Neuropsychologm,Vol.18,435 to 442 0028-3932/80/1001-0435 102.

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© PerBamonPress Ltd., 1980.printed in Great Britain

LOSS OF MENTAL IMAGERY: A CASE STUDY

ANNA BASSO, EDOARDO BISIACH and CLAUmO LUZZATT~

Centro di Neuropsicologla delrUniversitA di Milano

(Received 2g February 1980)

Almtract--A case of loss of mental imagery following a vascular lesion of the left occipital lobe is
described and discussed. The findings support a twofold (analogue and propositional) theory of
neural representations of the external world. It is argued that sanse-specifi¢ representations may he
preserved in spite of the reported loss of imagery in the corresponding modality. The possibility that
this disorder may reflect a functional disconnection between brain centres is discussed.

INTRODUCTION
IT IS known that people experience, in varying degrees, sense-specific represemations of the
external world [1]. In rare instances, patients suffering from brain damage report having lost
precisely this kind of representation. Their statements would appear to be related to the
breakdown of a definite system of processing of stored information which may be called
mental /maoery, without any preconceived implicatiom. The relations between the
introspective report and other behavioural aspects in the case we shall describe and in earlier
observations may contribute to the understanding of a topic which is a subject of inquiry and
debate. Specifically, the hypothesis of a twofold structure of mental representations of the
external world, analogue and propositional,is supported by the findings. We will also argue
that although the subjective experience of mental images is likely to reflect representations in
analogue format, their reported disappearance does not necessarily imply the absence of
representations of this kind. We shall also discuss whether this peculiar disorder could be the
consequence of a functional disconnection of these representations from language.

CASE HISTORY
M.G., fight-handed male with 6-yr schooling, tram-driver by occupation. Over a period of several years his blood
pressure was above normal values. Fourteen years previously he had suffered a coronary occlusion. On the morning
of 17 December, 1977, at the age of 63, he had a severe attack of giddiness associated with headache. After a short
while he noticed that he could no longer read. Three days later he developed a slight right hemiparesis; neurological
examination also disclosed dysphasia and right-sided homonimous hemianopia. The patient was first examined in
our aphasia unit on 17 January, 1978.
Picture naming was impaired: the patient could name only 7 out of 20 pictures of famillar objects. Object naming
was normal. He said he was able to identify the pictures he could not name; he could accurately point to pictures
named by the examiner. Writing of single letters to dictation showed no errors, but he could only read 8 letters out of
10. Writing of syllables, words, meaningless words and sentences was moderately impaired, rate of errors ranging
from 10 to 30 ~. It is possible that these errors were at least partly due to th6 slight paresis of the right upper limb and
to the inability to cheek his own writing. Reading of syllables and words was severely impaired (45 and 80~ errors
r~speetively); reading of meaningless words and of sentences was impossible. Four months later, writing to dictation
was almost normal; the patient had only some difficulties with meaningless words. Picture naming had improved
slightly; he could name 11 pictures out of 20. He made only rare errors in reading single letters and syllables; reading
of words was hesitant but accurate. In contrast, reading of meaningless words was still impaired to a considerable
degree and reading of sentences impossible. Though disorders of colour gnosis were not evident, they were detected,

