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 Introducing
Neuropsychology

Introducing Neuropsychology, second edition investi- edition, key topics are dealt with in separate focus
gates the functions of the brain and explores the boxes, and “interim comment” sections allow the
relationships between brain systems and human reader a chance to “take stock” at regular intervals.
behaviour. The material is presented in a jargon-free, The book assumes no particular expertise on
easy to understand manner and aims to guide the reader’s part in either psychology or brain
students new to the field through current areas of physiology. Thus, it will be of great interest not only
research. to those studying neuropsychology and cognitive
Following a brief history of the discipline and a neuroscience, but also to medical and nursing
description of methods in neuropsychology, the students, and indeed anyone who is interested in
remaining chapters review traditional and recent learning about recent progress in understanding
research findings. Both cognitive and clinical aspects brain–behaviour relationships.
of neuropsychology are addressed to illustrate the
advances scientists are making (on many fronts) in John Stirling has worked at Manchester Polytechnic/
their quest to understand brain–behaviour relation- MMU for over 30 years, teaching Bio- and Neuro-
ships in both normal and disturbed functioning. The psychology, Psychopathology and Experimental
rapid developments in neuropsychology and cogni- Design and Statistics. He has published over 30
tive neuroscience resulting from traditional research scientific journal articles, and three books.
methods as well as new brain-imaging techniques are
presented in a clear and straightforward way. Each Rebecca Elliott has worked at the University of
chapter has been fully revised and updated and new Manchester for 8 years, using brain-imaging tech-
brain-imaging data are incorporated throughout, niques to study emotion and cognition in psychiatric
especially in the later chapters on Emotion and disorders. She has published over 50 scientific
Motivation, and Executive Functions. As in the first research articles.
Psychology Focus
Series editor: Perry Hinton, Oxford Brookes University

The Psychology Focus series provides students with a new focus on key topic areas in psychology. It supports
students taking modules in psychology, whether for a psychology degree or a combined programme, and those
renewing their qualification in a related discipline. Each short book:

• presents clear, in-depth coverage of a discrete area with many applied examples
• assumes no prior knowledge of psychology
• has been written by an experienced teacher
• has chapter summaries, annotated further reading and a glossary of key terms.

Also available in this series:

Friendship in Childhood and Adolescence Stereotypes, Cognition and Culture

Phil Erwin Perry R. Hinton
Gender and Social Psychology Psychology and “Human Nature”
Vivien Burr Peter Ashworth
Jobs, Technology and People Abnormal Psychology
Nik Chmiel Alan Carr
Learning and Studying Attitudes and Persuasion
James Hartley Phil Erwin
Personality: A Cognitive Approach The Person in Social Psychology
Jo Brunas-Wagstaff Vivien Burr
Intelligence and Abilities The Social Psychology of Behaviour in Small Groups
Colin Cooper Donald C. Pennington
Stress, Cognition and Health Attention: A Neuropsychological Perspective
Tony Cassidy Antony Ward
Types of Thinking Attention, Perception and Memory
S. Ian Robertson Elizabeth A. Styles
Psychobiology of Human Motivation Introducing Cognitive Development
Hugh Wagner Laura M. Taylor
Introducing
Neuropsychology
Second Edition

John Stirling and Rebecca Elliott

First published 2008
by Psychology Press
27 Church Road, Hove, East Sussex BN3 2FA

Simultaneously published in the USA and Canada

by Psychology Press
270 Madison Avenue, New York, NY 10016

This edition published in the Taylor & Francis e-Library, 2010.

To purchase your own copy of this or any of Taylor & Francis or Routledge’s
collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.

Psychology Press is an imprint of the Taylor & Francis Group, an informa business

Copyright © 2008 by Psychology Press

All rights reserved. No part of this book may be reprinted or

reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from
the publishers.

The publisher makes no representation, express or implied,

with regard to the accuracy of the information contained
in this book and cannot accept any legal responsibility or liability
for any errors or omissions that may be made.

This publication has been produced with paper manufactured to strict

environmental standards and with pulp derived from sustainable forests.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress
Stirling, John D., 1951–
Introducing neuropsychology / John Stirling and Rebecca Elliott. – 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-84169-653-9 (hardcover) – ISBN 978-1-84169-654-6 (pbk.)
1. Neuropsychology. I. Elliott, Rebecca, 1969– II. Title.
[DNLM: 1. Neuropsychology. WL 103.5 S861i 2008]
QP360.S793 2008
612.8–dc22 2007048903

ISBN 0-203-84120-4 Master e-book ISBN

ISBN: 978–1–84169–653–9 (hbk)

ISBN: 978–1–84169–654–6 (pbk)
 CONTENTS
Preface to the series vii General features of sensory systems 72
Preface to the second edition viii The somatosensory system 72
Preface to the first edition xi Plasticity in the somatosensory cortex 78
Neuroplasticity beyond S1 84
1 The foundations of neuropsychology 3 Chapter summary 90
Introduction 3
Neuropsychology as a distinct 5 Motor control and movement
discipline 3 disorders 93
The (re)emergence of Introduction 93
neuropsychology 12 Brain–spinal cord pathways 94
Chapter summary 19 The cerebellum 96
The basal ganglia 98
2 Methods in neuropsychology 21 The cortex 103
Introduction 21 Peripheral and spinal movement
Invasive techniques for measuring disorders 113
brain structure and function 22 Cortical movement disorders 115
Electrical procedures 25 Subcortical movement disorders 119
In-vivo imaging 27 Chapter summary 126
Neuropsychological assessment 32
Chapter summary 37 6 Language and the brain 129
3 Lateralisation 41 Introduction 129
Introduction 41 The classic neurological approach and
Structural differences 42 aphasia 130
Unilateral neurological damage 44 Connectionist models of language 134
The split-brain syndrome 45 The psycholinguistic approach 138
Asymmetries in normal individuals 57 The modern era of language research 139
Individual differences in brain Language and laterality 149
organisation 60 Chapter summary 150
Lateralisation: A footnote on the
evolutionary perspective 67 7 Memory and amnesia 153
(contributed by Andrew Parker)
Chapter summary 68
Introduction 153
4 Somatosensation and neuroplasticity 71 Short-term memory and working
Introduction 71 memory 154
vi Contents

Long-term memory 157 The interaction between somatic and

Anterograde amnesia and non- emotional systems 269
declarative memory 160 The interaction between emotional
Anterograde amnesia and declarative and cognitive systems 272
memory 164 Neuroimaging of emotion and
Memory processes 168 motivation 273
Retrograde amnesia and Social neuroscience 279
autobiographical memory 171 Impairments of emotion, motivation,
Chapter summary 175 and social function 284
Chapter summary 285
8 Visual object recognition and spatial
processing 177 11 Executive functions 289
Introduction 177 Introduction 289
The “what” and “where” streams and Domains of executive dysfunction 290
visual perception 178 Task switching and multi-tasking 295
The ventral stream and object Issues with “executive tests” 297
recognition 181 Underlying mechanisms of executive
Functional imaging of object function 298
recognition 190 The brain and executive function/
Imaging category specificity 195 dysfunction 299
Spatial functions and the “where” Specialisation within the prefrontal
stream 197 cortex 302
Basic spatial processes 197 Executive dysfunction and psychiatric
Chapter summary 204 disorders 305
Chapter summary 307
9 Attention and consciousness 207
Introduction 207 Appendix: A primer of nervous
Types of attention 208 system structure and function 311
Issues in psychological investigations Introduction 311
of attention 209 Neurons and glia 312
Attention and the brain 215 Nerve impulses and synaptic
Neurological attentional disorders 226 transmission 313
Towards an integrated model of Developmental and ageing aspects 317
attention 232 Dividing up the nervous system 318
Consciousness 237 Chapter summary 326
Chapter summary 253
Further reading 327
10 Emotion and motivation 257
Glossary 333
Introduction 257
References 339
Definitions and measurement of
Author index 373
emotion and motivation 258
Subject index 385
Evidence from neurology and
neuropsychology 265
 PREFACE
TO THE SERIES
The Psychology Focus series provides short, up-to-date modules in a single year to obtain a degree at the end
accounts of key areas in psychology without assuming of their programme of study.
the reader’s prior knowledge in the subject. Psychology One possible problem with studying a range of
is often a favoured subject area for study, because it is separate modules is that the relevance of a particular
relevant to a wide range of disciplines such as sociology, topic or the relationship between topics may not
education, nursing, and business studies. These rela- always be apparent. In the Psychology Focus series,
tively inexpensive but focused short texts combine suf- authors have drawn where possible on practical and
ficient detail for psychology specialists with sufficient applied examples to support the points being made
clarity for non-specialists. so that readers can see the wider relevance of the
The series authors are academics experienced in topic under study. Also, the study of psychology is
undergraduate teaching as well as research. Each takes usually broken up into separate areas, such as social
a topic within their area of psychological expertise and psychology, developmental psychology, and cognitive
presents a short review, highlighting important themes psychology, to take three examples. While the books
and including both theory and research findings. Each in the Psychology Focus series will provide excellent
aspect of the topic is clearly explained with supporting coverage of certain key topics within these
glossaries to elucidate technical terms. “traditional” areas, the authors have not been con-
The series has been conceived within the context strained in their examples and explanations and may
of the increasing modularisation which has been draw on material across the whole field of psychology
developed in higher education over the last decade and to help explain the topic under study more fully.
fulfils the consequent need for clear, focused, topic- Each text in the series provides the reader with a
based course material. Instead of following one course range of important material on a specific topic. They
of study, students on a modularisation programme are suitably comprehensive and give a clear account of
are often able to choose modules from a wide range the important issues involved. The authors analyse and
of disciplines to complement the modules they are interpret the material as well as present an up-to-date
required to study for a specific degree. It can no longer and detailed review of key work. Recent references
be assumed that students studying a particular module are provided along with suggested further reading to
will necessarily have the same background knowledge allow readers to investigate the topic in more depth. It
(or lack of it!) in that subject. But they will need to is hoped, therefore, that after following the informative
familiarise themselves with a particular topic rapidly review of a key topic in a Psychology Focus text,
because a single module in a single topic may be only readers not only will have a clear understanding of the
15 weeks long, with assessments arising during that issues in question but will be intrigued, and challenged
period. They may have to combine eight or more to investigate the topic further.
 PREFACE
TO THE SECOND EDITION
For this revised and fully updated edition of Intro- the facts of the matter are that not everything in this
ducing Neuropsychology, John Stirling has been joined second edition could be said to be either strictly
by Rebecca Elliott as co-author. “cognitive” or even strictly “neuroscientific”—yet we
Although the first edition of Introducing Neuro- hope all our material falls within the domain of
psychology was published just 5 years ago, such has neuropsychology.
been the growth of interest in research into brain– In truth of course, such dividing lines are seen as
behaviour relationships that we felt an updated edition more important by some people than others. Take, for
would be timely. Much of this growth has been driven instance, animal research, which is quite widespread in
by the more widespread availability of in-vivo imaging the field of cognitive neuroscience, but rare in neuro-
techniques, an area of expertise for the second author. psychology—rare, but not unheard of (see Rizzolatti
Such techniques, of course, provide opportunities for et al.’s study of mirror neurons in macaque monkeys
researchers to identify brain regions that are engaged which we review in Chapter 5). Case study, on the
as participants undertake all manner of activities. other hand, could reasonably claim to be the modus
Recently, these have ranged widely, from basic cogni- operandi of traditional “clinical” neuropsychology.
tive tasks designed to tap working memory processes But combine it with longitudinal neuroimaging or
(Fletcher et al., 2003) to more elaborate “emotional” some other basic science assaying—such as analysis of
challenges aimed, for example, at invoking sympathy/ cerebrospinal fluid (CSF) or blood, for example—and
empathy in healthy controls and/or psychopaths it would unquestionably qualify as cognitive neuro-
(Farrow et al., 2001; Vollm et al., 2004). science research. In short, what we have is a difference
Data from such studies have been amalgamated of emphasis, but with many areas of overlap. Both
with more basic science research in the areas of authors have published research in cognitive neuro-
molecular genetics, neurophysiology, and psycho- science journals, and attended/spoken at neuroscience
pharmacology, initially in the US but increasingly in the conferences. However, both are psychologists by train-
rest of the world, to provide a knowledge-base for the ing, and this edition, like the first, is written primarily
discipline called “cognitive neuroscience” (Gazzaniga, with the needs of psychology students in mind. Thus,
Ivry, & Mangun, 2003). We considered whether we on balance we felt we should retain the original title yet
too should acknowledge this emerging enterprise by be entirely open to describing research that some
re-titling our book “Introducing Cognitive Neuro- authors might consider more cognitive neuroscience
science”. On balance, however, we felt that neuro- than neuropsychology. Three later chapters in this
psychology, as a subject area, was not yet ready to be edition, covering Attention and Consciousness
subsumed under the cognitive neuroscience banner. (Chapter 9), Emotion and Motivation (Chapter 10),
This may be seen as an exercise in hair-splitting, but and Executive Functions (Chapter 11), attest to the
 Preface to the second edition ix

