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Clinical Neuropsychology: A Brief
History
A.L. Benton and A.B. Sivan
Clinical Neuropsychology is the discipline that investigates the interre-
lations of the human brain with thinking and behavior on the basis of the
variations in brain function produced by injury or disease. That such
injury caused mental impairment must have been apparent even to
primitive man who resorted to trephining in an attempt to alleviate its
pernicious effects.
Interestingly, emphasis was placed not only on the brain substance itself
but also on the fluids, which it enclosed, ie, the ventricles. Early Greek
physicians (eg, Nemesius ca. 400 A.D.) placed sensation and perception
in the lateral ventricles, reasoning in the third ventricle, and memory in
the fourth ventricle. This ventricular concept accorded well with the
doctrine of the circulation of animal spirits. Moreover, it provided a
structural basis for a dynamic process wherein sensations were integrated
into perceptions in the lateral ventricles, moved to the third ventricle to be
reflected upon, and consolidated as memories in the fourth ventricle. In
the absence of better alternatives, “ventricular” theory survived for a
remarkably long time. It was displaced definitively by “brain substance”
concepts only in the 17th and 18th centuries.
It is also worth recalling that Aristotle, the greatest natural scientist of
the ancient world, maintained that the heart was the seat of thinking and
emotion, assigning the brain only the function of cooling the heat
generated by the heart. His conclusions were based on sound empirical
study. He noted that the exposed brain of animals was cold to the touch
and that poking the brain surface did not elicit movements or signs of
feeling. In contrast, the heart was warm and active; it accelerated during
excitement and was slower during periods of calm.
Aristotle’s cardiocentric concept of the seat of mental life had many
supporters during the Middle Ages, the Renaissance, and even as late as
the 17th century. That it was widely accepted is reflected in our language
today. We still “learn by heart”; we offer “heartfelt sympathy”; and we
“lose our heart” when we fall in love.
Dis Mon 2007;53:142-147
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By the end of the 17th century, however, the brain had largely displaced
the heart as the organ of mind. Thomas Willis (1621–1673) localized
perception in the corpus callosum and memory in the cerebral cortex.
Francois La Peyronie (1678 –1747) placed intelligence in the corpus
callosum. Emmanuel Swedenborg (1688 –1772) seems to have been alone
in deciding that intellectual functions were a distinctive property of the
cerebral cortex. Swedenborg also believed that the basal ganglia were
centers of motor control.
These broad concepts of cerebral localization were the rule in the early
18th century. A quantum leap to another mode of thinking took place in
the early decades of the 19th century when the anatomist and phrenologist
Franz Joseph Gall (1758 –1828) expounded his ideas and made them a
central issue in neurophysiology and neuropsychology. Gall’s basic
postulate was that the human brain was not a single organ but an
assemblage of organs, each of which formed the material substrate of a
specific cognitive ability or personality trait. Apparently he found no
difficulty in identifying the locus in the human brain of about 30 mental
characteristics, most of which he took from the analyses of the Scottish
school of psychology, represented by Thomas Reid (1710 –1796) and
Dugald Stewart (1753–1828).
Gall’s hypothesis that the human brain is not a unitary organ but instead
consists of an aggregate of specialized cortical areas attracted both loyal
supporters and vigorous opponents. One salutary effect of the controversy
was to stimulate detailed anatomic study of both cortical and subcortical
regions. For example, in 1854, Pierre Gratiolet (1815–1865) presented the
first description of the optic radiations arising from the lateral geniculate
nucleus and fanning out to the occipital and parietal cortex, thus providing
an anatomic basis for the subsequent abandonment of the thalamus as the
cerebral center for vision and the placement of the end station in the
occipital lobes.
At the same time, the gyri and sulci of the superior, lateral, and mesial
aspects of the human cerebral cortex were described and named so that,
by 1860, illustrations of the cortical surfaces were essentially the same as
those to be found in present-day textbooks.