435
436 ANNA BASSO, EDOARDO BISIACHand CLAUDIO LUZT.ATrl

in mild form, by special examination (27 January, 1978): the patient scored 338 on the Farnsworth-Munscll 100 hue
test and 41.5 on the coiour-figure matching test [2]. He did not show apractic disorders during any stage of the
illness. He never reported, nor did we detect impairment in mental arithmetic. His recollection of past events, both
preceding and following the stroke, was normal. He was alert, cooperative and pleasant. He stated his troubles
lucidly, infrequently betraying readily controlled emotional reactions.
A C T scan performed on 4 January, 1980 (Fig 1), showed an area of reduced density involving the lower mesial
region of the left occipital lobe and part of the juxtaventricular structures of the left temporal lobe with possible
inclusion "of the hippocmnpus. The left Sylvian fissure and trigone were markedly enlarged. An area of decreased
density was also apparent in the upper portion of the left cervbellar hemisphere, extending to the midline.
Curiously, the loss of mental imagery which, as it will be seen, was experienced as one of the most painful
consequences of his brain injury, was never referred to before the time of the first language examination, when we
found the patient to be completely unable to describe very familiar places. At this time, the patient had a slight motor
but a severe somatoseasory impairment confined to the right upper limb; he also showed a dense right-sided
homonymous hemianopia without macular sparing. His general behaviour, as well as cancellation tests and
drawing, showed no evidence of unilateral neglect. Initially, the patient had not been aware of his visual field defect.
This was gradually realized during the days following the stroke by the patient's wife and then by the patient himself
when they found that he failed to notice people and objects in his right visual field.
The disorder which we will subsequently take into consideration remained substantially unchanged up to June
1979, when the patient was last seen in our unit. The loss of visual imngery was first stated by the patient when
requested to describe the Cathedral Square of Milan. He was unable to add a single item to the description of the
square beyond the Cathedral itself and the equestrian monument in the centre of the square. He asserted that this
was not due to an inability to name individual details, but to the fact that he could recall none of them and was totally
unable to form a mental image of the Square. When asked whether 10 well-known buildings of the town (5 in the
square and 5 outside) belonged to the perspective he had to describe, he was quick and confident in rejecting the
wrong ones but hesitant about the others: he accepted one (the Arcade), rejected another (the department store La
Rinascente) and abstained from answering in the remaining three instances. Once taken to the Square, he failed to
identify all buildings and shops with the exception of the Cathedral and of the Arcade, despite the fact that the
buildings that enclose the Square, as well as several of the shops, restaurants and cafes are very familiar to most
people in Milan. tt may be added that, because of his occupation, the patient was particularly well acquainted with
urban geography. He was also unable to point to individual spots named by the examiner, with the exception of the
Royal Palace, which he was able to locate only after having argued that it had to be the second oldest building in the
Square after the Cathedral itself, as it had been the residence of a court at one time. He was unable to describe his way
home from the hospital, in spite of the fact that he could walk back and forth with no trouble, while admitting that all
houses except his own looked unfamiliar. He was also unable to state the route taken by tram No. 15 which he had
driven for many years. He was unable to give a description of his kitchen but volunte~ed the information that he
could move around in it and find objects quite adequately if he happened to do it absent-mindedly, whereas he got
lost whenever performed the same activities more deliberately, following an explicit programme of successive
actions. The inability to form mental images was not confined merely to buildings. The patient was also unable to
form a visual representation of faces. He said he knew his wife to be "small, grey haired, with almond-shaped eyes"
but was unable to conjure up a picture of her in his mind. After the stroke he frequently failed to identify the faces of
distant acquaintances, though recognizing them. He was however able to recite the parts of the human body as well
as the nomenclature of familiar objects (e.g. of a bicycle). He could also enumerate the provinces of Italy, but showed
some hesitancy in locating them on a map; he only succeeded after having verbally stated their geographical
relationships. A keen hunter prior to his illness, he now denied having any image of pheasants, hares and other game.
When asked to describe a pheasant, he only could say that it was a gallinacean. Asked about differences between the
cock and the hen, he replied that the former had more colours. Nonetheless he could draw a rough, still recognizable
silhouette of a pheasant. The patient also said that since the stroke his hypnagugic imagery was completely missing.
He asserted that he used to enjoy very rich imagery of this kind; especially before and after a day's hunting he
experienced very vivid images of game. "Now", he added in a broken voice, "when I am lying sleepless in my bed I
cannot even think!" Dreams also had fully disappeared.
The loss of mental imagery did not seem to be confined to the visual modality. The patient complained of being
unable to imagine odours, tastes and sounds. In fact, he was no longer able to hum even the most popular tunes.
Nevertheless, when asked to identify a target tune from others hummed by the experimenter, his answer was prompt
and accurate.