common ground between the two approaches and we (TMS) to reversibly manipulate brain activity, and
expect that such instances of overlap will become more as a possible therapeutic procedure (Heiser et al.,
commonplace in the years to come. However, it is 2003; Hilgetag, Theoret, & Pascual-Leone, 2001).
instructive to note that just as the rise of “cognitive
science” in the US in the early 1960s (Miller, 2003) did Of course, these changes need to be accommodated
not bring about the demise of mainstream psychology, within the framework of the Psychology Focus series,
so the rise of “cognitive neuroscience” from the 1990s meaning that we have tried to adhere to the criteria set
onwards has not yet brought about the demise of out by Perry Hinton (series editor) outlined above. As
neuropsychology. with the first edition, our book is written principally
In planning the format of this second edition we with the “interested beginner” in mind but we have not
have tried to adapt and revise the first in light of a used this as an excuse for failing to be up to date.
dramatically expanded research base and important Nevertheless, two early warnings may be in order:
refinements of existing research techniques and First, some readers might find sections of coverage in
methods, plus the arrival on the scene of some com- this edition rather complicated for an introductory
pletely new procedures that are now beginning to bear text. Our only excuse is that the brain, the principal
fruit. In no particular order, this work has included the subject of our book, has rightly been characterised as
following: the most complex entity known to man. We have tried
hard to keep things simple wherever possible, but
• Promising efforts to further characterise the frac-
tionation (functional subdivisions) of the frontal
admit to not always succeeding. However, skipping
complex sections (often separated from the general
lobes and the anterior cingulate gyrus (Botvinick, text in boxes) should not, we hope, detract from
Cohen, & Carter, 2004; Wagner et al., 2001). your general understanding of the material. Second,
• New insights into and models of consciousness
(Cooney & Gazzaniga, 2003).
despite the rapid growth in research, many funda-
mental neuropsychological questions remain to be
• Expansion and refinement of the concept of brain
modularity (Catani & ffytche, 2005; Cavanna &
answered. Our view is that in such instances it is better
to admit to uncertainty (while presenting the relevant
Trimble, 2006). material) than to offer glib but premature conclusions,
• Refinement of paradigms aimed at informing
models of attention, including attentional blink
even if the reader may find such lack of resolution
frustrating.
and inattentional blindness (Rensink, 2002; As in the first edition, we have made liberal use of
Sergent, Baillet, & Dehaene, 2005). “interim comment” sections in each chapter in order
• Confirmation of the existence of mirror neurons,
and their possible role in imitation and perhaps
variously to pull ideas together, identify inconsistencies
in the data, describe continued uncertainties about
even in empathy (Brass & Heyes, 2005; Rizzolatti what particular research findings mean, or simply
& Buccino, 2004). to summarise a body of research before the “gist” is
• Development of the field sometimes called “social
neuroscience” encompassing research into autism
lost. We have tried to avoid unnecessary jargon,
and where this has been impossible have sought to
and Asperger’s syndrome, psychopathy, and explain or define a term or concept there and then,
pathological gambling (Frith & Frith, 2003; with additional information provided in the expanded
Rilling et al., 2007). glossary. We have included an appendix (also some-
• Developments in the field of brain plasticity and
recovery of function coupled with confirmation
what expanded in this edition) on the structure and
basic workings of the brain and its key constituent
of the growth of new neurons (neurogenesis) in components as a reference for information rather
specific regions of the mature adult mammalian than as obligatory reading. Our book should be under-
brain (Brown et al., 2003; Carlen et al., 2002; standable to readers with a fairly modest working
Mirescu, Peters, & Gould, 2004). knowledge of the structure and functioning of the
• Refinements in functional imaging including
pathway tracing using diffusion tensor imaging
mammalian nervous system, but if you want to know
more, we offer sources in the Further Reading section
(DTI) (e.g., Minati & Aquino, 2006). at the end of the book. We have identified some key
• The use of transcranial magnetic stimulation journal articles/reading assignments for each chapter
x Preface to the second edition

to aid further understanding of particular topics and Nevertheless, this edition contains over 600 new
issues, along with some general recommended reading journal references, many post-dating publication of the
and some interesting, accessible, and relevant web- first edition, and 60 or more additional/revised figures
pages for you to explore. and diagrams.
In the interests of continuity we have retained the We are particularly grateful to Andrew Parker
broad chapter structure of the first edition, although from MMU who has contributed Chapter 7: Memory
each has been revised and updated. One entirely new and Amnesia, and made helpful comments on other
chapter, on Emotion and Motivation (Chapter 10), sections of the book. We would also like to thank
has been added, and the Summary and Conclusions Marilyn Barnett from MMU both for her work on
chapter from the first edition has been removed to collating references for this edition and for her help
make space for it. The methods chapter (Chapter 2) with numerous other administrative chores. Elsewhere
has been expanded to accommodate recent advances in writing the book, while one or other of us has
in imaging technology now available to the researcher, initially taken the role of lead author for a section or
such as magnetoencephalography (MEG) and diffu- chapter, the other has edited, revised, and even re-
sion tensor imaging, and consideration is also given to drafted. Thus, in the spirit of collective responsibility,
recent research in which TMS has been used to induce we (JS and RE) consider ourselves equally culpable!
temporary reversible disruptions to brain functioning. We hope you find the second edition of Intro-
The chapter on somatosensation (Chapter 4) now ducing Neuropsychology a useful entry point into the
additionally includes an extended section on neuro- neuropsychology literature, and that our interest in
plasticity. The chapter on attention (Chapter 9) has trying to understand brain–behaviour relationships
been extensively revised and now includes an extended through neuropsychological (and cognitive neuro-
section reviewing neuropsychological investigations science) research whets your appetite to learn more
into consciousness, an area that has recently seen about the structure and functioning of the astonishing
dramatic and exciting new developments. Other 1200 to 1500 grams of tissue we call the (mature)
chapters have changed more modestly, being updated human brain.
wherever possible to provide a flavour of the direction
    
that research (in that area) is going, and how it is
Manchester, August 2007
affecting the way we think about the subject material.
 PREFACE
TO THE FIRST EDITION
Just over 18 months ago I completed the first draft of jargon-free style (insofar as this is possible). However,
an introductory book about the brain entitled Cortical a glossary is included to cover highlighted first use
Functions, subsequently published by Routledge in the terms that may be new to the reader. I have also pro-
Modular Psychology series in 1999. While researching vided a large number of figures and diagrams to
the material for that book, I accumulated more infor- illustrate key points, and I have included several boxes
mation than could be shoe-horned into the Modular dotted throughout the book encompassing key
series format, and in discussing the fate of my surplus research findings or, in some cases, the results of
chapters/material with the editors at Routledge the neuropsychological case studies. Shaded “interim
idea of writing a concise up-to-date introductory text comment” sections can also be found at regular inter-
in the area of neuropsychology slowly took shape. vals in every chapter. As their name suggests, these
Introducing Neuropsychology is, somewhat belatedly, summaries are intended to allow the reader to make
the result. sense of particular passages of material in manageable
As with other books in the “Psychology Focus” chunks, before progressing further.
series, this one is intended as an accompanying text Although Introducing Neuropsychology aims to do
for courses in neuropsychology for students new to the what the title says—with coverage of the core ideas,
subject area. I have written the book in such a way concepts and research findings in each of the sub-
that a detailed understanding of neurophysiology stantive chapters—I have also tried to add a flavour of
(neurons, action potentials, synapses and so on) is not recent/current research in each area, but particularly
a necessary prerequisite to getting something out of in the later chapters. The recommended reading for
it, so the book should also be accessible to non- each chapter (set out in the “Further reading” section)
psychology students too. However, to be on the safe also reflects my wish to encourage readers to seek out
side, I have included an appendix to which the reader up-to-date research reports if they want to take their
may want to refer for a quick reminder of the basic studies of a topic further. There are several excellent
layout of the nervous system, the structure and func- texts with a broader and deeper coverage of the
tion of neurons, and the ways we might usefully wish material than can be achieved in Introducing Neuro-
to divide up the central nervous system in order to psychology, and I would urge enthusiastic readers to
make more sense of it. Complete novices may prefer to research these resources too. I have listed some of
read the entire appendix before tackling the rest of the my preferred texts in the “Further reading” section.
book. This is allowed! Similarly, there is some valuable material available on
Mindful of the difficulties students sometimes the Internet. The sites listed in the “Selected neuro-
have with the subject matter of neuropsychology, I psychology web sites” section provide an entry point to
have tried to write Introducing Neuropsychology in a this material, and links will soon take you to 3D images
xii Preface to the first edition

of the brain, lists of gory neurological disorders and about how a structure weighing as little as an adult
the web pages of research institutions and even indi- human brain (usually less than 1500 grams) can do
vidual neuroscientists and neuropsychologists. Happy everything it does, often faultlessly, for 70, 80 or even
surfing! more years! I hope that as you read this book,
For me, neuropsychology represents a confluence you come to share my wonder about this rather
of most of the things I am interested in as a psycholo- insignificant-looking lump of tissue, and that Intro-
gist: normal and particularly abnormal behaviour, the ducing Neuropsychology whets your appetite to learn
workings of the brain, lifespan changes, the common more about it.
ground between neurology, psychology and psychiatry,  
and even the concept of “consciousness”. The more we Manchester, July 2001
learn about neuropsychology the more amazed I am
 “Into the highlands of the mind let us go”

(Adapted from the emblem on the portico of the State Supreme Court, Capital Building,
Sacramento, CA. Source: “Shakespeare”, from A hundred poems by Sir William Watson,
selected from his various volumes. New York: Dodd-Mead & Co., 1923.)
 CHAPTER 1
CONTENTS

Introduction 3

Neuropsychology as a
distinct discipline 3

The (re)emergence of
neuropsychology 12

Chapter summary 19

2
The foundations of
1
neuropsychology
INTRODUCTION
We take the view that a proper understanding of the current status of neuro-
psychology cannot be formed without at least a rudimentary appreciation of its
origins. Thus, in this chapter we offer a brief history of the beginnings of scientific
research into the brain, and we introduce some of the theories (and debates) that
have surfaced as our understanding of the relationship between structure and
functions has developed. We describe some discoveries that led to the development
of the so-called “brain hypothesis”, a concept that is central to neuropsychology
(if not to psychology as a whole). We then introduce the “localisation of function”
debate, which has rumbled on from its origins in the work of the 19th-century
neuroanatomists, and continues to influence the distinct approaches and method-
ologies of clinical and cognitive neuropsychologists that we describe towards the
end of the chapter. Fodor’s concept of modularity (of mind: he is a philosopher
rather than a researcher) is introduced and re-assessed in light of recent findings.
Its current status is considered, by way of illustration, in relation to the neuro-
anatomy and connectivity of a little-known region of cortex called the precuneus
(Cavanna & Trimble, 2006).

NEUROPSYCHOLOGY AS A DISTINCT DISCIPLINE

Neuropsychology is a bridging discipline that draws on material from neurology,
cognitive psychology, and even psychiatry. However, its principal aim is to try to
understand the operation of psychological processes in relation to brain structures
and systems. It is the oldest branch of scientific psychology and it retains a degree
of distinctiveness that distinguishes it from other related areas. It has, for example,
historically relied on small N or even single-case study designs, a tradition that
continues to this day. Like cognitive neuroscience (see preface to this edition) it
embraces the concept of converging operations (in which research findings from
different sources and even different levels of inquiry are “used” to inform a par-
ticular debate). But unlike cognitive neuroscience, we should expect some fairly
direct reference to human behaviour, and also unlike cognitive neuroscience, the
3
4 Chapter 1 The foundations of neuropsychology

brain itself may seem quite marginalised from the debate. Brain structures barely
merit mention in Ellis and Young’s classic text Human cognitive neuropsychology
(1996), for example. (See also Coltheart, 2001, whose ideas are summarised later in
this chapter.)
The term “neuropsychology” was used as a subtitle in Donald Hebb’s influen-
tial book The organisation of behaviour: A neuropsychological theory, published
in 1949, although the term itself was not defined. With the demise of behaviourism
(terms in bold type in the text indicate that the term is included in the Glossary
section at the end of the book) and renewed interest in cognitive processes in the
1950s and 1960s, the term appeared with increasing frequency, although its defin-
ition remained vague and it was used in different senses by different people.
Although, as you will see, researchers had been interested in the effects of brain
damage and disease on behaviour for many years, it was arguably some time after
behaviourism’s fall from grace that neuropsychology came to develop a distinct
identity within psychology, and its parameters were further clarified by the publi-
cation of the first edition of Kolb and Whishaw’s Fundamentals of human neuro-
psychology and Lezak’s Neuropsychological assessment in 1980 and 1983
respectively.
It would be misleading for us to suggest that, following its protracted birth,
neuropsychology has emerged as an entirely unified discipline. In reality there
remain different emphases among practitioners and researchers, which broadly
divide into two domains: those of clinical and cognitive neuropsychology. At the
risk of oversimplifying the distinction, the former tends to focus on the effects of
brain damage/disease on psychological processes such as memory, language, and
attention, and often has a clinical remit for assessment and even treatment. Con-
versely, the latter tries to understand impairments to psychological processes in
terms of disruptions to the information-processing elements involved. In other
words, the clinical approach goes from the damaged brain to psychological
KEY TERMS
Behaviourism: The school dysfunction and its remediation, whereas the cognitive approach goes from
of psychology founded by psychological dysfunction to hypothetical models about the individual stages of
Thorndike and popularised
information processing that could explain such dysfunctions, which may (or may
by Skinner, which places
emphasis on the acquisition not) then be “mapped” onto various brain regions. This division has led to quite
of behaviour through heated debates among neuropsychologists about, for instance, the merits/short-
learning and reinforcement.
comings of single-case versus group research designs, and the extent to which
Clinical neuropsychology:
A branch of clinical cases of localised brain damage can ever definitively be used as evidence in support
psychology that specialises of functional localisation. (We take up each of these points in the following
in the assessment of patients chapters. However, see the special issue of the journal Cognitive Neuropsychology,
with focal brain injury or
neurocognitive deficits. 2004, vol 21, for a flavour of the arguments.)
Cognitive Incidentally, a glimpse at the chapter titles in this book might suggest to the
neuropsychology: A reader that we too have chosen to take a cognitive approach to neuropsychology.
branch of neuropsychology
However, this is not the case, and it is our hope that you will see that both
that studies how brain
structure and function relate approaches have much to offer in our quest to understand the relationship(s)
to specific psychological between psychological processes and brain functioning. Besides, the ever-
processes.
increasing use of in-vivo imaging techniques has inevitably blurred this distinction,
In-vivo imaging
techniques: A range of chiefly because they provide the researcher with the opportunity to observe brain
imaging techniques that activity in healthy individuals as they undertake some sort of cognitive or other
explore structure and/or psychological challenge, arguably permitting a more direct (i.e., less inferential)
function in living subjects.
link between structure and function.
 Neuropsychology as a distinct discipline 5

THE ORIGINS OF THE BRAIN HYPOTHESIS

We know from historical records from the Middle East (e.g., the Edwin Smith
Surgical Papyrus, found in Luxor, Egypt, in 1862) that the importance of the brain
as a “behaviour control centre” (henceforth referred to as the brain hypothesis)
was first considered at least 5000 years ago, although the predominant view then,
and for many centuries thereafter, was that the heart was the organ of thinking
and other mental processes. The ancient Greeks debated the relative merits of
heart and brain, and Aristotle, noting that the brain was relatively cool in com-
parison with the heart, came down in support of the heart as the seat of mental
processes, arguing that the brain’s principal role was to cool blood. Hippocrates
and Plato, on the other hand, both had some understanding of brain structure,
and attributed various aspects of behaviour to it: Hippocrates, for example,
warned against probing a wound in the brain in case it might lead to paralysis in
the opposite side of the body.
In first-century () Rome, the physician Galen spent some time working as a
surgeon to gladiators and became all too well aware of the effects that brain
damage could have on behaviour. The “heart hypothesis” was fundamentally
undermined by Galen’s descriptions of his clinical observations: he showed that
sensory nerves project to the brain rather than the heart, and he also knew
that physical distortion of the brain could affect movement whereas similar
manipulation of the heart could not.
For reasons that are never entirely clear, the knowledge and understanding of
these early writers was lost or forgotten for the next 1500 years or so of European
history. Those with any interest in the brain concentrated on attempts to find the
location of the soul. Their search focused on easily identifiable brain structures
including the pineal gland and the corpus callosum, structures that today are
known to be involved in the control of bodily rhythms and communication
between the two sides of the brain respectively.