In the 1860s, the momentous (and counter-intuitive) discovery of Paul
Broca (1824 –1880) that speech is mediated by the left hemisphere added
a new dimension to brain function, that of hemispheric cerebral domi-
nance. The observation that aphasic patients often suffered from cognitive
deficits that were of a non-verbal as well as a verbal nature had the effect
of broadening the concept of left hemisphere dominance to include
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cognitive functions. Thus, the left hemisphere became, in the minds of
many clinicians, the “intellectual” hemisphere.
The demonstration by Gustav Fritsch (1838 –1927) and Eduard Hitzig
(1835–1907) in 1870 that electrical stimulation of the precentral gyrus
produced movement in the contralateral limbs was as revolutionary in its
way as Broca’s discovery of the role of the left hemisphere in speech had
been. It provided the impetus for intense efforts during the ensuing
decades to localize the functional properties of each and every gyrus in
the cerebral cortex, a period called the “golden age” of cerebral localiza-
tion.
In 1873, Roberts Bartholow, a Cincinnati physician, took advantage of
the circumstance that one of his patients had a skull defect that permitted
stimulation of the exposed cortex to confirm the Fritsch–Hitzig finding in
a human subject. Bartholow was censured for what was considered to be
unethical conduct for this initiative. Today, such stimulation of the
exposed human cerebral cortex during the course of neurosurgery is
commonplace.
Yet during this “golden era” of localization, there were thoughtful
students of the nervous system who objected to this placement of
numerous cognitive capacities in sharply delimited cortical centers. They
found it inconceivable that a restricted aggregate of nerve cells could be
the seat of a complex intellectual function. Hughlings Jackson (1835–
1911), who was well aware of the facts of clinical localization and applied
them in his neurological practice, cautioned that identifying the lesion that
leads to an aphasic disorder was not the same as identifying the locus of
speech. In short, he accepted the concept of centers for its clinical utility,
but not as a neuropsychological theory.
Jackson’s conception of the nature of aphasic disorder was also
incompatible with the notion of cortical centers. He maintained that
aphasia always entailed an impairment in intellectual functioning, a
position that was diametrically opposed to that of Carl Wernicke
(1848 –1904) who insisted that there was no intrinsic connection between
aphasia and intelligence.
One or another of Jackson’s ideas was later expressed in the 1880s and
1890s by the physiologist, Jacques Loeb (1859 –1924), by Sigmund Freud
(1856 –1939), who was then a neurologist as well as a psychiatrist, and by
the philosopher Henri Bergson (1859 –1941). Their approach to the
problem of localization in turn influenced the thinking of some early 20th
century neurologists such as Arnold Pick (1851–1924), Henry Head
(1861–1940), and Kurt Goldstein (1878 –1965).
On the whole, however, mainstream neurology remained wedded to the
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doctrine of cerebral centers and interconnected conduction pathways, the
“telephone system” conception of the functional organization of the brain.
No doubt many neurologists regarded the concept of centers as a fiction,
although it was a convenient and useful fiction. For example, H. Charlton
Bastian (1837–1915), a leading 19th century authority on aphasia,
believed that the cerebral substrates of speech were, as he phrased it,
“diffuse but functionally unified nervous networks.” Nevertheless, he
wrote that, although he did not accept the common conception of a neatly
defined center “. . .for the sake of brevity it is convenient to retain this
word and refer to such networks as so many centers.” Thus, the concept
of centers was of some heuristic value in clinical practice in that it pointed
to the probable locus of a suspected focal lesion.
Hemispheric Cerebral Localization
As has been mentioned, following Broca’s discovery that the left
hemisphere was endowed with a broader significance, encompassing
cognitive functions beyond the realm of speech, it became indeed the
dominant hemisphere in all respects. During this period, when the left
hemisphere was assigned importance for cognitive function, there were
scattered attempts to suggest that the human right hemisphere possessed
its own distinctive cognitive capacities, particularly those expressed in
visuospatial performances, in route finding and in geographic orientation.
In the face of neurosurgical findings that the whole right hemisphere
could be extirpated without causing major cognitive disability, however,
these suggestions were ignored. The most that could be said was that the
right hemisphere might possess left hemisphere abilities in latent form,
capacities that under some circumstances could be brought into play when
the left hemisphere was damaged.