DISCUSSION
As far as w e k n o w a loss o f i m a g e r y b e i n g m o r e o r less i n d e p e n d e n t o f a g n o s i a h a s b e e n
i n t r o s p e c t i v e l y r e p o r t e d b y five p a t i e n t s . T h e s e a r e C h a r c o t ' s c a s e M . X . d e s c r i b e d b y
BERNARD ['3], C~OLDSTEIN a n d GELS'S p a t i e n t S c h n . [ 4 ] , t h e t w o c a s e s r e p o r t e d b y BRAIN [ 5 ] ,
a n d o u r p a t i e n t . F o r all t h e s e p a t i e n t s w i t h t h e e x c e p t i o n o f t h e last, t h e c o m p l a i n t w a s
Fl~3. 1. CT scan of patient M.G. (The date was incorrectly printed; it should have been 4 January 1980.)
 LOSS OF MENTAL IMAGERY: A CASE STUDY 439

confined to visual imagery. In Brain's case II, only intentionally evoked images were lacking.
Our patient reported a complete disappearance of dreams, whereas in Charcot's case and in
Brain's case I only the visual content of the dreaming activity was allegedly lacking. No
mention is made in the earlier observations of a loss of hypnagogic imagery as that
experienced by our patient. Paradoxically, Brain's case II was able to give a fairly good
description of absent objects such as his house or his wife's face,whilst keeping his eyes open,
whereas, when he closed them, he was no longer able to do so. Mental descriptions of familiar
objects and environments were severely impaired or totally impossible in the other patients
of this group, with the striking exception of Goldstein and Gelb's patient, whose good
performances however could have relied on motor imagery, as the authors rather
convincingly argued. On visual presentation, the verbal identification of objects which could
not be visualized or described was comparatively unimpaired in Brain's two patients. Even in
those remaining, however, it was considerably less impaired than the visualization and the
verbal description of the same objects. In the everyday life of ~.ll these patients, the
behavioural identification, i.e. the adequate responsiveness to objects and surroundings
which could neither be imagined nor described was even better.
Loss of mental imagery may occur as a comparatively isolated phenomenon, as
demonstrated by Brain's cases, of which only case I showed a mild aphasia. A "pure" alexia
was however present in the other three observations. A disorder of colour gnosis of a mixed
(apperceptive and associative) character was detected in our patient through special testing,
whereas it. is not possible to assess exactly to what extent, and in which form symptoms of
colour agnosia were present in Charcot's and in Goldstein and Gelb's observations.
Prosopoagnosic" disorders are described in Charcot's case; our patient only reported slight
difficulty in identifying faces of some distant acquaintances, nonetheless r e c o ~ i ~ b l e to him.
A more pervasive visuoagnosic disorder was found in Goldstein and Gelb's patient through
special testing.
The anatomical location of the lesion, probably a vascular accident, could not be specified
in Charcot's observation. The patient of Goldstein and Gelb had sustained a left occipital
wound. Unfortunately, a precise localization, which would have been of considerable interest
due to the purity of the syndrome, is lacking in Brain's cases, both of a traumatic aetiology.
Only in case I, a mild disorder of responses to photic stimulation suggested a dysfunction of
the posterior regions of the left heinisphere.
Several questions arise from these clinical records. To begin with: which inferences, if any,
can we draw about the brain-processes rdated to mental imagery? Further: are mental
images a necessary stage for further cognitive processing? And last: are the. proce-'~s which
give rise to mental images actually lacking in these patients, or, rather, have they merely been
disconnected from the verbal system?
Concerning the structure of the brain-processes involved in mental imagery, the high
degree of isomorphism between the subjective experience of such representations and the
perceptions of the external world would seem to require continuous, point-to-point sense-
specific replicas of past impressions. It has however been claimed that we cannot assume an
identical structuring for our subjective experiences and their neural embodiment 1.6]. It has
also been argued 1"7] that although suggestive of an analogue model of information
processing, the results of experiments on imaginal inference 1.8] are compatible with a
propositional model of representations, that is with a model where the information to be
represented is coded into a finite set of symbols interconnected through manifold relations.
On the other hand, evidence from patients showing symptoms of unilateral neglect suggests
440 ANNA BASSO, EDOARDO BISIACHand CLAUDIO LUZZATTI