LOCALISATION OF FUNCTION KEY TERMS

Paralysis: Loss of movement
The renewed interest in rationalism and science that accompanied the Renaissance in a body region (such as a
in Europe in the 15th and 16th centuries prompted scientists of the day to revisit limb).
the brain and to try to establish the functions of particular brain structures. Sensory nerves: Nerves
carrying action potentials
Because a lot of brain tissue appears relatively undifferentiated to the naked eye, from sensory receptors
these researchers also concentrated their efforts on the same easily identified struc- towards the CNS (e.g., the
tures as the earlier “soul-searchers”. They explored, for example, the functions of optic nerve).
Descartes: French
the fluid cavities of the brain (the ventricles), the pineal and pituitary glands, and
philosopher famous for his
corpus callosum. However, their ideas about the functions of these structures were ideas about the separate
usually well wide of the mark: Descartes (1664), for example, mistakenly argued identities of mind and body.
that the pineal gland was the point of convergence of bodily sensory inputs giving Mind–body problem:
Explaining what relationship,
rise to a non-physical sense of awareness—thus encapsulating the key idea of the if any, exists between mental
mind–body problem, although it should, perhaps, have been more aptly described processes and bodily states.
as the mind–brain (or even the brain–mind) problem! To reiterate, the pineal gland Localisation of function:
The concept that different
is today regarded as an entirely soul-less endocrine gland involved in the control of
parts of the brain carry out
bodily rhythms. different functions and,
Nevertheless, implicit in this early work was the core idea of localisation of conversely, that not all parts
of the brain do the same
function —that different regions of the brain are involved in specific and separate
thing.
aspects of (psychological) functioning. This idea later intrigued both Gall, the
6 Chapter 1 The foundations of neuropsychology

Austrian physician, and his student Spurzheim, whose work represents the
starting point of what we might call the modern era of brain–behaviour research.
It should be noted at the outset that Gall and Spurzheim, like modern-day
neuropsychologists, were more interested in localisation of function within the
cerebral cortex (the outer surface of the brain), with its characteristic bumps (gyri)
and folds (sulci), than in the subcortical structures mentioned earlier. Gall (1785–
1828) readily accepted that the brain rather than the heart was the control centre
for mental function and, with Spurzheim, made several important discoveries
about the anatomy of the brain, its connections with the spinal cord, and its ability
to control muscles that have stood the test of time. For example, Gall was the first
person to distinguish between grey and white matter (neuron cell bodies and
their bundled axons respectively) in the brain, and also described the first case of
aphasia (impaired language production) associated with frontal damage resulting
from a fencing injury.

THE RISE AND FALL OF PHRENOLOGY

Despite their other notable lasting contributions, Gall and Spurzheim are pri-
marily remembered for their ideas about what is sometimes called “strict” localisa-
tion of function in the brain. Through a combination of serendipity and chance
observations, Gall came to the view that each of the two sides of the cerebral
cortex (also sometimes called the left and right cerebral hemispheres) consisted
of 27 compartments or regional faculties. These ranged from commonsense (or at
least recognisable) ones such as language and perception, to ambiguous and
obscure ones including hope and self-esteem. Accordingly, the more a person used
particular faculties, the bigger the brain in that region grew, causing the shape of
the skull to be distorted. Thus was born the “science” of phrenology, which
claimed to be able to describe an individual’s personality and other “faculties” on
the basis of the physical size and shape of the skull (see Figure 1.1a and b).
KEY TERMS Interest in phrenology gradually spread widely through both Europe and the US
Cerebral cortex: The outer (thanks largely to Spurzheim’s efforts; he and Gall fell out over the matter of
surface of the brain which
phrenology’s popularisation and the attendant commercial benefits). In England,
has, in higher mammals, a
creased and bumpy for example, it received royal support when Queen Victoria had her children’s
appearance. heads measured and analysed, and gradually an entire industry of phrenological
Gyri: Elongated bumps “science” was spawned, involving journals, books, and pamphlets offering advice
(convexities) in the cortex
(singular: gyrus). on marital compatibility and, of course, the opportunity for a personal
Sulci: The smaller folds or assessment.
indents on the surface of the Over time, thousands of phrenology measurements were collected, including a
cortex (singular: sulcus). series taken from the skulls of 25 murderers, and even from an amorous widow
Larger ones are called
fissures. who was described as having prominent features (bumps) behind her ears. Each
Neuron cell bodies: The observation was simply taken as confirmation of the general theory, except that
central part of neurons the number of faculties crept up to 35. When, for example, cases were found of
(nerve cells) that contain the
nucleus. individuals with unilateral (one-sided) cortical damage but incomplete loss of
Axon: Long, thin projection function, phrenologists were able to say that the other (intact) hemisphere had
from a neuron that carries taken over responsibility for the faculty in question. However, doubts about
electrical impulses from the
cell body. phrenology first arose when it became apparent that the shape of the skull bore
Aphasia: Deficit in the little relationship to the shape of the underlying brain. Obviously, Gall and
production and/or Spurzheim had no way of measuring internal brain structure in living people,
comprehension of language.
save for those rare instances of individuals surviving (and often not for very long)
 Neuropsychology as a distinct discipline 7

FIG. 1.1 (a) Franz Joseph Gall (1785–1828). (b) A phrenology skull. The concept of phrenology stemmed from Gall’s ideas but was
developed by Spurzheim. Although most scientists dismissed it as a pseudo-science, it enjoyed popular support in the mid-1800s,
gaining royal patronage in the UK and spawning a mini-industry in charts, journals, and consultants.

open head injuries. Actually, records show that Gall had access to a small number
of such cases, but unfortunately he seemed to regard them as being of only anec-
dotal interest, failing to realise that brain-injured people could offer an important
test of his theory. Instead, he and Spurzheim continued to accumulate more and
more measurements from members of the general population that “confirmed”
their ideas.
Just as phrenology was catching on with the general population in Victorian
England, Europe, and North America, the French scientist Pierre Flourens (1824) KEY TERMS
provided the first scientific evidence questioning its validity. Working mainly with Open head injuries: Head
injuries involving damage to
birds, he developed the technique of surgically removing small areas of brain the cranium so that the brain
tissue and, after a period of recovery, observing the effects of the surgery on is exposed or visible. Often
behaviour. (We now refer to these procedures as lesion and ablation, and they are compared with “closed head
injury” in which brain
described more extensively in Chapter 2.) Flourens’ research led him to the con- damage has occurred
clusion that the degree of behavioural impairment was more closely linked to the although the cranium has
amount of damage than to its location, a finding that runs counter to the principle not been penetrated: for
example, dementia
of localisation of function that Gall and Spurzheim had so vigorously promoted. pugilistica (brain damage
Flourens believed that the entire brain operated as a single faculty to serve the associated with boxing).
functions of perception, memory, volition, and so on, as required—an idea that Lesion: A cut in (or severing
of) brain tissue. This may
came to be known as “aggregate field theory”. He also believed that undamaged occur as the result of an
regions could take over the responsibilities of damaged ones—an idea giving rise accident or may be part of a
to the popular (but mistaken) belief that people only use a small proportion of surgical procedure.
their brains, keeping other areas in reserve for learning new skills or replacing Ablation: The surgical
removal of brain tissue.
damaged areas.
8 Chapter 1 The foundations of neuropsychology

Although Flourens’ findings dealt something of a blow to Gall and

Spurzheim’s ideas about localisation (and, by implication, phrenology), hindsight
suggests that his conclusions were probably wrong. First, he worked with pigeons
and chickens, which are now known to have almost no cortex. Second, his
behavioural measures assessed activities (such as eating, movement, and so on)
unrelated to Gall and Spurzheim’s faculties. Third, his surgical procedure was
imprecise, leaving open the possibility that behavioural changes were caused by
damage or lesions to brain structures beyond the cortex.

INTEREST IN APHASIA
Despite Flourens’ lack of enthusiasm for localisation of function, interest in it
was rekindled following a series of case studies of aphasia. French physicians
Bouillaud and Dax had independently described a handful of patients they had
seen who had lost the power of speech after brain damage. Those with left-sided
damage often became paralysed in the right side of their bodies too, despite no
apparent loss in intelligence. Bouillaud’s work was reported in 1825, and Dax’s in
1836 (although neither actually published their findings in a journal), yet little
interest was shown until Auburtin (who happened to be Bouillaud’s son-in-law)
described the same work at a conference in 1861 that was also attended by Paul
Broca. A few days later, Broca met Monsieur Leborgne, a patient who became
known as Tan because this was almost the only sound he could utter. However,
Tan could understand speech well and could, for example, follow quite compli-
cated instructions. Like many of Dax’s patients, he too was paralysed on his right
side. Broca proposed that Tan had suffered damage to the same area of cortex (the
KEY TERMS left frontal region) earlier identified as crucial for language production by Dax and
Stroke: A catch-all term for
disturbances of the blood Bouillard. When Tan died from an unrelated disease later that year, Broca con-
supply to the brain. Most ducted a superficial post-mortem on his brain and confirmed that he had indeed
commonly, strokes are incurred damage to the left frontal cortical region variously attributed to epilepsy,
caused by obstruction to, or
rupture of, blood vessels in syphilis, or a stroke.
the brain. Within two years, Broca had collected post-mortem data on eight similar
Fluent aphasia: Another cases. This research led him to conclude that language production depended on
name for Wernicke’s
aphasia. Language is fluent intact left frontal function, and that, in more general terms, the two sides of the
but nonsensical. brain controlled the opposite sides of the body. (In fact, neither of these ideas was
Conduction aphasia: new—the relationship of one side of the brain to the opposite side of the body had
Aphasia in which the
been described by Galen at the beginning of the first millennium, and the link
principal deficit is an inability
to repeat spoken language. between left-sided damage and aphasia could be dated back to Gall.) Neverthe-
Temporal lobe: The region less, Broca seemed to gain the credit, and the region of brain he described (part of
of the cortex (on both sides the left frontal cortex) is now known as Broca’s area.
of the brain) running
forward horizontally above Soon, other regions of the cortex on the left side were identified as being
and in front of the ear, important for various aspects of language. In 1874 Carl Wernicke described two
known to be involved in additional forms of aphasia that were distinct from Broca’s type. In fluent aphasia
language, memory, and
visual processing. the patient could speak at a normal rate but what was said usually made little
Disconnection: The general sense. In conduction aphasia the patient seemed able to understand what was said
term for a group of disorders to them but was unable to repeat it. Wernicke surmised (on the basis of just one
thought to be caused by
damage to a pathway documented post-mortem investigation) that fluent aphasia was caused by damage
between two undamaged to the posterior region of the left temporal lobe. He speculated that conduction
regions (e.g., split-brain aphasia was caused by a disconnection (literally a break in the pathway) between
syndrome).
this region (which we now know as Wernicke’s area) and Broca’s area.
 Neuropsychology as a distinct discipline 9

INTERIM COMMENT
Two important consequences followed from Wernicke’s observations. First,
language could no longer be considered a unitary “faculty” and would have to be
subdivided (at least) in terms of receptive and expressive functions. Second, it was
clear that focal disease could cause specific deficits. The first observation meant
that the scientists of the day would have to rethink the concept of “faculty”. The
second lent considerable weight to the idea of localisation of function. When, in
1892, Dejerine identified the cortical area (these days called the angular gyrus)
related to the loss of the ability to read from text (known as alexia), three
language areas, all on the left side, had been identified, and the localisation of
function concept had received a major boost (see Figure 1.2).
To this work on aphasia, we might add the pioneering work of Fritsch
and Hitzig (1870) who showed that discrete electrical stimulation of dogs’
brains could induce movement of specific body parts in a consistent and
predictable way. We might also note the subsequent cytoarchitectonic maps
(maps of cortical regions differentiated by cell type and density) of Vogt (Vogt &
Vogt, 1903) and Brodmann (1909). The latter has stood the test of time (with
minor modification to some of his regional boundaries), and present-day
researchers still frequently identify cortical locations by their Brodmann number
KEY TERMS
(see Figure 1.3). BA 44 (and into BA 45) on the left, for example, correspond with Angular gyrus: A region of
Broca’s area, and BA 7 corresponds to the precuneus, which we will discuss cortex on the temporal/
towards the end of this chapter. Cytoarchitectonic maps are primarily concerned parietal border roughly
equivalent to Brodmann’s
with structure, but there is general agreement that most of the mappers area 39. The left side is
anticipated there would be correspondences between structurally distinct regions probably involved in reading
and underlying functions. (sentences).
Alexia: Inability to read.

MASS-ACTION AND
EQUIPOTENTIALITY
Despite the evidence presented in the previous
section, it would be misleading to suggest that after
Dejerine’s findings all researchers quickly accepted
the basic principles of cortical localisation. For
instance, the renowned British neurologist John
Hughlings-Jackson supported localisation for some
cortical functions, but was also aware that focal
damage rarely led to complete loss of the function.
As if to underline this point, the German physiolo-
gist Goltz regularly attended scientific meetings
in the 1880s with a dog whose behaviour seemed
relatively “normal” despite Goltz himself having
removed a large chunk of its cortex!
FIG. 1.2 Some language areas in the brain. W is Wernicke’s area,
At the beginning of the 20th century European
conceptualised as the region responsible for linking speech sounds
psychology came under the influence of the to stored representations of words. B is Broca’s area, identified as
“Gestalt” movement, which emphasised the im- involved in the generation of speech. AG depicts the angular gyrus,
portance of “the whole as being greater than the known to be important in understanding visually presented material.
10 Chapter 1 The foundations of neuropsychology

FIG. 1.3 Brodmann areas. Brodmann used a light microscope

to analyse the cellular organisation of the cortex, identifying 52
distinct regions. Many (though not all) of these are still
recognised and used today to identify particular locations.

sum of its parts”. This view was anathema to

localisationists but it prompted other scientists,
such as the British neurologist Henry Head, to
describe the brain as a dynamic, interconnected
system that should be considered in its own right
rather than as a collection of independently func-
tioning units. Head’s ideas were shared by Karl
Lashley, an American psychologist, whose theories
of mass-action (that the entire cortex is involved in
all functions), and equipotentiality (that each cor-
tical region can assume control for any given
behaviour) were based on the same “holistic” prin-
ciples, and were, for a while, extremely influential,
particularly in psychology.
Lashley’s ideas can be traced back to the
earlier work of Flourens: like him, Lashley used
brain lesions and worked exclusively with animals.
Many of his studies were designed in an attempt
to establish the anatomical location of the
“engram”—the representation of memory in the
brain. To address this, he measured the effects of
lesions and ablations (cutting or removal of brain
tissue) on maze learning in rodents (see Figure
1.4a). Initially there would be a period of orienta-
tion during which an animal learned its way around
a maze to locate a food pellet. Then Lashley would
remove a small region of cortex and, following a period of recovery, see how many
KEY TERMS trials it took the animal to relearn the maze and find the food pellet (see Figure
Mass-action: The principle 1.4b). After many such experiments, Lashley came to the view that his quest to
(alongside equipotentiality)
that cortical regions of the locate the engram would never succeed. On the contrary, his research had shown
brain are inherently non- that the amount of lesioned brain tissue rather than its location best predicted how
specialised, and have the long it would take the rat to relearn the maze. This finding is clearly at odds with
capacity to engage in any
psychological function. the idea of a localised memory system, and lends weight to the ideas of mass-
Equipotentiality: The term action and equipotentiality.
associated with Lashley, These findings jibed well with new ideas about behaviourism emanating from
broadly meaning that any
region of cortex can assume American experimental psychology at the beginning of the 20th century. This
responsibility for a given approach stressed the importance of learning and reinforcement at the expense of
function (memory being the interest in the brain. However (and notwithstanding the difficulties in generalising
function of interest for
Lashley). from rat to human behaviour), there are a number of flaws in Lashley’s argument,
Reinforcement: Typically and his findings could, in fact, be used to support localisation of function. Think
some form of reward for a moment about the information a rat might use to find food in a maze—this
(positive reinforcement) or
is likely to include sensory information from the visual, tactile, and olfactory
punishment (negative
reinforcement) that affects modalities, in addition to any more sophisticated conceptual information such as
the likelihood of a response sense of direction, distance travelled, and so on. Indeed, effective maze learning
being repeated.
probably depends on the integration of all this information. When Lashley
 Neuropsychology as a distinct discipline 11

FIG. 1.4 Lashley’s lesions and one of his mazes. (a) The anatomical location of some of the lesions
performed by Lashley. (b) The types of maze used by Lashley in his search for the engram in rodents’
brains.

lesioned different parts of cortex, he might have interfered with the animal’s tactile
skills or sense of smell, while leaving other functions intact. The animal could still
learn the maze using the “localised” functions that remained, but perhaps not as
quickly as before.

