I after recovery. 4r,u 6. Writing disturbances in relation to other disorders o f higher corticalfunctions {H.C.F.) ._t -. The dysgraphia demonstrated by our patients was far more severe and constant than M r .any other concomitant disorder. /I n spoken language, there were some word-finding jW.'sSeV'si"vs?- difficulties and a few errors in reading aloud and repetition, but the overall pattern of 'spontaneous speech was normal. On the other hand, oral spelling did not change signi- ;ficantly between the two testing sessions;"furthermorej although this was not formally "studied, we had the impression that an acutely confused patient could spell a word aloud better than he could write it; and when a patient was asked to compose a word with block letters, he made fewer errors than when he wrote it (wc gave him only the letters composing the word). In regard to the other H.C.F., there was impairment in the drawing tasks and minimal difficulty with right-left orientation, finger recognition and calculation. During the A.C.S. (examination A), the rate of misspelled words covaried with the -- * T.**** motor difficulties in writing (r=0.39; d ./ 2 8 ; p<0-05), as well as with disturbances in drawing* (r=0.62; d ./.= 2 8 ; pcO.OOl). When the scores obtained out of A.C.S. (examina ir7 rfe ;-.- tion B) were considered, the disturbances on written spelling were correlated with the oral spelling score (r=0.63; d ./. = 23; /7<0.0l), and to a lesser degree, with the educational fe -v /-` z& y ;iy " *. background ( r = 0.39; d ./. = 23; p<0.10). / ' DISCUSSION V ' `' -O r ' These results indicate that a writing disorder may be associated with an A.C.S. regard less of the etiology. This writing disorder has common characteristics which vary only in fe Motor difficulties in writing and drawing difficulties were scored according to a three point scale by Pli' two independent judges. . \* 4^ 3: II . t : ; ;/ -- f 350 F ranois Q dru and N orman G eschwino severity and which involve the motor and the spatial aspect of writing, as well as spelling and syntax. It is a transient phenomenon which disappears when the A.C.S. has cleared. This dysgraphia is the most striking and the most constant linguistic disorder seen in A.C.S. ~ y '/' The spelling disorder has the following features: a high error rate in consonants and of small grammatical words in their entirety, a high rate of omission and substitution, a . high rate of involvement of the last letters of the words. V-t'v* ; *: ;- *- -..T he fact that a widespread acute cerebral disorder can lead to a relatively isolated . dysgraphia seems, to us, to be the most interesting conclusion of this study and may throw a new light on the old problem of pure agraphia (P.A.). : . ,y-;. ; '* `.'.We will review the cases which have been claimed to be examples of P.A. We will .' not discuss here the "P.A. cases" in which agraphia was associated with disorder of oral language, (Eskridge and Parhill [16]), reading (Marcus [17]), or of fine hand movements, (Mahoudeau et ah [18]). The agraphia, in these cases, was part of a wider syndrome and .'cannot be considered " pure". V-.* > .,,l : 1', ; If we focus on the cases in which agraphia was the sole'or the most prominent symptom, .we are struck by the high proportion of reports in which mention is made of "mental ' deterioration", "obtundation", " brain atrophy", "increased intra-cranial pressure". Thus, the patient of McConnell [19] was said " to fix his attention and keep his mental machinery in action with difficulty". -The patient of Sinico [20] is reported as being in a'state o f . "demenziale progressive". In the first of Hecaen's scries (in which the agraphia is not actually described as "pure" but as a "symptme privilgi" ), 4 out of 7 patients had , *brain tumors and were obtunded, 2 had cortical atrophy and I had been operated on for a frontal rpileoto^err'c soar arid was rrnorted~a.s both mentally deteriorated and illiterate, (Hecaen and Angelergues [21]). In H ecaen's second series, 4 patients out of 6 had intel lectual impairments, a fifth patient was said to be alert but had