that, at least in some stages of the representational process, information can be organized in
an analogue format [9, 10]. Anyway, the two models are not mutually exclusive; even if it
might appear more parsimonious to assume a single procedure for storage and
representation of information in the nervous tissue, the coexistence of different
representational systems [11] would not constitute the sole instance of neural redundance.
Clinical observations corroborate the hypothesis of a twofold representational procedure.
Our patient, though firmly denying being able to call up pictures of any kind whatsoever and,
as a consequence, to describe the visual appearance of known objects, still in many instances
retained the ability to retrieve information about them, even if in a rather peculiar way.
Whereas the "blind" description of his wife's appearance would not differ to any great extent
from a description of a picture of her, except for its poverty of detail and perhaps the
"staccato" enumeration of her features, the description of the pheasant would not go beyond
a single taxonomical statement. Even more interesting, however, is the seemingly
paradoxical behaviour of this patient with relation to the Royal Palace. Why, in fact, should
the words "Royal Palace" key up comparatively marginal fragments of stored information
and not others, associated through much more reinforced links? By assuming manifold
representations of single objects we could explain why the patient, still able to generate
sentences like "the pheasant is a gallinacean" or "the Royal Palace was the residence of a
court disappeared long since" (thus retrieving merely conceptual information which is likely
to be organized in a propositional format), can no longer say what these items look like. That
would betray the selective inaccessibility of an analogue visual medium for the representation
oftbe external world. It might be objected that predicates of the kind "beside the Cathedral"
are likely to be derivable from a propositional representation as well and yet our patient
proved unable to locaee the Royal Palace. A tentative answer would be that whenever a
response depends on the representation of sensible data, it is primarily a representation in the
analogue format which is called up. Should this format not be available, the response cannot
be given, unless by having recourse to, in some instances, a propositional data base, as might
have been the case for the patients's awkward description of his wife's appearance. The fact
that under the a,bove considered conditions, the natural way of responding is one which
proceeds from perceptual simulation, might be related to the evolution of our thought
processes from procedures used in perception [12].
As for the second questioh, it has already been observed by Brain that the loss of voluntary
visualization does not necessarily entail an impairment of those functions in which it might
have been expected to play some part. Clearly, these patients, unlike patients showing loss of
topographical memory, or patients in whom loss of mental imagery has been inferred from
agnosic disorders [13, 14] retain adequate, sense-specific internal representations of the
external world: the existence of these representations is indeed a necessary condition for the
perceptual identification of objects and for the ability to find one's way in surroundings
whose image is said to be absent and which cannot be described.
That leads us to the last point. We have hitherto avoided the question of whether the self-
report of these patients means that mental imagery has really disappeared from
consciousness (as would primo fac/e be suggested). In fact, we suspect that the concept of
consciousness, ff referred to a damaged brain, may become nonsensical. This is suggested by
the behavioural analysis of commissurotomy patients [15] and, notably, by the inherent
precariousness of all attempts at localizing consciousness in the left hemisphere on the
grounds of clinical observations [16]. If the possibility is acknowledged that some patients
can form mental images but cannot report them owing to a functional disconnection which
 LOSSOF MENTALIMAGERY:A CASESTUDY 44.1

isolates the related processes from language, it makes little sense to pose the question of the
conscious properties of these images. The denial of visual imagery could be similar to the
verbal denial of visual experiences in callosal patients flashed with pictures of objects in their
left visual field, sharply contrasting with the retained ability to select the flashed picture
accurately when shown in full vision among distractors 1"151. The hypothesis that loss of
visual imagery is the result of a functional disconnection is supported by the frequent
association with '~pure" alexia and with disorders of colour gnosis, which also have been
argued to be dependent upon visuoverbal disconnection 1"17]. Both these disorders were
present in our patient, whose lesion, involving the striate area and extending to the
juxtacallosal region of the left occipital lobe, could lay the conditions for a partial visuo-
verbal cleavage. On a much more conjectural ground one could point to the involvement of
the deep temporal structures, and perhaps of the limbic system, to explain the loss of mental
imagery outside the visual modality.