INTERIM COMMENT
In fact, sound experimental support for Lashley’s ideas has been hard to come by,
and it is probably helpful to know that most neuropsychologists continue to
favour some form of localisation. Indeed, at present the main questions in this
area are less to do with whether or not the human cortex is organised locally,
12 Chapter 1 The foundations of neuropsychology

than the extent to which localisation of function applies, and whether it applies
equally on both the left and right sides of the brain (an issue we consider in
Chapter 3). There is, additionally, a very important lesson for neuropsychologists
embedded in the alternative explanation of Lashley’s findings. This concerns the
interpretation of results about “recovery of function” in brain-damaged
individuals, and we will return to it later in the book.

THE (RE)EMERGENCE OF NEUROPSYCHOLOGY

Historians seem unsure why, after such a promising start in the late 19th century,
neuropsychology seemed to go into a form of hibernation until after World War
II. In reality a combination of factors was responsible, notably the increased
interest shown by mainstream psychology in behaviourism and psychoanalysis,
rivals perhaps, but both understandable without direct reference to the brain.
During this period there was also a distinct lack of progress in understanding
basic brain physiology. Cajal and Golgi engaged in a protracted argument about
whether the brain was, in effect, a single complex nerve field (as Golgi thought), or
comprised individual structurally distinct units (neurons) as Cajal believed. More-
over, the discovery of chemically mediated synapses was made only in the 1930s by
Otto Loewi, and even then there was a further delay of several years before the
chemical that Loewi had found in his classic experiment was identified as acetyl-
choline (see Box 1.1).

Box 1.1 Brain discoveries in the early 20th century

Early in the 20th centrury Camillo Golgi, a neuroanatomist working in a small
university in northern Italy, discovered that a silver salt could be used to stain
brain tissue. For reasons that are still not fully understood, some tissue absorbed
the stain giving it a distinct black appearance, and it could then be examined
more closely under the light microscope. Golgi’s stain highlighted individual
neurons, but he was convinced that he was actually staining small regions of a
continuous mass of relatively undifferentiated tissue. Santiago Ramon y Cajal
(1913, 1937), a Spanish neuroanatomist, used Golgi’s method to show that the
regions of stained tissue were, indeed, individual neurons and, moreover, that
they carried electrical information (we would now identify this as volleys of action
potentials) in one direction only, from the cell body (or more specifically the axon
hillock) to the end of the axon (see Appendix). Despite jointly receiving the Nobel
KEY TERMS prize in 1906, the two men remained fierce rivals, Golgi in particular rebuffing
Psychoanalysis: The school
of psychology initiated by
Cajal’s ideas—although time has shown that Cajal, rather than Golgi, was right.
Freud that emphasises the By the time Otto Loewi discovered chemically mediated synaptic trans-
role(s) of unresolved mission in 1931, most researchers accepted the “neuron” hypothesis (the direct
subconscious conflicts in
psychological disorder.
conclusion from Cajal’s work) but assumed that “contacts” between neurons
Synapses: The tiny fluid- were electrically mediated. Loewi is reputed to have come up with the idea for his
filled gaps between neurons “frog-heart” perfusion experiment following a dream. He was aware that a frog’s
where synaptic transmission heart could be slowed down by electrical stimulation of its vagus nerve, but he
(see below) may occur.
Typically 20–30 nanometres did not know what actually caused this effect. He repeated his experiment on a
(millionths of a millimetre) live frog, stimulating its vagus nerve while bathing the exposed heart with water.
wide. The “run-off” fluid was collected then trickled over the exposed heart of a second
 The (re)emergence of neuropsychology 13

frog, which slowed down. This showed that some chemical in the perfused water
from the first frog mediated the effect seen following vagus nerve stimulation.
Some 8 years after this study, the chemical in question was identified as
acetylcholine (ACh), now recognised as one of the most widespread neuro-
transmitter substances. Among its many vital functions in our own nervous
system, ACh is a key neurotransmitter at neuromuscular synapses, and also plays
many critical roles in the brain.

CONNECTIONISM TO MODULARITY
As we have already suggested, the 1950s and 1960s were marked by a gradual
increase (or perhaps re-emergence) of interest in both physiological and cognitive
psychology, each making important contributions to the subject matter that we
now consider under the heading of neuropsychology. Meanwhile, the concepts of
mass-action and equipotentiality gained little support from the new wave of brain
research, and interest in them dwindled. New understanding about the connectiv-
ity of the brain, on the other hand, prompted a revival of interest in “connection-
ist models” of brain function. Such models had first appeared almost a century
earlier as explanations of how, for instance, the various aphasic conditions might
be related to one another, and how they in turn might be linked to pathology in
different but interconnected left-sided brain regions (Lichtheim, 1885). Similar
types of model were also proposed to explain agnosia(s) (loss of ability to recog-
nise visually presented commonplace objects; Lissauer, 1890) and apraxia(s)
(inability to perform or copy gestures on demand; Liepmann, 1905). However, in
each case, a combination of problems with the original conceptualisation of the
model (for instance, the identification of cases whose profile did not conform to
the stereotypic disorder) coupled with the rise in 20th-century (non-brain) psych-
ology worked to marginalise them, and connectionist models fell out of favour
with researchers.
In neuropsychology, their re-emergence in the 1960s as “neural wiring dia-
grams” was an attempt to clarify the different cortical regions that might be
responsible for particular psychological processes. One of the most influential was
Geschwind’s neo-associationist model of language and aphasia (Geschwind,
1965), considered in Chapter 6. That the model itself contained a number of flaws
is not now, some 40 years later, seen as being as important as the impetus it gave to
neuropsychological thinking at a critical time in the subject’s re-emergence. Most
neuropsychologists now think that the human brain coordinates mental processes
through the collaboration of (and interconnections between) multiple brain
regions. It thus follows that circumscribed deficits in higher brain function should
KEY TERMS
be attributable to (1) loss through damage or disease of some specialised cortical Agnosia: Loss of ability to
function, or (2) loss through damage or disease to connecting pathways, or (3) recognise objects, persons,
sounds, shapes, or smells in
both. At present the first alternative is better understood, mainly because of the
spite of intact sensory
continuing difficulty in establishing functional connections within the brain, but function.
new “in-vivo” pathway-tracing techniques such as diffusion tensor imaging (DTI) Apraxia: The inability to
are likely to lead to rapid developments in this area (see Chapter 2) carry out certain motor acts
on instruction without
The circuits comprising areas of specialised cortical function and their evident loss of muscle tone
interconnections are sometimes called “distributed control networks”. Although (acts may be performed
this sounds rather complicated, think of it as meaning that psychological spontaneously, for example).
14 Chapter 1 The foundations of neuropsychology

functions (such as language or movement) depend on the activity of, and connec-
tions between, several (many) different but specific locations. Clearly this is a
different idea from the “strict” localisation of function concept mentioned earlier,
because it implies that no one region has sole responsibility for a particular psy-
chological function (or faculty in Gall’s terms). However, it is also quite distinct
from Lashley’s ideas of mass-action and equipotentiality, because it suggests that
some regions of cortex are fundamentally involved in particular psychological
processes while others are not.
In a way, the concept of distributed control is a compromise between the two
approaches, because it implies cortical specialisation (localisation of function) but
also suggests that several (perhaps many) interconnected but anatomically distrib-
uted centres may be involved in the overall process. As Kosslyn and Anderson
(1992) have commented, the problem for the strict localisationists was of thinking
that psychological processes like memory, attention, or language were equivalent
to Gall’s faculties, and therefore could be localised to one particular brain
region. In reality, such processes are complex and multi-tiered, involving the
collaborative efforts of many underlying mechanisms. These subsidiary elements
could, of course, be “localised” to very specific cortical regions, but the network as
a whole may nonetheless actually “engage” broad swathes of cortex when the
subsidiary elements interact to serve the particular psychological process.
For some neuropsychologists, Jerry Fodor captured the essence of this
emerging view in his influential book The modularity of mind (1983). He argued
that it was necessary to distinguish between two classes of cognitive processes:
central systems and modules. The former are non-specific in the sense of operating
across cognitive domains: attention, thinking, and memory have been suggested as
examples. Modules, on the other hand, are domain specific in that they only
process very particular types of input information: colour, shape, movement,
faces, and so on. In Fodor’s view, modules are likely to be hard-wired (immutable),
autonomous, and localised. Critically, they can process information rapidly, and
without reference to other modules; something that Fodor called “informational
encapsulation”.
It must be said at this point that debating the relative merits of different
conceptual models of brain functioning takes us into “difficult” territory, certainly
beyond the scope of this introductory text. However, we can say that Fodor’s
model (presented, by the way, without detailed reference to particular brain
structures) had at least one advantage over Geschwind’s. It allowed for, and indeed
presumed that, the brain used parallel information processing, at least at the lower
“modular” level, so different modules could become simultaneously active,
whereas Geschwind’s was essentially a serial processing model.
As for the distinction between localised modules and non-localised higher-
order cognition, here we must tread very carefully. Certainly there is good evidence
for modularity within perceptual systems: Zeki et al. (1991) have described over 30
“modules” in the mammalian visual system for example. But as for non-localised
KEY TERMS higher-order cognitive processes, current thinking envisages these as mediated by
Module: A core unit in an networks of multiple specialised cortical areas, connected through parallel, bi-
integral modular system. directional pathways. Thus it could be argued that even processes such as atten-
Parallel information
tion and memory, though not localisable to singular specific locations (modules),
processing: The idea that
the brain processes two are nevertheless localisable to networks (or is this a contradiction in terms?).
sources of information The extent to which components in networks are then dedicated to particular
simultaneously.
higher-order cognitive functions, or shared between several, is another current
 The (re)emergence of neuropsychology 15

matter of debate. (See Box 1.2 for further consideration of this complicated issue,
and Chapter 9 for an introduction to the concept of the global workspace model
of consciousness.)

Box 1.2 The precuneus: Trying to make sense of its

many connections and behavioural correlates
In this focus box we hope to illustrate how our understanding of brain–behaviour
relationships has advanced beyond the early connectionist models described in
the text, as in-vivo imaging procedures, coupled with ingenious psychological
challenges, have been refined. The precuneus (BA [Brodmann area] 7) is located
medially (in the longitudinal fissure) above the occipital lobe, forming part of the
posterior parietal cortex (see Figure 1.5). You actually have both a right and a left
precuneus (one in the right hemisphere and another in the left). The precuneus
has reciprocal cortical connections (inputs to and outputs from) with other
parietal regions: parts of the frontal and temporal lobes and the anterior
cingulate gyrus. It has reciprocal subcortical connections with the thalamus, and
sends outputs to the striatum and several brainstem areas.
Functional investigations have identified at least four roles for this hitherto
poorly understood region. A series of PET and fMRI studies suggest that the
precuneus is part of a network (also involving other parietal areas and the
supplementary motor region of the frontal lobes) concerned with visuospatial
processing and imagery, particularly self-referential imagery such as imagining
reaching or pointing, or planning of movements in environments with lots of
obstacles that have to be avoided (Malouin et al., 2003). Second, the precuneus
has been strongly implicated (along with the prefrontal and anterior cingulate
regions) in imagery components of episodic memory retrieval (memory for
previously experienced events sequenced in time, in which, presumably, one
might use imagery to run through the sequence of events to be recalled) and was
labelled by Fletcher et al. (1995) as “the mind’s eye”. Closer investigation has
indicated that the anterior part may be particularly involved in imagery, while
the posterior region is associated with successful retrieval in general. A third
important observation about the precuneus is that it is more active in tasks related
to self—“seeing” things from one’s own as opposed to another person’s
perspective. This network also includes other medial and lateral parietal regions,
and a lateral frontal region known as the insula. Fourth, and most intriguing of
all, it appears that the precuneus (in combination with posterior cingulate and
medial prefrontal regions) is more metabolically active during conscious resting KEY TERMS
states (such as during meditation) than during goal-directed active tasks. The Brodmann area: A region
of the cortex defined on the
opposite side of this coin is that it becomes markedly inactive during altered basis of cytoarchitecture.
conscious states including slow-wave sleep, hypnosis, and anaesthesia. This Thalamus: A multi-
preliminary evidence has been marshalled to suggest that the precuneus may be functional subcortical brain
region.
an important node in the neural network mediating consciousness. Striatum: A collective name
Taken together, these findings suggested to Cavanna and Trimble (2006) for the caudate and
that: “the precuneus may be involved in the integration of multiple neural putamen; key input regions
in the basal ganglia.
systems producing a conscious self-percept” (p. 579). A somewhat more modest
Brainstem: The lower part
interpretation might be that it plays a key role in the modulation of conscious of the brain, adjoining and
processes, perhaps supporting mental representations of “self”. structurally continuous with
the spinal cord.
16 Chapter 1 The foundations of neuropsychology

Cognitive neuropsychologists have also made extensive use of diagrams and

models to identify both the component processing units (modules) and the way
they collaborate to enable psychological processes such as memory, object recogni-
tion, or attention to operate. In certain respects, however, the cognitive neuro-
psychology approach and methodology is quite distinct from that of clinical
neuropsychology (as exemplified by Geschwind). Whereas clinical neuro-
psychologists develop models that are anatomically referenced to specific cortical
regions, cognitive neuropsychologists generate
hypothetical models that more closely resemble
“box and arrow” flow diagrams, and may make
little or no reference to possible underlying brain
regions (see, for example, Riddoch & Humphreys’
2001 model of visual object recognition, intro-
duced in Chapter 8 and illustrated in Figure 1.6).
Such models serve as templates (hypotheses) that
attempt to account for known cases—of a neuro-
psychological deficit such as prosopagnosia (dif-
ficulty in recognising faces), or amnesia (loss of
some aspect of memory) for example—but which
must be amended if other cases come to light that
do not fit. Cognitive neuropsychologists therefore
put great weight on detailed case study of indi-
viduals with particular disorders, eschewing
research based on groups of individuals, on the
grounds that brain damage is infinitely variable and
it therefore makes little sense (they would say) to