The empirical studies of the British psychologist Oliver Zangwill
(1913–1986), and the French neurologist Henry Hecaen (1912–1983),
initiated during and shortly after World War II, demonstrated conclu-
sively that patients with right hemisphere disease did show a very high
frequency of specific visuosperceptual, visuospatial, and constructional
defects.
The Zangwill–Hecaen studies had a number of consequences. Their
implications led to a widespread exploration of the role that the right
hemisphere might be playing in the mediation of different aspects of
cognition. The result was that a remarkably diverse array of capacities and
attributes, far beyond the visuoperceptual and visuoconstructional defects
described by Zangwill and Hecaen, were reported. Among the disabilities
ascribed to right hemisphere dysfunction were slowed reaction time,
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mood disorders, auditory defects, and even speech impairments that
conventionally had been considered signs of left hemisphere disease.
A Summing Up
This brief historical survey has outlined some of the successive stages
in the evolution of concepts of the relationships between brain function
and behavior. Clinical observation alone provided most of the data upon
which the conclusions were drawn.
Herbert Birch (1918 –1973), the renowned investigator of human
development, was fond of pointing out that concepts of the nature of brain
function tended to reflect the dominant technology of a period. In classical
times, the ingeniously designed aqueducts, dams, and waterways were the
products of a remarkably advanced hydraulic technology. Ventricular
theory (rather than “brain substance” theory) was consonant with that
technology.
The late 19th century witnessed the development and eventually
universal application of a transforming new system of communication:
the telephone. Not surprisingly, the notion that the brain can be conceived
as being one immensely complicated telephone system was readily
accepted. Today the brain is a “computer.”
It is nothing of the sort. Of course, the brain can compute (badly). It is
not an efficient computer because it is fundamentally different from even
the most complex computer, even those modifiable ones that are capable
of learning and self-correction, ie, those that can be said (not unfairly) to
possess intelligence. The brain is a living organ that is both sensitive to
internal and external stimuli and that has the capacity to apprehend these
stimuli and to deal with them as best it can. The brain does not necessarily
discharge its task very efficiently. There is just too much on its plate. It
is a generative as well as a multisensory organ. It must impose order on
the internal and external world and reach at least a partial view of the
nature of the real world.
Given the complexity and varied nature of the stimuli and events with
which the brain must deal, this is a truly daunting task. It is not surprising
that it often makes mistakes. That, in fact, it often makes mistakes is
amply documented by the innumerable false conclusions reached through
observation and experimentation over the centuries.
What then accounts for the advances in knowledge and control that have
been achieved over the centuries? We could say that it is the creativity
which is reflected in the tools of investigation that have been developed:
the microscope, the x-ray, current neuroimaging procedures. Without the
microscope there would be no histology and hence no histopathology.
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Without x-ray we would have no direct knowledge of the status of the
brain in living patients. Our understanding is made possible by (and
limited by) our remarkable neuroimaging procedures. No doubt these
procedures will be displaced by even more informative techniques that
permit deeper insight into the nature of brain function and brain-behavior
relationships. The future of the discipline of neuropsychology should be
very bright.
If you wish to further explore the history of neuropsychology, the
following references are available for your examination:
1. Akert K, Hammond HP. Emmanuel Swedenborg (1688-1772) and his
contributions to neurology. Med Hist 1962;6:255-66.
2. Benton AL. Exploring the History of Neuropsychology. New York,
NY: Oxford University Press, 2000.
3. Benton AL, Tranel D. Historical notes on reorganization of function
and neuroplasticity. In: Levin HS, Grafman J, eds. Cerebral Reorga-
nization of Function after Brain Damage. New York, NY: Oxford
University Press, 2000:1-23.
4. Clarke E. Aristotelian concepts of the form and function of the brain.
Bull Hist Med 1963;37:1-14.
5. Finger S. Origins of Neuroscience. New York, NY: Oxford University
Press, 2001.
6. Head H. Aphasia and Kindred Disorders of Speech. London: Cam-
bridge University Press, 1926.
7. Pagel W. Medieval and renaissance contributions to knowledge of the
brain. In: Poynter FN, ed. The Brain and Its Functions. Oxford:
Blackwell, 1958.
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