THE FICTION OF THE “GERSTMANN SYNDROME”

Theproblem withwhichthis study isconcerned canbestated asfollows. A patient withparietooccipital disease mayshowoneormoreofarelatively large numberofdiverse behavioural deficits. When hepresents withtwo,three, ormoreofthese symptoms, thelatter maybeviewed bytheclinical observer asforming anaturally occurring combinationofdeficits andgiven thestatus ofasyndrome, this status implying thattheconcurrence ofdeficits isnota chance one,thatthere isanunderlying factor responsible forit,andthatitpossesses a distinctive neuropathological significance. Once sucha special combination orsyndrome isestablished, notonlyisitusedintheobservation and description ofsubsequent casesbutitmay also determine whichaspects ofapatient's behaviour are selected forstudy andwhicharenot.The"Gerstmannsyndrome" represents suchacombination of behavioural deficits. Thestudy tobereported examines thequestion ofwhether, asisusually assumed, this "assembly ofunlikely andunexpected symptoms" (Critchley, 1953) isanaturally occurring combination orwhether itisonly oneofaverylarge numberofmoreorless fortuitous combinations of behavioural deficits whichmaybeencountered in patients withcerebral disease. Thehistory oftheGerstmann syndrome hasbeen recounted indetail elsewhere (cf. Critchley, 1953; Benton, 1959); onlya fewmajorpoints needbe mentioned tointroduce thepresent investigation. Before theendofthenineteenth century, thefour behavioural deficits comprising thesyndromeright-left disorientation, acalculia, agraphia, and finger agnosia-had beendescribed asoccurring in patients withcerebral disease. Thefirst three were well-known symptoms butthedescription offinger agnosia in1888byJules Badalhadescaped the attention ofneurologists, a factwhichisnotaltogether surprising inviewofthecircumstances that theBordeaux eyespecialist published inanophthalmological journal, andthefinger agnosia whichhe quite clearly described wasonlyoneofa large numberofdeficits shownbyhispatient. In1924, Gerstmann onceagain described finger agnosia, designating itas "a circumscribed disorder of orientation toone's own body". In 1927,he advanced theideathat finger agnosia andagraphia formed "anewsyndrome". However, in1930he enlarged thesyndrome toinclude right-left disorientation andacalculia andproposed thatithad ahighly specific neuropathological significance. At thesametime, hediscussed thequestion ofthe Grundstorung responsible forthispresumably "natural" concurrence ofbehavioural deficits. Clinical experience appeared toconfirm thereal existence ofthesyndrome; casereports ofpatients manifesting itappeared intheliterature andspeculations regarding thebasic impairment underlying its occurrence wereoffered. However, itwascertainly notraretoencounter patients whoshowed one,two, orthree deficits butnotthefull syndrome. While suchobservations wereoften interpreted assimply representing formes frustes ofthesyndrome, they didindicate atleast that thefoursymptoms didnot necessarily occur together inevery caseandtheydid haveimplications regarding thecogency ofthose theoretical formulations whichhadbeenadvanced toaccount foranobligatory concurrence ofthe deficits. Ontheother hand, awidevariety ofother deficits werealsoobserved tooccurinconnexion withanyorallofthefour symptoms. Thesewere given asubordinate status asaccompanying symptomswhichmightormightnotbemanifested.