FIG. 1.5 The location and connections of the precuneus. (a) The precuneus forms part of the medial parietal lobe. It is hidden in the
posterior part of the longitudinal fissure [after Critchley, M. (1953). The parietal lobes. London: Edward Arnold]. (b) Cortical and
subcortical connections of the precuneus. [Adapted from Cavanna, A. E. & Trimble, M. R. (2006). The precuneus: A review of its
functional anatomy and behavioural correlates. Brain, 129, 564–583. Reproduced with permission.]
 The (re)emergence of neuropsychology 17

FIG. 1.6 Riddoch and Humphreys’ (2001) model of visual object recognition. Typical of the
cognitive neuropsychological approach, the model describes the component processes (and their
connections) assumed to underpin normal and faulty object recognition. We describe this model in
more detail in Chapter 8. [Adapted from Riddoch & Humphreys (2001) in B. Rapp (Ed.), Handbook of
cognitive neuropsychology. Hove, UK: Psychology Press. Reproduced with permission.]

group individuals together simply because they may have vaguely overlapping
areas of damage. Coltheart et al.’s (1998) review of the case of AC (neuro-
psychological cases are often identified by initials in this way) provides a typical
illustration of this approach which we have summarised in Box 1.3.
According to Coltheart (2001), cognitive neuropsychology attempts to
interpret cognitive disorders in terms of selective impairments of functional
architectures. (Note his use of the term “functional architectures” referring to
18 Chapter 1 The foundations of neuropsychology

“box and arrow” diagrams, rather than reference to brain regions or “structural
architectures”, i.e., anatomically referenced neural networks, loops, or circuits.)
The approach is premised on four key assumptions:

• Functional modularity: simply stated, this means that cognitive systems are
actually configurations of modules, each of which has quite specific functions
(see our earlier reference to “modularity of mind”).
• Anatomical modularity: meaning that such modules probably occupy rather
specific anatomical locations.
• Uniform functional architecture: meaning that the above relationship is
consistent from one person to the next.
• Subtractivity: meaning that damage may impair or “knock out” a module or
connection in a system (or architecture), but not replace it with a new one.

Are these assumptions legitimate? According to Coltheart if they were not,

cognitive-neuropsychological research would have run into severe difficulties by
now, whereas in fact the approach continues to be very informative. However, this
is a rather glib answer, and a more prudent approach may be to consider these
not as “key assumptions underlying cognitive neuropsychology” but simply as
working hypotheses about brain functionality. So, as with any other hypotheses,
the scientist retains them until the evidence dictates that they should be rejected
(Popper, 1934).

Box 1.3 The case of AC (Coltheart et al., 1998)

AC, a 67-year-old male, had recently suffered a major stroke, creating an area of
damage on the left side of his brain. A CT scan additionally indicated evidence
of earlier cerebrovascular incidents (probably minor strokes) in both hemispheres.
Not surprisingly in view of the left-hemisphere damage, AC’s language ability
was severely compromised, both in terms of reading and writing and in relation to
verbal expression, where it was apparent that although he knew what he wanted
to say, he struggled to find the appropriate words to say it. However, careful
examination of his cognitive impairments revealed an additional specific problem
with his knowledge of objects, suggesting a profound semantic impairment.
When asked how many legs an oyster had, he replied “a few”, and for a seagull,
“four”. Yet he had a 95% success rate in classifying animals as dangerous (or
not), and a 96% success rate in determining whether or not an animal would be
considered “edible”. In other words, he certainly retained considerable semantic
information about animals despite not knowing how many legs they had. Further
testing indicated that AC’s deficit was, in fact, related to loss of knowledge about
the appearance of objects including animals, as he also struggled to identify
those with tails, or indeed their general shape.
From a cognitive neuropsychological perspective, the implication of these
findings is that there must be separate independent systems of knowledge about
the properties of objects and their visual appearances. Of course there may, in
fact, be separate systems of perceptual knowledge (about objects) for each of our
senses, in addition to a system for non-perceptual object knowledge.
 Chapter summary 19

INTERIM COMMENT
Although the cognitive neuropsychology approach has been useful in certain
domains such as language (see Chapter 6) and object recognition (see Chapter 8),
its reliance on case study rather than group comparisons and its indifference
towards brain structures have not been to everyone’s taste. Small N research
makes for problems of generalisability in any discipline, and neuropsychology
cannot be excepted. As for the inclination to marginalise, or even ignore, matters
of brain neuroanatomy, it should be noted that the continuing development of
in-vivo techniques (see Chapter 2) means that data about functional activation in
the brains of people both with and without damage as they undertake various
psychological challenges are now readily accessible, and this is likely to mean that
cognitive neuropsychologists will, in the future, have to take more notice of the
brain. A concise account of the key events in the history and development of
neuropsychology is offered by Selnes (2001).

CHAPTER SUMMARY
Scientific interest in the relationship between brain structure and function can be
traced back to the work of the 19th-century European neurologists. In the
intervening years, researchers have debated the extent to which the brain operates
on the basis of localisation of function or according to the principles of
equipotentiality and mass-action. Although still a matter of considerable debate,
most modern-day researchers favour some form of localisation, albeit one involving
specialised distributed networks, as providing the best account for our
understanding of how the brain actually operates. Equipotentiality and mass-action
currently have few advocates among brain scientists.
In this chapter we have traced the development of scientific brain research, and
introduced some of the theories that have surfaced as our understanding of these
relationships has developed. A promising start in the 19th century gave way to a
period in the first half of the 20th when psychology was dominated by theories and
ideas that made only passing reference to the brain. Renewed interest in
physiological psychology in the second half of the 20th century, along with greater
interest in cognitive processes within psychology, set the scene for the birth
(rebirth?) of the discipline we recognise today as neuropsychology. Although it is not
an entirely unified enterprise, its cognitive and clinical strands complement one
another in many respects. The rapid increase in access to, and consequent use of, in-
vivo imaging procedures (which brings into the equation both clinical and non-brain-
damaged cases) is likely to lead to greater convergence. These techniques also
provide exciting new insights into the functions of particular cortical regions, and the
precuneus is an excellent example of this.
 CHAPTER 2
CONTENTS

Introduction 21

Invasive techniques for measuring

brain structure and function 22

Electrical procedures 25

In-vivo imaging 27

Neuropsychological assessment 32

Chapter summary 37

20
Methods in
2
neuropsychology
INTRODUCTION
In this chapter we introduce some of the methods that are used in neuro-
psychology to explore the relationship between brain structure and function.
In Chapter 1 we described neuropsychology as a “bridging discipline” and
consequently there are a wide range of methodologies involved—from neuro-
anatomical procedures at one end of the spectrum, through to experimental
psychology assessments at the other. The advent of in-vivo neuroimaging tech-
niques over the last 20 years has revolutionised neuropsychology, providing
research opportunities that were previously unthinkable. In-vivo imaging has, for
example, confirmed some of the long-suspected roles of particular brain regions
in certain psychological processes (e.g., the role of anterior cingulate cortex in
attention; see Chapter 9). Imaging techniques have also revealed the complexity
inherent in functions that traditional neuropsychology had previously over-
simplified. Imaging of language processes is an example of this, as discussed in
Chapter 6.
While imaging techniques have undoubtedly provided a wealth of new infor-
mation, it is important to be aware that they are not without limitations. Older
techniques have therefore remained valuable, in spite of predictions of their
demise. In fact imaging and traditional neuropsychology techniques provide
complementary methodologies, generating more information when used in con-
junction than either could do alone. A key element of imaging studies in neuro-
psychology is the vital importance of good experimental design aimed at testing KEY TERMS
Anterior cingulate: A
specific hypotheses. In the excitement of newly available techniques, it is important midline frontal lobe
to remember that they are simply techniques to answer interesting questions— structure implicated in
attention, response
neuroimaging is a means not an end.
inhibition, and emotional
An important though sometimes unspoken concept in neuropsychological response (especially to pain).
methodology is that of converging operations. Human neuropsychology is Converging operations:
inevitably constrained by many practical and ethical concerns: for example, repeat- The use of several research
methods to solve a single
ing Lashley’s research with human subjects would be impossible. Putting this problem so that the
another way, definitive, theory-changing experiments are actually few and far strengths of one method
between in neuropsychology. Rather, researchers develop ideas (and ultimately balance out the weaknesses
of the others.
theories) about different aspects of neuropsychology by “being receptive” to
21
22 Chapter 2 Methods in neuropsychology

research findings derived from quite distinct approaches. For example, as dis-
cussed in Chapter 3, current ideas about the differing responsibilities of the left
and right sides of the brain derive from:

• case studies of individuals with localised brain damage;

• individuals who have been surgically operated on;
• experimental psychological studies of healthy individuals;
• imaging studies of both healthy and brain-damaged individuals.

All these data should additionally be “evaluated” in relation to both basic neuro-
anatomical observations of similarities and differences between the two sides of
the brain, and (we suggest) broader comparative/evolutionary perspectives. Using
all this information to generate neuropsychological theories would, in effect, be to
endorse the concept of converging operations—something that the authors of this
text are, with certain caveats, happy to do. However, it is important to know that
this approach is not to everyone’s liking, and most neuropsychological methods
have their critics (see, for example, Caramazza’s objections to studying groups of
individuals with similar brain damage: Caramazza, 1986).
Interestingly, a “new take” on converging operations derives from combining
methods in a single study (as we hinted earlier), and we review this potentially
fruitful line of inquiry towards the end of this chapter. However, we start with a
brief review of classic techniques that are, for the most part, neuroanatomical in
origin. We then consider the use of electrical stimulation and electrical recording
in the brain. Then we review the in-vivo neuroimaging procedures that have been
increasingly used to characterise brain structure and function. Lastly we review
the neuropsychological approach. Where possible, we try to refer readers to
specific examples of the use of these techniques described elsewhere in this book.

INVASIVE TECHNIQUES FOR MEASURING BRAIN

STRUCTURE AND FUNCTION
EXAMINING TISSUE
Until quite recently, the only options for measurement of brain structure were
post-mortem investigation or, very occasionally, biopsy. The latter technique
involves the removal and examination of small (but irreplaceable) samples of
KEY TERMS
Biopsy: The removal of brain tissue from the brain region in question. Biopsy is essentially somewhat “hit
tissue (in a living individual) and miss” and also causes inevitable damage to the brain. It is therefore hardly
for analysis. ever used in humans. Post-mortem analysis by contrast, has a long and sometimes
Alzheimer’s disease: A
colourful history in medicine. It does, of course, require the subject to be dead,
form of dementia involving
progressive loss of and therefore early signs of disease are typically masked by changes that have
psychological functions as a occurred as the disease process has progressed.
result of widespread loss of
Sometimes the damage that is revealed in post-mortem is blatantly obvious. In
cortical and subcortical
neurons. one of neuropsychology’s classic cases, Broca observed the brain of his aphasic
Huntington’s disease: A patient “Tan”. His very superficial post-mortem revealed clear damage to the left
rare, genetically determined, frontal cortex (in the region still referred to as “Broca’s area”). The brain of a
neurological disorder
causing dementia and death patient who has died due to Alzheimer’s disease or Huntington’s disease will
due to progressive loss of look abnormal even to the naked eye. It will appear shrunken, with deflated gyri
neurons in the striatum. (surface bumps) and widened sulci (surface grooves). These changes are, however,
 Invasive techniques for measuring brain structure and function 23

probably of less interest to researchers than the more subtle brain changes that
occurred at the start of the disease, or even before clinical symptoms of the disease
were noted. Since the patient would still have been alive at this point, post-mortem
investigation would not have been an option.
In other cases, a brain can appear externally normal at post-mortem, and it
is only on closer inspection of internal structures and tissues that damage or
disease becomes apparent. Brain tissue looks solid to the naked eye, so such closer
inspection depended on two crucial developments. The first was the invention and
gradual refinement of light microscopy: Van Leeuwenhoek first used a microscope
to examine biological tissue in 1674, and since then improvements in lens manu-
facture have led to the technique becoming ever more effective. Light microscopes
can now magnify by a factor of several hundred. The newer technique of electron
microscopy provides magnification by a factor of several thousand. It is now
possible to view images of individual synapses or even individual receptor sites for
neurotransmitters.
The second crucial development for post-mortem analysis was the discovery
of staining techniques that can be used to “highlight” particular component struc-
tures of tissue. Staining was pioneered by Golgi in the late 19th century and his
silver-staining method (“Golgi staining”) is still used today to highlight neurons. KEY TERMS
Other staining techniques, such as horseradish peroxidase (HRP), have been Receptor sites: Molecular
developed to enable the tracing of connections between neurons. This stain is structures on (or in) the
membranes of neurons that
absorbed by the distal (remote) parts of neurons but is carried back to the cell neurotransmitter substances
bodies, thus revealing the path that the axons take. A combination of these stain- (and hormones) can
ing techniques in post-mortem tissue provides evidence of functional connectivity “influence” when they
occupy them, usually by
between brain regions, such as the innervation of the striatum by the substantia making the neuron more or
nigra, which deteriorates progressively in Parkinson’s disease (see Chapter 5). less excited.
At the start of the 20th century, Brodmann used a combination of microscopy Neurotransmitters: A
heterogeneous group of
and staining to map the cytoarchitecture of the human cortex. His research
chemical messengers usually
revealed that different cortical locations are characterised by structurally distinct manufactured by, stored in,
cell types. His comprehensive map, which is still used today (with minor modifica- and released by neurons that
can influence the excitability
tions) for reference and anatomical location, identified 52 numbered regions
of other neurons (or
(Brodmann, 1909). For example, the primary visual cortex is known as muscles).
Brodmann’s area 17 (BA 17), while Broca’s area spans Brodmann’s areas (BA) 44 Distal: Far away; as
opposed to proximal,
and 45 in the left hemisphere (see Figure 2.1).
meaning near to.
Substantia nigra: Another
component of the basal
ganglia. Neurons originating
LESION AND ABLATION in the substantia nigra
terminate in the striatum,
Lesion (cutting) and ablation (removal) of nerve tissue are long-standing techniques where they release the
in neurology. Lashley, whose work we introduced in Chapter 1, put forward the neurotransmitter dopamine.
Parkinson’s disease: A
theory of mass-action based on lesion studies in animals. For obvious reasons,
neurological disorder in
these procedures are not used experimentally in humans. However, brain tissue is which movements become
sometimes ablated for medical reasons (e.g., the removal of a tumour). Surgical slowed or are lost altogether.
Rigidity and tremor are also
lesioning is also occasionally undertaken. For example, lesioning the corpus
found. Associated with loss
callosum has been used as a treatment for epilepsy, which will be discussed further of cells in and around the
in Chapter 3. Sometimes lesions or ablations may occur as the result of accidents. basal ganglia.
A famous case is that of Phineas Gage, who had an accident involving an iron rod Epilepsy: The term for a
group of neurological
and some dynamite that resulted in extensive damage to his prefrontal cortex. disorders characterised by
Another less famous case is NA, who developed amnesia after an accident with a synchronised but excessive
fencing foil (see Chapters 7, 10, and 11). neuronal activity.
24 Chapter 2 Methods in neuropsychology

Lesions can also be induced through the use

of chemicals or drugs. The Wada test (Wada &
Rasmussen, 1960) involves the administration of a
fast-acting barbiturate via the carotid artery to
one hemisphere at a time. This causes a temporary
lesion lasting a matter of minutes, and has his-
torically been used to establish hemispheric
dominance for language prior to brain surgery.
Other chemicals may induce permanent lesions via
toxic influence. The substance MPTP, a toxin that
was inadvertently mixed with synthetic heroin by
recreational drug users in 1980s California,
irreversibly destroys dopamine neurons in the sub-
stantia nigra, resulting in a very severe form of
induced Parkinsonism. (We review the case of the
“frozen addicts” in Chapter 5.)