a brain tumor; only the last patient, examined only one month after a cerebrovascular accident, was said not to be deteriorated or confused, (Dubois, Hecaen and Marcie [22]). .The famous case o f O ordiner [4] is, to us, no more conclusive: I--there was an extensive frontal lobe tumor with signs of increased intracranial pressure (diplopia, papil ledema); `2--the writing performances demonstrated by his patient (reiterated drawing of 'curves) might be considered as showing frontal perseveration rather than agraphia. We raise similar objections to the cases of Campbell [13] and the first case of Mahoudeau [23]. The case reported by Penh eld and Roberts [24] was a young man, alert preopera tivcly, who was operated on for a frontal epileptogenic scar and presented an agraphia on the 9th day after the operation. The fact that the agraphia was a delayed and transitory phenomenon at least raises the possibility of a confusional state on the basis of edema. The same problems arise in the case of Morselli [25]. . T h e case of N ielsen [26] was a- left-handed man who had always written with the right hand. He developed an agraphia of the right hand alone ^association with a right hemiplegia affecting primarily the leg. This clinical picture strongly suggests an anterior . cerebral occlusion with probable infarction of the callosum in a patient with speech in the right hemisphere. Although we have much less information about the case of Pitres [27], the same analysis may well apply. TTiese cases thus resemble the case of G eschwjnd and Kaplan [28] who1manifested a left unilateral agraphia. This patient showed other signs of callosal disconnection and subsequent post-mortem confirmation of an infarction of the corpus callosum without any lesion in the right hemisphere. o; th ca of m nc Pc the to me are ass we . (2) in c heir - in ** We diSO Sine test havt than -, * out i ;subje were - const syndi of dy comp :V depen lingui comp their fractic extens Acknow assistati Kaplan Corwin - y J . W RITING DISTURBANCES IN ACUTE CONFUSIONAL STATES 351 In summary, niost of the cases in the literature support the idea that an isolated disorder of writing occurs primarily in the presence of a diffuse brain dysfunction. -We assume T.that, with the possible exceptions of one of Hecaen's cases and Henschen's [5] personal i case, in which the lesions were vascular, the so called " P.A. syndromes" .were the expressions I ?-:of general brain dysfunctions, not of specific language output disturbances. .T ' ; ; , : : - - r~T.\r-^~S'/re % .f:' D ubois* Hecaen and Marcie [22] have called attention to a relative increase in P.A. / in left handed subjects. The reasons for this phenomenon are not clear, and we will therefore not discuss this problem here. We wish to point out that our preceding comments may perhaps not apply to this group, since the possibility of pure agraphia in left-handers on ^"the basis o f a different cerebral organization cannot be "ruled out at this time. -v *-- /;":AVc`dc not imply that the dysgraphia found in A.C.S. paticiiisis necessarily identical :lto the one described in cases of P.A. : ' (1) impairment of the spatial aspect of writing is :,more marked and more frequent in A.C.S. than in cases of P.A." These spatial disturbances "are similar to those described by Marcie et a i [29] in cases with right-sided tumors. If we .assume that an A.C.S. results in a global dysfunction of the cerebrum, the spatial defect *we have observed can indeed be accounted for by the right hemisphere involvement . (2) the written spelling disorder n A.C.S. is, on the whole less severe than the ones reported r:. urea :j r Zc^r/Z'.zz. 1er rxr.ziflc. ' IH: pcriV.c the! r. ! -f-'*-. - f thi h it . hemisphere might play a role, possibly through involvement of the cortical language areas, in "magnifying" a writing disorder provided by a superadded diffuse brain dysfunction. _Wc would wish, however, to point out that the relatively lower degree o f written spelling }disorder in our cases may not reflect a true difference but may be a result of patient selection. Since patients were