730 T.SHALLICE AND P.W.BURGESS Case 2 s head injury in a road traffic acciden em frontal depres dskull fracture and an intracerebral haematom nsive low at oeddnorhtre atrophy of the right medial i corex.Both later after stay of6 months he hanges but w unahle to carr it out.He failed a higher d but obtained a eacher's.For the next5yrs he held a succession of jobsfrom his wife's testimony were in ement over his domestic behaviour.He is untidy.He only bathes if going somewhere important.Shaving. ving his ed out when his v NesheprepaaionofamcalihsI0y,ods8.1Wa task she ome er.,his wife 50c1 th rela uld Clinical neuropsychological tests.D.N.was tested in the Nationa of neuropsychological ss On the WAIS,he obt ned a V bal IQ of 126 and a Pe and in the e 1).On memoryt PCasiiwetoftonitallotbclesionshispet ormance was ger satisfactory.but it was rather poo on of the Sel ory tes t(see Tab 3). while his performance on verbal mem memory tasks Case 3 ith slight let paralysis ness but as a result has had a p of her ss of smell DA CT scan carried out yrs after the oral ventricle For the past room.He very untidy ever ou and virtually never travels way from h hom tow Others always make a when any activity s to be carric for h weeken d could give no example anything.Her sister that these comptheprm Newdu Rdin Ver730 T. SHALLICE AND P. W. BURGESS Case 2 D.N. a right-handed professional man, had sustained a serious head injury in a road traffic accident at the age of 26 yrs, involving a right frontal depressed skull fracture and an intracerebral haematoma treated surgically. He still has severe left hemiparesis. He says that consciousness was reduced or altered for 3 months. A CT scan carried out at age 48 yrs showed an extensive low attenuation area in the right frontal lobe and marked local atrophy of the right medial insular cortex. Both lateral ventricles were enlarged, the right more than the left. There were additional mild changes in the left frontal lobe. On leaving hospital after a stay of 6 months he returned to his previous employment but was unable to carry it out. He failed a higher degree but obtained a teacher's certificate. For the next 5 yrs he held a succession of jobs from most of which he was dismissed. His responses in a clinical interview and his wife's testimony were in agreement over his domestic behaviour. He is untidy. He only bathes if going somewhere important. Shaving, changing his clothes or undergarments, washing his hair and having his hair cut are only carried out when his wife tells him. He hardly ever spontaneously tackles any domestic chores such a laundry, cleaning, cooking, making repairs or paying bills. If his wife is out he normally leaves the preparation of a meal to his 10-yr-old son. When he shops he never makes out a list himself and also usually comes home without all the items on the list his wife prepares. When she gives him a task she has to specify exactly what is required and even so he might carry out some parts only and then starts reading a newspaper. In addition, his wife organizes all trips, outings and social contacts with relatives. His wife said that he was occasionally irresponsible over money; for instance, even though they were in financial difficulties as he was out of work, he would buy gadgets they did not really need, including a sophisticated music system, costing £500. Clinical neuropsychological tests. D.N. was tested in the National Hospital on a wide range of neuropsychological tests. On the WAIS, he obtained a Verbal IQ of 126 and a Performance IQ of 112, which may well be a little below his premorbid level but in fact corresponds well with the results of the National Adult Reading Test (Nelson, 1983) of 119. For all Verbal subtests he was in the superior range and in the Performance subtests in the average or bright average ranges (see Table 1). On memory tests he performed well with verbal material but poorly with visual material (see Table 2). On tests held to be sensitive to frontal lobe lesions his performance was generally satisfactory, but it was rather poor on the picture version of the Self-Ordered Memory test (see Table 3). In summary, D.N. performed well on a wide range of perceptual language and frontal lobe tests. However, while his performance on verbal memory tests was well within the normal range, it was impaired on visual memory tasks. Case 3 F.S., a 55-yr-old right-handed woman, employed in an undemanding post, as a 'media resources officer', had earlier sustained two separate head injuries. Thirty years before she had been thrown from a horse, had fractured her skull and had been left with a posttraumatic amnesia of unknown length. She was also aphasic at the time. The accident had left her with slight left-sided facial paralysis. Two years before being tested she had been knocked off her bicycle by a car and hit her head on the road; she did not lose consciousness but as a result has had a permanent loss of her sense of smell. A CT scan carried out 2 yrs after the second accident showed an extensive lesion to the left frontal lobe with atrophy causing enlargement of the frontal hom of the lateral ventricle. There was also some atrophy in the left temporal lobe. For the past 25 yrs she has worked in the same position. She lives by herself in a single room. Her responses in a clinical interview show that she undertakes virtually no inessential or novel activities. She is very untidy, never putting things away. She seldom goes out in the evening, and virtually never travels away from her home town. Others always make arrangements when any joint activity is to be carried out. She is said by her sister never to organize anything. She shops every day buying only a few things on any occasion and never visits supermarkets. She had no activity planned for the following weekend and could give no example where anyone had relied on her to do anything. Her sister confirmed that these behaviours were characteristic. Clinical neuropsychological tests. F.S. was tested at the National Hospital on a large range of neuropsychological tests. On the WAIS she obtained a Verbal IQ of 135 and a Performance IQ of 114 comparable with the estimate of the premorbid IQ of 127 derived from the New Adult Reading Test. Verbal by guest on April 8, 2016 http://brain.oxfordjournals.org/ Downloaded from