“VIRTUAL LESIONS”: TRANSCRANIAL

MAGNETIC STIMULATION
Transcranial magnetic stimulation (TMS) was
originally investigated as a possible treatment in
various therapeutic settings, however it also pro-
vides a potential tool for neuropsychologists
because it can be used to induce a “virtual lesion”.
TMS uses strong pulses of magnetisation that can
be focally administered via a hand-held coil (see
Figure 2.2). Thus, different areas of cortex can
be stimulated depending on the positioning of
FIG. 2.1 Brodmann’s cortical areas revisited. Brodmann identified the coil. Single pulses of TMS or brief trains
52 cortical areas on the basis of the type and density of neurons of repetitive TMS at higher frequencies typically
present. increase neuronal excitability. However, continuous
stimulation at lower frequencies suppresses
neuronal excitability, an effect that can last several minutes after TMS is stopped
KEY TERMS (Hoffman & Cavus, 2002). Essentially, it is this low-frequency TMS that induces
Wada test: A test that
involves the administration the “virtual lesion”. The potential value of this technique is highlighted by a study
of a fast-acting barbiturate by Hilgetag et al. (2001) who reproduced the classic neurological symptom of
(via the carotid artery) to one
spatial neglect (see Chapter 8) by stimulating the parietal cortex in normal
hemisphere at a time, to
determine, among other subjects.
things, the hemisphere that TMS can also be used in conjunction with structural neuroimaging to investi-
is dominant for language.
gate the effects of virtual lesions in anatomically localised brain regions. Various
Dopamine: A
catecholamine studies have shown the utility of the technique in diverse areas of perception and
neurotransmitter found in cognition. However, despite its obvious potential, the technique is not without
the brain. limitations. Concerns have been raised about the safety of the procedure, particu-
Spatial neglect: A
condition in which damage larly in subjects who may be vulnerable to developing neurological abnormalities
to one side of the brain such as epilepsy. Also, TMS is better suited for the investigation of superficial
causes a deficit in attention brain regions (the cortex for example) than for probing less accessible regions and
to the opposite side of space.
deeper structures.
 Electrical procedures 25

ELECTRICAL PROCEDURES
ELECTRICAL STIMULATION
The neurosurgeon Wilder Penfield was responsible
for much of the pioneering work on mapping
primary somatosensory and motor cortex. His
subjects were patients who required surgery for
life-threatening conditions, typically the removal of
tumours or blood clots. He asked these patients
whether during the course of surgery he could
apply mild electrical stimulation to the surface of
their brains. Brain surgery is typically carried out
with the patient awake, due in part to the lack of
pain receptors in the brain, and resultant pain
insensitivity. Therefore Penfield was able to talk to
his patients about their sensory impressions and
motor responses as he stimulated specific regions.
Penfield was the first researcher to discover the
amazing topographic representation of body parts
in the primary motor and somatosensory cortex
(which we describe in Chapters 4 and 5). (See
Penfield & Rasmussen, 1950.)

ELECTRICAL RECORDING
We can also learn about brain function by record-
ing its electrical activity. In electroencephalography
(EEG) and the closely related procedure of event- FIG. 2.2 Transcranial magnetic stimulation. A subject receiving
stimulation with a typical “figure of eight” TMS stimulator.
related potential (ERP) recording, this involves
attaching electrodes to the scalp. The underlying activity is detected and amplified,
and usually displayed on a chart recorder or computer screen. Surface recording is
possible because electrical activity in the brain is conducted passively through
the meninges (protective membranes surrounding the brain) and the skull to the
scalp. Of course, voltages recorded represent the sum of activity from millions of
neurons in the area of brain closest to the recording electrode. So, in order to get
an idea about the spatial distribution of activity, several separate channels of EEG
corresponding to electrodes in different positions on the head can be recorded
simultaneously. This procedure has been widely used in research and also has
clinical relevance, having proved invaluable in the diagnosis of epilepsy and in the
identification of sleep-related disorders (see Figure 2.3).
In a research study with ERPs, a series of stimuli such as tones or light flashes
are presented to a participant. The raw EEG for a precise 1- or 2-second period
following each stimulus is recorded and fed into a computer where it is summed
and averaged. There will be a response (or “event-related potential”) in the brain
to each separate stimulus but this will be small (millionths of a volt) in comparison
with the background EEG (thousandths of a volt). By summing all the EEGs
KEY TERM
and averaging them, the more-or-less random EEG averages to zero, to leave an Meninges: The system of
ERP that has a characteristic waveform when shown on the computer screen. membranes that enclose the
Abnormalities in this waveform have been linked to clinical disorders, for example central nervous system.
26 Chapter 2 Methods in neuropsychology

FIG. 2.3 Recording of EEGs and ERPs. Raw EEG can be recorded from surface electrodes on the scalp. If a series of stimuli are
presented to the respondent there will be a small but characteristic response to each stimulus but this will be “hidden” in the EEG. ERPs
are obtained by feeding brief “epochs” of the EEG (typically 500 to 1000 ms following each stimulus) into a computer that averages
them. The random background EEG tends to average to zero, leaving the characteristic ERP waveform.

a predisposition to alcoholism or schizophrenia. The ERP technique has also been

useful as a tool to explore the mechanisms of attention, and we describe some of
this research in Chapter 9.
Recently, a variant of ERP known as magnetoencephalography (MEG) has
been developed. (Mogilner et al.’s 1993 study of remapping in the cortex described
in Chapter 4 employs this procedure.) MEG involves upwards of 60 electrodes
attached to the participant’s scalp, and takes advantage of the fact that when
neurons are active they generate tiny magnetic fields. Event-related fields (ERFs)
can be detected by an MEG analyser in much the same way as ERPs, but they
provide a more accurate means of identifying the origin of particular signals.
MEG can therefore locate the source of maximum magnetic field activity in
response to stimuli and, if required, map these areas three-dimensionally and in
real time. This technique has been of use in identifying the precise focal origins of
epileptic seizures and, as hinted above, it has also been used to map areas of the
somatosensory cortex. Perhaps surprisingly, MEG had not, until recently, become
a widely used research technique. Although it has superior spatial resolution
compared to EEG, both techniques are constrained by the fact that they are only
 In-vivo imaging 27

suitable for looking at surface structures of the brain. The MEG technology was
developed at the same time as the spatially superior in-vivo imaging techniques
discussed below, and historically relatively few
research groups have chosen to invest in MEG.
However, this appears to be changing, as more
groups recognise the advantages of combining
MRI and MEG technologies. Many leading
research centres are opting for MEG technology
and the technique is likely to become increasingly
influential over the next few years.

IN-VIVO IMAGING
The first of the in-vivo imaging techniques was
computerised tomography (CT, or sometimes
CAT) scanning, which came on stream in the early
1970s. As technologies developed, and the value of
scanning became clearer, it was soon followed by
other procedures including PET (positron emission
tomography), rCBF imaging (regional cerebral
blood flow), and MRI (magnetic resonance
imaging). The common feature of these procedures
is that researchers can produce images of the struc-
ture or functional activity of the brains of living
people (see Figure 2.4).

STRUCTURAL IMAGING
Computerised tomography (CT, but also known as
computerised axial tomography or CAT) provides
structural images of the brain. To generate brain
scans, low levels of X radiation are passed through
an individual’s head at a series of different angles
(through 180°). A computer analyses each “image”
and generates what is, effectively, a compound
X-ray. It can produce a “slice-by-slice” picture of
the entire brain, or other parts of the nervous
system such as the spinal cord. A drawback of CT
scanning is that the contrast between more and less
dense tissue is not particularly good, although this
can be improved by the administration of a dye
(injected into the bloodstream just before the scan FIG. 2.4 CT, MRI, and PET scanning. CT scans provide reasonably
is taken). CT scans cannot measure functional well-defined images of brain structure. PET scans generate images
activity but they have provided valuable infor- of functional activity, although structure is only poorly defined. MRI
mation about structural changes seen in the brains can generate “photographic”-quality images of brain structure,
and functional MRI (see Figures 2.5 and 2.6) can produce
of some people with dementia, and about the
integrated structural and functional images. Source: Rosenzweig
effects and location of brain damage in general. et al. (1999). Biological psychology. Sunderland, MA: Sinauer
Magnetic resonance imaging (MRI) is a more Associates Inc. Reproduced by permission of Sinauer Associates
recent development and the technique is very Inc.
28 Chapter 2 Methods in neuropsychology

complex. In summary, it depends on the fact that protons in tissue act as little
bar magnets that spin. When a strong magnetic field is applied externally by the
MRI scanner, these spinning protons interact with the external field in a way that
produces small but detectable changes in magnetic signal that the scanner can
measure. Different types of (brain) tissue have different concentrations of protons
and different chemical environments which influence the magnetic properties.
Thus different tissues produce different signals and the scan data can be computer-
processed to generate images that clearly show, in remarkable detail, the structures
of the brain. The entire brain can be imaged in successive slices, which can be
produced in sagittal (side), coronal (front), or horizontal transverse planes.
Structural MRI has significant advantages over CT; for example, the images are
much higher resolution and do not involve exposing people to X radiation.

FUNCTIONAL IMAGING
PET scanning was the first widely used functional imaging technique and provides
images of a person’s brain that show which regions are activated as they under-
take different sorts of task, such as reading words, solving mental arithmetic, and
listening to music. There are different types of PET scanning. One of the com-
monly used techniques involves injecting subjects with water that has been labelled
with the short-lived radio-isotope oxygen 15. When a region of the brain is more
active, blood flow to that region increases and therefore more radio-labelled water
will be carried to active areas. As the oxygen 15 decays, with a half-life of around
2 minutes, gamma rays are emitted that can be detected by the PET scanner. The
scanner can determine whereabouts in the brain the gamma rays were produced,
and thus provide a picture of regions where blood flow is increased, indirectly
determining areas of enhanced neural activity.
Another PET technique uses radio-labelled glucose rather than water. More
active regions of the brain need more glucose (as a fuel), so again the radiotracer
becomes concentrated in the more active regions and this can be detected as it
decays. It is also possible to use PET to look at neurotransmitter function by
manufacturing more complex radiotracers. For example, raclopride is a molecule
that binds to dopamine receptors in the brain. A radio-labelled form of raclopride
can be prepared that uses the isotope carbon 13. If this tracer is used, it will bind
directly to dopamine receptors, in competition with endogenous dopamine, and
therefore provides information about dopamine function. This technique has been
used to study reward systems in the brain (Koepp et al., 1998; and see Chapter 10).
PET is thus a powerful means of assessing functional brain activity, although
it does not directly measure neuronal events. Rather, it indicates relative levels of
(or changes in) activity under different conditions. To do this, “image subtraction”
is often employed, meaning that activity during a control condition is (literally)
subtracted by computer from activity during the active test condition, and the
remaining PET activity taken as an index of the activation specific to the test
KEY TERMS condition (see Box 2.1 below). Two other variants of the PET technique that you
Sagittal: Sideways, as in
sagittal brain scans taken may read about are regional cerebral blood flow (rCBF) and single photon emis-
from the side of the head. sion computerised tomography (SPECT). In rCBF, the participant inhales a small
Coronal: (As in section) the
amount of a radioactive gas such as xenon, which is absorbed into the blood-
orientation of a brain slice if
you were looking “face on” stream and thus transported around the body. The participant sits in a piece of
and the brain was sliced apparatus that looks a little like a dryer seen in old-fashioned hair-salons. This has
vertically.
a series of sensors that detect the radioactivity from the transported xenon,
 In-vivo imaging 29

Box 2.1 Cognitive subtraction, conjunction,

and factorial designs
Many early neuroimaging experiments used a technique called “cognitive
subtraction”. This is based on the idea that a complex process involves a number
of stages, and if you are interested in a particular stage you need an active task
that involves that stage and a control task that involves all other stages but for the
critical one. By subtracting brain activity in the control task from brain activity in
the active task, you isolate brain activity associated with the process of interest.
For example, if we are interested in object naming we might have an active task
involving naming pictures of objects and a control task involving passively viewing
the same pictures. On the face of it, the critical difference is that the object is only
named in the active condition. One obvious problem with this is that there may
well be incidental naming in the passive condition. It is likely that participants
instructed to view pictures of objects passively will nevertheless find themselves
mentally naming the objects. Many experiments using the cognitive subtraction
approach have used “serial subtraction” where they attempt to isolate a series of
stages in processing. So in our object-naming experiment we might also include
a condition of viewing meaningless shapes. Subtracting this from the passive
viewing condition might identify regions involved in object recognition. The serial
subtraction approach makes the assumption of “pure insertion”; that is, it
assumes that each process of interest is independent. In fact, many cases are likely
to involve a degree of interaction between component processes, such that
adding (or subtracting) a cognitive component may affect the other components.
To overcome these limitations, many of the best functional imaging
experiments use “cognitive conjunction” or “factorial designs”. The logic of
cognitive conjunction is to select several tasks that activate the same process of
interest, each with an appropriate control. By considering common activations
across these tasks, we can be confident that we are identifying the core process
of interest. Factorial designs explicitly tackle the issue of interactions between
processes. This type of design can best be illustrated using an example. Imagine
we are still interested in object recognition and naming. We develop a task with
four conditions:

1 Naming pictures of objects (naming and object recognition both present).

2 Naming colour of a meaningless design (naming present, object recognition
absent).
3 Viewing pictures of objects (object recognition present, naming absent).
4 Viewing a meaningless design (naming and object recognition both absent).