excluded from the study unless they could cooperate for the entire test battery, some more severely involved subjects were almost certainly omitted. .We '. have, in fact, "seen clinically patients in A.C.S. with even more severe writing disorders _ ith a n those described here. Z Writing thus appears to be a very delicate, fragile task.' Such fragility has been pointed out in the past. D avis and Davis [30J, in an experimental study of hypoxemia in normal subjects, noted that handwriting changed.simultaneously with the E.E.G. when the subjects were oxygen deprived; they stated that writing seemed to be "a very delicate indicator of t consciousness impairment". Benton and Abramson[31], in their studies of the Gerstmann syndrome in patieots recovering from electro-convulsive therapy, mentioned the presence ;"of dysgraphia but did not point out any discrepancy between this symptom and the other 'components of the syndrome. ---V : 'V Why is writing so fragile? It is possible that writing is readily disturbed because it depends on so many components (motor, praxic, visuo-spatial as well as kinetic and linguistic). Furthermore, most normal humans exercise their speaking abilities and their comprehension of spoken language constantly. Many people, although fewer, exercise their reading comprehension abilities very extensively. It is, however, only a minute fraction o f the population, even among the highly educated, who use their writing abilities extensively. Writing is therefore very rarely, if ever, an overlcarncd'and automatic skill. Acknowledgements--We wish to thank Herv Lcbras for help in the statistical analysis, Martin Albert for assistance in the original preparation of the manuscript, Frank Benson, Harold Goodglass. and Edith Kaplan for aid in the experimental design. We wish to express our appreciation to Norman Andrew, Corwin Fleming, and Simeon Locke for making patients available for study. 352 '- F ranois C hdru and N orman G eschwind REFERENCES ; Marce. M. Mmoire sur quelques observations de physiologie pathologique tendant dmontrer l'existence d'un principe coordinateur de l'criture et ses rapports avec le principe coordinateur de la parole. Cx. Soc. Biol. 3, 93-115, 1856. \ .. Benedikt, M. (1865). Quoted by Leischner, A. (1969). Leischner, A. The agraphias. In Handbook o f Clinical Neurology, Vol. 4, pp. 141-180, P. J. Vinken and G. W. Bruyn (Editors). N orth Holland Publishing Co., Amsterdam, 1969. Gordinter, H. C. A case of brain tumor at the base of the second left frontal convolution. Am. J. mcd. Sei. 117, 526-535, 1899. ...- - . r. - ... HenscHEN, E. S. Klinische und anatomische Beitrage zur Pathologie des Gehirnes. Teil VII. Nordiske Bokhandcln. Stockholm, 1922. .. . " ` ' Exner, S. Untersuchungen ber die Lokalisationen in der Grosshirnrinde des Menschen. Wilhelm Braumuller. Wien, 1881. --- V* .. .. 7. Dejerine, J. Sur un cas de ccit verbale avec agraphie, suivi d'autopsie. Mem. Soc. Biol. 3, 197-201, 1891. - , ;" ' . - : r `: ,\V ; ' 8. Wernicke, C. Ein Fall von isolierter Agraphie. Mschr. Psychiar. Near. 13, 241-265, 1903. 9. Rawak, F. Zur Klinik der Agraphie. Arch. f. Psych. 99, 773-803, 1933. 10. R ussel, W. R. and Espir, M. L. E. Traumatic Aphasia. Oxford University Press. London, 1961. 11. Hecaen, H., Anceixrcues, R. and Douzenis, J. A. Les agraphies. Neuropsychologia 1, 179-2C8, 1963. 12. Bonhoeffer, K. Die Psychosen. Frantz Dcuticke. Leipzig, 1912. " v 13. Campbfi i , C. McFie. Agraphia in a case of frontal tumor. J. nerv. ment. Dis. 38, 168-169, 1911. 14. Crjtchley, Mcd. The Parietal Lobes. Hafner, London. 1953. -' . 15. Lecours, A. R. Serial order in writing. A study of misspelled words in "developmental dysgraphia" . Neuropsychologia 4, 221-241, 1967. .u \ : : -LX..-:V . ? . } 6' Eskridge, J. T. and Parxhill, Med. News 48, 176-180, 1896. C. Oro-lingual paralysis and slight motor disturbances in writing. -r:_r "C ------- - *..V 17. Marcus, H. Contributions la localisation de Pagraphic. Acta Psych. 12, 431--446, 1937. ' ** 18. Mahoudeau, D., D avid, M. and Lecoeur, J. Un nouveau cas d'agraphie sans aphasie, rvlatrice d'une tumeur mtastatique du pied de la deuxime circonvolution frontale gauche. Rey. Neurol 84, 159-161,1951. :: ^ W-- . . 