Acknowledgement--Research supported by CNR Grant 78.01998.04.115.4935.

REFERENCES
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3. BERNARD,D. Un cas de suppression brusque et isoi6e de la vision mentale des signes et des objets (formes et
couleurs), proo. Mdd. !1, 568-571, 1883.
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Untersuchungen Hirnverletzter. Zeitschr. Ges. Neurol. Psychiat. 41, 1-142, 1918.
5. BRAIN,R. W. Loss of visualization, proc. R. Soc. Med. 47, 288-290, 1954.
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1-24, 1973.
7. ANDERSON,J. R. Arguments concerning representations for mental imagery. Psychol. Rev. 85, 249-277, 1978.
8. StmPAXD,R. N. and POOOOaNY, P. Cognitive processes that resemble perceptual processes. In Handbook of
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9. BmAoa, E. and LUZZATn, C. Unilateral neglect of representational space. Cortex 14, 129-133, 1978.
10. BISIACH,E., LUZZAYn,C. and I'ERANhD. Unilateral neglect, representational schema and consciousness. Brain
102, 609-618, 1979.
11. PAlVIO,A. The relationship between verbal and perceptual codes. In Handbook of Perception, E. C. CARTL~-~rL
and M. P. FRn~MAN (Editors), Vol. VIII, pp. 375-396. Academic Press, New York, 1978.
12. W|LTON,R. N. Explaining imaginal inference by operations in a propositional format. Perception 7, 563-574,
1978.
13. NIELSEN,J. M. Agnosia, Apraxia, Aphasia, pp. 188 IT. New York, 1946.
14. MACRO, D. and TaOLLE, E. The defect of function in visual agnosia. Brain 79, 94--110, 1956.
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16. ECCL~S,J. C. Brain and free will. In Consciousness and the Brain, G. G. GLOBUS,G. MAXWELLand I. SAVODNIK
(Editors), pp. 101-121. Plenum Press, New York, 1976.
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NSY 1 8 ~ / 5 - - D
442 ANNABASSO,EDOAeDOBISIACHand CLAUDIOLUZZAT'n

R6sum6 :
On d 6 c r l t a t on d l s c u t e un t e e de p a r t s de l ' l ~ g e r i e mentele & la suite
d°une 14ston v a s c u l e t " r e du l o b e o c c i p i t a l gauche. Ces c o n s t a t a t i o n s s e n t en ~ a v e u r
d'une th6oris & 2 plans (analogue at proPosltlonnel] des repr~sentatlone nerveusss
du monde ext6rleur. On edmet qua lee repr~santetlons sp~olflques des modellt~s sen-
eorlslles peuvent I t r e pr~eerv~es malgr~ le perte de l'Imagerle dens la modallt6
correspondents. On dlscute le posslblllt~ que oe d6sor~re tredulse une disconnexlon
~onctionnelle entre oentres o6r~breux.

Zula~ne~assu~:
Nach e i n e r vaskulttren L l s i o n i m linken Occipitallappen v e r l o r ein Patient
die FJdligkeit z u r blldlichen Vorstellung. Die Beobachttmg tmtersttitzt die
T h e o r i e e t h e r zweifachen, analogen und propoeitioneUen neuronalen
Reprttsentation der Au~enwelt. Es wird e r S r t e r t , da~ s i n n e e s p e z i f i s c h e
R e p r b e n t a t i o n e n e r h a l t e n bleiben kOnnen, such wenn die V o r s t e l l u n g s k r a f t
in d er entsprechenden M o d a l i t i t v e r l o r e n geht. Die M6glichkeit wird diskutiert,
da~ d i e s e Funktionsst6rung eine funktioneLte LeitungsstOrung zwischen H i r n -
zen t r en anzeigt.