Subtracting 3 and 4 from 1 and 2 will show us the main effect of naming.
However we can also look at the interaction between object recognition and
naming. By performing the subtraction (1-2) − (3-4), we can see whether the
process of retrieving a name has an effect on object recognition, thus identifying
whether or not the processes are independent. These types of designs can
provide important clarification of models from cognitive neuropsychology.
30 Chapter 2 Methods in neuropsychology

and because more blood is required by “active” brain regions, a computer can
build up an image of areas of greater (and lesser) activity based on the detection
rates. SPECT differs from PET in certain technical respects, the upshot of which is
that the clarity of the scans is less precise because they take longer to generate.
PET and its associated techniques were a major step forward in understanding
brain function. However there are certain limitations with these methods. At a
practical level, PET is a very time-consuming and expensive technique. It also
involves exposing subjects to ionising radiation, and this precludes repeat scanning
of the same person. The approach is also very limited in terms of temporal reso-
lution—each PET image takes a matter of minutes to generate and represents
activity across that period. It is therefore not possible to study activity related to
brief or transient stimuli. Thus PET is being superseded by functional MRI for
many applications. However, it still has a place in brain research, particularly in
the area of neurochemistry. As more sophisticated radio-ligands are developed, it
is becoming possible to use PET to ask questions about neurotransmitter function
that other techniques simply cannot address. For example, Thomasius et al. (2006)
have studied directly the effect of the drug ecstasy on brain serotonin function
(using a PET ligand that binds to serotonin receptors), and related this to mood
and cognitive function.
For many purposes, however, functional magnetic resonance imaging (fMRI)
has become the imaging technique of choice. fMRI is carried out using the same
scanner as structural MRI (see Figure 2.5)—in fact an advantage of the technique
KEY TERM is that both structural and functional information can be obtained in a single
Radio-ligand: A scanning session. fMRI depends on a lucky chance of biology: that oxygenated
radioactive biochemical
marker that binds to a and deoxygenated haemoglobin (the molecule in the blood that transports oxygen)
specific receptor type in the have different magnetic properties. Changes in the relative concentrations of oxy-
brain. genated and deoxygenated blood therefore produce a detectable magnetic signal.
This is referred to as “BOLD (blood oxygenation
level dependent) contrast”. BOLD contrast provides
an indirect measure of neural activity, as neuronal
firing has an effect on relative concentrations of oxy-
genated and deoxygenated blood (see Figure 2.6).
These changes are subtle and detection depends on
careful “tuning” of the MRI scanner. Using more
powerful magnets also improves fMRI sensitivity.
fMRI has been enthusiastically embraced by
neuroscience, and there has been a huge prolifer-
ation of research papers in which the technique has
been used. However, fMRI is not without its limita-
tions. Although the temporal resolution is better
than that of PET, allowing neuronal responses to
single events to be measured, it is still not in the
league of EEG. The BOLD response occurs over a
number of seconds and therefore the millisecond
accuracy of EEG or MEG is not possible. It is
also important to remember that fMRI measures
secondary changes in haemodynamic activity
FIG. 2.5 A subject being set up in an MRI scanner. Photo courtesy and metabolism rather than directly measuring
of Philips Medical Systems. neuronal activity. This causes problems in spatial
 In-vivo imaging 31

accuracy and in quantitative measurement

(although these are now being addressed to some
extent; see Ugurbil, Toth, & Kim, 2003). Good
fMRI studies also depend on good experimental
design. Using fMRI to make inferences about
cognitive processes is only possible if carefully
designed, theory-driven experiments are used (see
Henson, 2006; Poldrack, 2006).
In-vivo imaging continues to develop. In par-
ticular, MRI scanners are being used in new ways
to explore different questions about brain structure
and function. One example is diffusion tensor
imaging or tractography, a technique that allows
bundles of white-matter fibres, not identifiable
using CT or conventional MRI, to be visualised.
This allows the investigation of connectivity within
neural networks (Minati & Aquino, 2006). Another
example is magnetic resonance spectroscopy
(MRS), a technique that studies the concentration FIG. 2.6 An fMRI scan. These scans identify brain regions involved
of particular neurochemicals within specified in winning money during a simple target detection task (scans
obtained in the Wellcome Trust Clinical Research Facility, University
regions of the brain. Both of these techniques have of Manchester, UK).
enormous potential for research as well as clinical
applications.
Developments in analysis procedures are also opening up new possibilities. In
particular, it is now possible to analyse patterns of connectivity between brain
regions as well as region-specific activations. Thus we can determine the strength
of connections between brain regions under different task conditions, and assess
how these are modulated by neurological and psychiatric disease.

INTERIM COMMENT
The development of in-vivo scanning marked the beginning of a new era in brain
research. For the first time scientists could examine the structure or functioning
of the living brain. It became possible to see exactly how extensive a patient’s
internal brain injury or damage was, and researchers could begin to do valuable
brain research in individuals with “intact” brains. By using special “labelling”
techniques it even became possible to observe for the first time where in the brain
drugs were acting.
Despite the scientific advances that have been made as a result of the wider
availability of CT, PET, and MRI, there are drawbacks to each technique, as
discussed. One additional practical drawback is worth remembering. All scanning
techniques currently require the respondent to lie in a scanner. Not only can this
be uncomfortable and, in the case of MRI, very noisy, but it also places significant
constraints on the sorts of psychological investigation that can be conducted.
Additionally, it raises questions about whether we are imaging the “normal” KEY TERM
White matter: Parts of the
function of the brain. In drawing inferences from scanning results, we implicitly brain comprising axons of
assume that the brain would act in the same way if a person was going about nerve cells, mainly
their day-to-day life as it does when they are lying in a strange scanning responsible for neuronal
transmission rather than
environment. That assumption is obviously questionable. information processing.
32 Chapter 2 Methods in neuropsychology

NEUROPSYCHOLOGICAL ASSESSMENT
The neuropsychological approach relies on using tests designed to reflect, usually
in a relatively specific way, different aspects of cognitive function. Poor perform-
ance on a test may indicate focal (localised) brain damage. Poor performance on a
series of tests may, on the other hand, reflect diffuse (widespread) damage. Neuro-
psychological assessment serves several purposes. First, it can give a “neuro-
cognitive” profile of an individual, identifying both strengths and weaknesses in
cognitive performance. For example, an individual’s initial assessment may high-
light a specific problem with spatial memory set against a background of above
average IQ. Since many tests are “standardised”, a person’s performance can be
readily compared with scores generated by other age- and/or sex-matched
respondents (a process known as norm-referencing). Second, repeated testing over
time can give an insight into changes in cognitive functioning that may relate
either to recovery after accident/injury or to the progression of a neurological
illness.

STANDARD AND CUSTOMISED TEST BATTERIES

In a typical neuropsychological assessment, a series of tests (called a test battery)
will be given. One widely used battery is the Halstead-Reitan, which includes
measures of verbal and non-verbal intelligence, language, tactile and manipulative
skills, auditory sensitivity, and so on (Reitan & Wolfson, 1993). Some of the
tests are very straightforward: for example, the tapping test, which assesses motor
function, requires nothing more than for the respondent to tap as quickly as
possible with each of his/her fingers for a fixed time period on a touch-sensitive
pad. The Corsi block-tapping test measures spatial memory using a series of
strategically placed wooden blocks on a tray (see Figure 2.7a). A third test
measures memory span for sets of digits. Another example of a test battery is the
Luria-Nebraska (Luria, 1966; see also Christensen, 1979), an even more exhaust-
ive procedure that takes about 3 hours to administer and includes over 250 test
items. Today, this battery is regarded as somewhat unwieldy, poorly standardised,
and biased towards sensory, verbal, and motor functions—away from core
cognitive domains of current interest such as attention, memory, and executive
functioning. The battery is probably of more use as a clinical tool.
The administration of a standard lengthy test battery may be unsuitable
for some individuals (such as demented or psychiatric patients) who simply do
not have the requisite attention span. In such instances a customised battery
may be more appropriate. Such assessments typically include some overall index
of intelligence: the comprehensively norm-referenced WAIS-R (the revised
Wechsler Adult Intelligence Scale; Wechsler, 1981) is still commonly used
(though see below). In addition, specific measures may be adopted to test par-
ticular hypotheses about an individual. For example, if the person has received
brain damage to his/her frontal lobes, tests might be selected that are known
to be especially sensitive to frontal damage. The Wisconsin card sort test (see
Figure 2.7b), the trails test (in which respondents have to join up numbered dots
on a page according to particular rules), and verbal fluency (generating words
starting with a particular letter or belonging to a specific category) are typical
examples.
 Neuropsychological assessment 33

FIG. 2.7 (a) Corsi’s block tapping task and (b) the
Wisconsin card sort test. Corsi’s test assesses spatial
memory. The tester taps out progressively longer sequences
of blocks to establish spatial memory “span”. The
respondent cannot see the numbers, so must memorise the
correct sequence using spatial memory. In the Wisconsin
test, the respondent sorts cards into four piles according to
an “unspoken” rule: by colour, shape, or number. The only
feedback received from the tester is whether or not a
particular card has been correctly sorted. The respondent
must use this feedback to guide future card sorts. Every
so often the tester changes the sorting rule and the
respondent must try to adjust to it. Source of 2.7(b):
Gazzaniga et al. (1998). Cognitive neuroscience: The
biology of the mind (Figure 11.5). © 1998 by
W. W. Norton & Company, Inc. Reproduced by
permission of W. W. Norton & Company, Inc.

The CANTAB (Cambridge Automated

Neuropsychological Assessment battery; Rob-
bins et al., 1994) has been developed as a battery
of some 12–14 tests administered via a touch-
sensitive screen. Many of the tests resemble
computer games in certain respects, and are
essentially computerised versions of standard
pen and paper neuropsychological tests. For
example the “stockings of Cambridge test”
is analogous to the Tower of Hanoi test (see
Figure 2.8), and the “intra/extra dimensional
shift” test is based on the Wisconsin card sort test. Test norms are built into the
CANTAB software, so that a particular respondent’s performance on any given
test can be interpreted in relation to age- and sex-matched peers (norms). The
majority of the CANTAB tests are non-verbal—predominantly aimed at assessing
34 Chapter 2 Methods in neuropsychology

executive and memory functions. This fully com-

puterised battery has quickly become particularly
popular with researchers and, at time of writing,
has formed at least part of the neuropsychological
assessment of participants in over 400 published
studies. While the CANTAB battery is widely used,
other computerised test batteries have also been
developed in recent years and different neuro-
psychological research centres advocate different
batteries.
Poor across-the-board performance on test
batteries may indicate generalised damage, while
poor performance on a particular test may signal
possible localised damage or dysfunction. (In gen-
FIG. 2.8 Stockings of Cambridge test from the CANTAB battery.
This is a test of executive function from the widely used CANTAB eral, non-specific deficits across tests are relatively
battery of neuropsychological tests. This particular image shows a less interesting than more specific problems.) A
four-move problem; respondents must try to copy the template patient with advanced dementia may perform
pattern in four moves. Image kindly provided by Cambridge poorly on all tests, commensurate with the wide-
Cognition (© 2007 Cambridge Cognition Limited. All rights
spread brain damage seen in severely demented
reserved. Reproduced in 2-colour from coloured original with
permission). individuals. But the neuropsychologist needs to be
aware that apparent generalised deficits might
alternatively represent a fundamental problem with
concentration or motivation. If a person simply can’t or won’t make the effort to
perform tests, they will typically do badly on all measures; this is sometimes seen
in psychiatric patients. There are various strategies neuropsychologists can use to
get round this problem, for example offering incentives or performing testing over
a number of very short sessions. However, in some cases, it may remain a signifi-
cant concern.
Where a subject has very selective deficits, neuropsychological test batteries
can be extremely informative and allow inferences to be drawn about the
location of brain damage. For example, inability to recognise objects by touch
(astereognosis) may be a sign of damage to a fairly specific region in the parietal
lobe (see Chapter 4). A poor verbal test score (compared with a normal non-verbal
test score) may indicate generalised left hemisphere damage (see Chapter 3). In a
patient with very early Alzheimer’s disease, selective deficits on certain learning
and memory tasks are seen, which has contributed to understanding how the
pathology of the disease develops.

ASSESSING GENERAL COGNITIVE FUNCTIONING

The WAIS-R, referred to earlier, has been particularly useful for studying selective
KEY TERMS deficits because the 11 component subtests address a wide range of psychological
Astereognosis: An agnosic
functions. Moreover, it is possible to derive separate verbal and non-verbal
condition in which objects
cannot be recognised by estimates of IQ by amalgamating scores on the six verbal and five non-verbal
touch alone. subtests. Norms for each of these were derived from a sample of almost 2000
Parietal lobe: Region of (US) respondents. The WAIS III was launched in 1997 as an updated and
cortex behind the frontal
extended battery. Now comprising 14 subtests (the original 11 plus 3 new ones),
lobes and above the occipital
lobes. It plays key roles in with updated norms and the removal of items deemed to be culturally biased,
spatial function and subtest scores can be used to calculate verbal, performance, and general IQ as
attention.
before. But additionally, four so-called “index” scores (of verbal comprehension,
 Neuropsychological assessment 35

perceptual organisation, working memory, and processing speed) can be derived,

which are said to better reflect the underlying factor structure of cognitive
function than the older binary distinction.
On the minus side, it should be remembered that all three of the Wechsler
intelligence scales were devised primarily to assess cognitive function in non-
pathological groups, although they have in fact been extensively used with both
psychiatric and neurological patients. None has proper parallel versions, and this
makes retesting of individuals (who may be of interest to neuropsychologists
wishing to plot change in function over time) complicated by carry-over—that is,
residual learning from the first exposure to the tests. Perhaps with this problem in
mind, the WASI (Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999) was
developed with parallel versions to facilitate retesting, and has quickly become
an important tool for neuropsychologists. It comprises alternate versions of the
most-informative four tests from the WAIS III: block design, matrix reasoning,
vocabulary, and similarities. In fact a reliable assessment of general IQ can, the
author claims, be derived in less than 15 minutes from just the vocabulary and
matrix reasoning subtests.
An even briefer measure of IQ is the National Adult Reading Test (NART;
Nelson, 1982). This allows the researcher to obtain an estimate of an individual’s
IQ prior to damage or disease onset. This may be useful if a neuropsychologist is
making an initial assessment of a person who has been brain damaged/ill for some
time. The NART rather cunningly comprises 50 words that sound different from
their spelling (such as yacht, ache, and thought). The respondent reads through
the list until they begin to make pronunciation errors. Such words were almost
certainly learned before the onset of illness or brain damage, and because this test
has been referenced against the WAIS, the cut-off point can be used to estimate
IQ prior to illness, disease, or accident.