19 M cC onnell, J. WV A case of tumor of the left first and second frontal convolutions with motor agraphia as us ciue;' jocalizujg symptom, v.m . ~j } tut.jj'.cr.L .A-'. J*.-.'.'. 1Z, !5^-!5', 'fTf 20. Snico, S. Neoplasia della II circonvoluzione frontale sinistra. Agrafia pura. Gazz. degli Osp. e dell. Clin. 47, 627-631, 1926. - ....... 21. H ecaen, H. and A ncerjjercltes, R. L'agraphie secondaire aux lsions du lobe frontal. Intern. J. Neurol. 5, 381-394, 1966. -- 22. D ubois, J., Hecaen, H. and M arcie, P. L'agraphie pure. Neuropswhologia 7, 271-2S6, 1969. 23. Mahoudeau, D. Un cas d'agraphie chez un traumatisme du crne porteur d'une lsion des 2e et 3e circonvolutions frontales gaudies. R ev. Ncur. 82, 20-52, 350. - . 24. Penfieed, W. and R oberts, L. Speech and Brain Mechanisms. Princeton Univ. Press, Princeton, 1959. 25. Morselli, C. E. A proposite di agrafia pura. Riv. Sper. Frenat. 54, 500-511, 1930. - - . - ~ . 26. N ielsen, J. M. Agnosia, Apraxia, Aphasia. P. B. Hoe ber. New York, 1946. . '--.j-. >. .-A. '.-J,-'A.' 27. Pttres, A. Considrations sur Pagraphie. Rev. de Med. 3, 855-873, 1884. r`-.- *.-v- - 28. G eschwind, N. and Kaplan, E. A human cerebral dcconncction syndrome. Neurology 12, 675-685, *'*-1962 \ '*w-' r.~.-- ' T . - 'v 29. M aroe, P., H ecaen, H., D ubois, J. and A ngerlercues, R. Les ralisations du langage chez les --malades atteints de lsions de Phmisphcre droit. Neurops)xhologia 3, 217-245, 1965. .. 30. Davis, H. and D avis, P. A. The electrical activity of the brain: its relation to physiological stales of impaired consciousness. In The Interrelationship o f Mind and Body. A.R.N.M.D. Vol. XIX, F. Kennedy, A. M. Frantz and C. C. H are (Editors). The Williams Co.. Baltimore, 1939. 31. Benton, A. L. and A bramson. L. S. Gcrstmann symptoms following electroshock treatment. A.M .A. . Arch. Neurol. Ps)xhiat. 67, 248-157, 1952. . _ e - . * - - -- -- , . Rsum--Une etude de l'criture a t entreprise chez 34 malades en tat confusionnel aig. Les ralisations graphiques de ces malades ont t compares celles de 10 sujets tmoins ainsi que. pour 24 d'entre eux. leurs propres ralisations, apres rgression de Ptat con- ' fusionne!. ............ .... ' *- . - - * *. L'criture tait altre dans 33 cas sur 34. L'altration pouvait concerner les aspects moteur et spatial de Pccriture aussi bien que l'orthographe et la syntaxe. Le trouble de l'criture constituait chez ces malades le dsordre linguistique le plus constant et le plus marqu. II avait disparu lorsque Ptat confusionnel tait dissip. La dysorthographie avait les caractres suivants: frquence des erreurs concernant les consonnes et les petits mots fr ont rer de la ..NKEN m. J. disfce heim -201. I. 363. l! ' V*. -ig. ce 34, lia IL J. r] le 9. r -_* : V v v '; ; ` .-V V*.7 '' ' ' -- V** r V *vu- ..* . W R rriN G DISTUR DANCES IN ACUTE CONFUSIONAL TTA l ES 353 M - 7 - grammaticaux dans leur totalit, frquence des omissions et des substitutions, frquence des ` ' erreurs touchant les dernires lettres des mots. -*.vit 'r ^ *t-.y.* - - -;x L e problme de i'agraphie pure est discut dans le contexte de ces rsultats. -V ' ' Zusammenfassung--Das Schreibvermgen von 34 akut verwirrten Patienten wurde unter- .fj-"-*:* : sucht. Die Ergebnisse wurden mit denjenigen von 10 Kontrollpersonen und von 24 Fllen .' nach Aufklaren aus dem Verwirrtheitszustand verglichen. '33 von 34 Pat. waren schreib- gestrt. Die Schreibstrung konnte Motorik und Raumgliederuhg, aber auch Buchstabenord- . nung und Syntax betreffen. Die konstanteste und ausgeprgteste linguistische Strung 'bestand hierin. Sie verschwand, wenn die Verwirrtheit behoben war. Die Gliederungs- .* :S t ru n g bot folgendes Bild: Starke Fehlcrrate bei Konsonanten und bei kurzen grammeti- kalischen Wrtern in ihrer Gesamtheit, hohe Auslassungs und Substitutionsrate, besonders - hufiges Bctroffensein der letzten Buchstaben im Wort. v - .v \ -.r , t\ *mr r sj'-v-": **-v v b-lv* ig f: ,VlV 1t - -* *`v=;- - " ` * _* lS-V: ; iif # jr. # ?>; : r <v V-