COMBINING IN-VIVO IMAGING TECHNIQUES WITH

NEUROPSYCHOLOGICAL CHALLENGES
The use of neuropsychological tests in combination with in-vivo techniques
promises to be one of the most informative research approaches. If a test is known
to draw on the capacity of a particular brain region, it could be given to a person
while he or she is being scanned. This combined technique was used by Smith and
Jonides (1994) to examine the role(s) of the frontal lobes in working memory.
They selected various neuropsychological tests of verbal and non-verbal working
memory, and recorded PET scans of normal people as they completed them. The
results showed a clear division of labour: non-verbal working memory led to
KEY TERM
increased right frontal activation, whereas verbal working memory caused greater Working memory: A form
activation in the left frontal (and parietal) regions (see Chapter 7 for a further of short-term memory, first
discussion of Smith and Jonides’ findings). Many other examples of combining characterised by Alan
Baddeley, which allows a
neuropsychological challenge with functional imaging are discussed in subsequent person to hold “on-line”
chapters. For instance, see Chapter 11 for a discussion of how neuroimaging has (and manipulate) a certain
informed our understanding of executive function using classic tests such as the amount of information for a
few seconds after it has
Tower of London. been presented. For
A slightly different way of combining neuropsychology and imaging is to example, keeping a phone
perform detailed neuropsychological testing outside the scanner and then scan the number in mind until you
have dialled it.
people during performance of specific tasks. One area where this approach is
36 Chapter 2 Methods in neuropsychology

proving particularly useful is in studying the early stages of dementia. Mild

cognitive impairment (MCI) is relatively common in elderly populations,
but in some cases MCI can progress to Alzheimer’s disease. Early diagnosis of
Alzheimer’s disease is very important for optimal treatment and care, however it
is not always easy. Recent research that combines focal neuropsychological
assessment and functional imaging has suggested that this combined approach
facilitates early detection. Cabranes et al. (2004) showed that lower test scores and
lower left frontal blood flow predicted progression from MCI to Alzheimer’s
disease with high sensitivity and specificity. Similarly, Elgh et al. (2003) found
that people at high risk for developing Alzheimer’s disease showed poorer scores
on episodic memory tasks and reduced prefrontal activation during cognitive
challenge fMRI. Thus the combined neuropsychology and neuroimaging
approach has clinical implications as well as furthering our theoretical under-
standing of how the brain works.

INTERIM COMMENT
Neuropsychological testing has gained considerable respect in recent years.
However, it would be wrong to think that a battery of neuropsychological tests
alone could somehow provide the researcher or clinician with a complete map
of brain functioning. At best they give an indication of underlying problems.
Two further concerns also merit consideration. First, an apparently normal
performance on neuropsychological tests can be deceptive. We know that, as
individuals recover from brain damage, they often develop alternative strategies
or techniques to overcome remaining deficits—see, for example, the case study
of the brain-damaged architecture student (Clarke, Assal, & DeTribolet, 1993)
which we present in Chapter 4. Second, although neuropsychological and in-vivo
assessments usually agree about what regions of brain are dysfunctional or
damaged, they do not always do so and the reasons for this are usually unclear.
A further concern about neuropsychological testing that has received
attention recently is the ecological validity of tests. A puzzling conundrum for
neuropsychologists is that patients’ performance on neuropsychological tests
can, in fact, be inconsistent with their performance in everyday life (Wilson,
1993). Ideally, test performance should predict this, but ecological validity
actually varies from test to test. For example, Chaytor, Schmitter-Edgecombe, and
Burr (2006) have studied the ecological validity of executive function measures
and found some standard tests “wanting” in this regard. Some researchers are
now starting to develop more ecologically valid tests that aim to mimic real-life
scenarios (see Burgess et al., 2006). Obviously, the test situation is likely to be
different from everyday life, but the continuing challenge for researchers is to
develop tests that capture everyday performance as well as possible. We return to
this issue in Chapter 11.

DISSOCIATIONS AND DOUBLE DISSOCIATIONS

Neuropsychologists typically try to design studies that provide evidence of the
differential performance of brain-damaged and control participants because such
 Chapter summary 37

studies can inform structure–function relationships. Consider the following

example: The right frontal lobe is thought to be important for memorising designs.
To test this hypothesis, a researcher assesses memory for designs (MemD) and
memory for words (MemW) in a group of people with known right frontal
damage and a second group of non-brain-damaged controls.
Hypothetical results from this study are shown in Table 2.1a. At first glance
they seem to support the hypothesis, because the right frontal participants appear
to be selectively impaired on the MemD condition. Many neuropsychological
investigations employ this sort of design, and might use the evidence of a (single)
dissociation between groups in the MemD but not the MemW conditions as
support for the hypothesis under investigation. However, there is a design
problem with single dissociation studies stemming from the assumption that the
two conditions are equally “sensitive” to differences between the two groups of
participants (which may or may not be the case). For example, it could be that
right frontal participants have poor attention, which happens to affect the MemD
task more than the MemW task.
A much “stronger” design is one with the potential to show a double dissoci-
ation. For example, if we also thought that left frontal damage impaired MemW
but not MemD, we could recruit two groups of patients—one with left and the
other with right frontal damage—plus a control group—and test all participants
on both measures. Hypothetical results from this design are shown in Table 2.1b.
They indicate that one group of patients is good at one test but not the other,
and the reverse pattern is true for the second group of patients. In other words, we
have evidence of a double dissociation (similar to the one found by Smith and
Jonides and described earlier), which suggests to neuropsychologists that the two
tasks involve non-overlapping component operations that may be anatomically
separable too.

TABLE 2.1 A SINGLE AND A DOUBLE DISSOCIATION EXPERIMENT (% CORRECT)

(a) Single dissociation experiment
Group MemD MemW
Right frontal 70% 90%
Control 95% 95%
(b) A double dissociation experiment
Group MemD MemW
Right frontal 70% 90%
Left frontal 93% 60%
Control 95% 95%
In the single dissociation experiment, frontal patients appear worse on the MemD task than controls, and about
the same on the MemW task. However, this result might be due to poor attention (or some other extraneous
variable) which happens to affect the patients on this test. In the double dissociation experiment, the
“opposite” performance of right and left frontal patients suggests that damage to the different brain regions
has a specific and selective effect on the two memory tests.

CHAPTER SUMMARY
Researchers interested in understanding brain function and its relations to
psychological function can now draw on a wide range of investigative techniques. In
Exploring the Variety of Random
Documents with Different Content
noodige zouden behoeven te doen, en [170]in geen geval iemand van
dien kant, Ella uitgezonderd, in hun huis zouden behoeven te
ontvangen. En Carel mocht geen cent van Wiechens geld
aannemen. Dat geld, door woeker of misdrijf verkregen, kon toch
nooit geld zijn waar zegen op rustte.

Carel had alles beloofd en toegegeven. Als hij Ella maar had, was hij
tevreden; meer begeerde hij niet.

Wiechen was verrast.

Aan deze mogelijkheid had hij nu het allerminst gedacht! Dat een
meisje, dat men laat studeeren, het in haar hoofd krijgt, om vlak vóór
het eindexamen van het Gymnasium, zich te willen engageeren,
vond hij iets onbehoorlijks. Dat beetje, dat volgens hem voor een
getrouwde vrouw noodig is, had men goedkooper kunnen leeren. Nu
was het weggegooid geld, en daar hield hij niet van.

Hij wilde niets beslissen, zoo dadelijk, en begon, om tijd te winnen,

den jongen man de vragen te stellen, die hij meende dat bij een
gelegenheid als deze gebruikelijk waren, te weten naar Carels
toekomst en de financieele positie zijner ouders.

En Carel, die van beide niets dan goeds kon zeggen, vond dit een
gunstig teeken, en antwoordde zoolang hij wat te zeggen had, terwijl
Wiechen luisterde en nu en dan korte vragen deed. De macht der
gewoonte toonde zich ook hier weer. Het was langzamerhand of het
een te sluiten geldleening betrof. Werktuigelijk begon Wiechen de
gegevens, die hem Carel gaf, met potlood op een voor hem liggend
stuk papier op te teekenen.

„Ik zal informatie nemen,” zeide hij opeens. „Wanneer moet het geld
er zijn?”
„Geld, meneer?” riep Carel verbaasd uit. „Daar heb ik in de
allerlaatste plaats aan gedacht, of liever in het geheel niet.” [171]

„O neen,” zeide Wiechen, zich herstellende. „Ik was een oogenblik

absent. Maar nu we er toch over spreken, konden we dat ook
behandelen. U verwacht natuurlijk, dat Ella wat meekrijgt. Misschien
moet ik daarover met uw papa spreken …”

„Neen meneer. Vader is … te oud,” redde zich Carel, die begreep dat
nu het moeielijke punt kwam. „Hij mag nergens in gemengd worden,
te wille van zijn gezondheid. Hij geeft zijn toestemming, ziedaar
alles. En het zou hem en mij aangenaam zijn, als over geld niet werd
gesproken. Met mijn tractement en de toelage, die mijn vader zal
geven, is te dien aanzien gezorgd.”

„Zoo,” deed Wiechen langzaam. „Nu, we zullen zien. Ik had andere

plannen met haar, en wil eerst weten, of het haar ernst is die op te
geven. En dan, moet ik haar moeder erin kennen.”

„Wanneer mag ik dan mijn antwoord verwachten?”

„Morgenavond om dezen tijd. Is dat goed? Iets vroeger kan ook,

maar niet vóór zessen. Als de zaak doorgaat, zullen we toch nog een
en ander te bespreken hebben …”

„Ik zal om half zeven hier zijn,” beloofde Carel, opstaande.

Het was een vervelend geval, vond Wiechen. Hij wilde dat Ella
onbezorgd zou zijn in de toekomst, en dat bood zich nu aan, al was
het niet op de manier, die hij gedacht had. Want dat ooit iemand, laat
staan in Holland, om zijn dochter zou komen, had hij niet verwacht.
Maar hij had een tweede bedoeling. Zoodra zij klaar was, wilde hij
haar aan zijn practijk verbinden, door haar gedekt zijn. En dát
ontging hem op deze wijze.
„Ella!” riep hij, en het antwoord kwam van zóó dicht bij, dat hij
besefte, dat zij zich in de buurt van het kantoor had opgehouden.

„Ga eens zitten,” zeide hij, toen zij binnenkwam, de [172]sporen

dragend van te hebben gehuild. „Je weet wat er geweest is.”

En op haar toestemmend knikje, deelde hij haar mee, niet geheel te

hebben willen weigeren, maar dat zijn inzicht in de zaak was, dat
men het moest laten afhangen van het eindexamen. Dat begon nu
over enkele dagen. Slaagde zij, dan bleek het, dat zij voldoende
studeerkracht had, om ook verder te komen. Men zou zoolang het
antwoord kunnen uitstellen.

„Dat is niet noodig, pa,” zeide Ella. „In dat geval kunnen we nu
evengoed beslissen.”

„Ben je zóó zeker, dat je er komt?”

„Neen,” zeide Ella, zacht doch beslist. „Ik zou het diploma graag
hebben, en zal er mijn best voor doen. Maar als ik dan Carel niet
hebben mag … dan laat ik mij expres zakken.”

Vloekend sprong hij op en schudde haar doorelkaar.

Zij bood niet den minsten tegenstand.

„Zoo zal het ook op het examen gaan,” zeide zij apatisch. „Geen
behoorlijk antwoord zal men uit mij krijgen.”

Hij liet haar los. Ja, dat was wel zijn dochter! Zoo was ook hij
geweest, toen hij indertijd zijn militair pensioen wilde halen.

„Gévédé! Trouw dan voor mijn part. Maar doe ook je examen.”
„Dat beloof ik u,” riep Ella uit, hem om den hals vallend. „U meende
het toch ook niet. wel? U wou maar eens zien of het mij ernst was,
nietwaar?”

„Al goed,” bromde hij.

Zij keek op de klok.

„Mag ik het nog even aan moeder gaan zeggen?” vroeg zij. „En als
ik thuis kom, zal ik gauw een briefje aan mevrouw schrijven. De post
zal haar adres toch wel weten.” [173]
[Inhoud]
 HOOFDSTUK XVI.

De voorspelling van Dr. Arnolds was uitgekomen. Zijn zoon en

Viehof werden vrijgesproken. Beiden waren in vrijheid gesteld, en
men had hun de effecten moeten teruggeven, die destijds in beslag
genomen waren. Die waren nu op de gewone wijze in Engeland
verkocht, waartoe Boom daarheen was gegaan. Zijzelf hadden dat
niet aangedurfd, maar op Boom, die van onbesproken reputatie was,
kon geen verdenking vallen. En hij had dit te eer gedaan, daar dit de
eenige manier was om aan het hem rechtmatig toekomend deel van
den buit te komen. Heel eerlijk zond men ook Hervau zijn deel, zich
herinnerende, dat deze bad verteld nog meer zaken te hebben,
waaraan geld te verdienen was.

Er was een tweede reden, waarom Boom de geschiktste persoon

voor dit karreweitje was geweest. Ieder wist, dat hij naar het
buitenland ging om te trouwen. Dat had men in alle couranten onder
de huwelijksaankondigingen kunnen lezen. Het was niet meer dan
natuurlijk, dat hij een poosje vóór den dag der voltrekking er al heen
ging. Zulke dingen duurden altijd wat, en reeds was men verbaasd
geweest over de snelheid waarmee aan de formaliteiten, die de
wetten van beide landen voorschrijven, was voldaan, dank zij den
door Arnolds aanbevolen advocaat, de eenige die [174]over zijn werk
niet tevreden was, daar hij buiten een klein voorschot, geen
honorarium ontvangen had.

Maar in elk geval, de effecten waren verkocht, en Boom was

getrouwd teruggekomen. De dankbaarheid der familie zijner vrouw
was ook meegevallen, zoodat hij thans netjes ingericht woonde. Het
eenige wat tegenviel, was dat hij in alles op de vingers gekeken
werd door zijn vrouw, en ongenadig onder de plak zat.
Geen opstaan tegen den middag, geen vertoef in koffiehuizen des
nachts; slechts bij hoogst enkele gelegenheden mocht hij alleen uit.

Ook in geldzaken hield zij de teugels strak. Niets mocht bij doen
zonder haar geraadpleegd te hebben, en alle accepten of ander
papier nam zij hem af, om het zelf te bewaren, en er hem tegen de
vervaldagen mee uit te sturen. Zijn zakgeld was afgepast.

Enkele dagen na zijn thuiskomst had Boom de anderen op een glas

wijn genoodigd, daar Arnolds had medegedeeld een zaak te weten.
En daar mevrouw Boom van oordeel was geweest, dat men die zaak
evengoed, ja veiliger thuis kon bespreken, dan in Café Central, was
men thans bijeen.

De zaak was een renpaard te koopen, en op de Hollandsche banen

te laten loopen. Het paard was op de rennen nog nagenoeg
onbekend, en had feitelijk pas een paar maal in het buitenland
geloopen tot proef.

„Zit Hervau erin?” vroeg Boom, en op toestemmend knikken, ging hij

voort: „Dan is de zaak veilig. Hij kent dat. Maar hoeveel kost die
grap?”

„Voor ons een kleinigheid,” zeide Viehof. „Enkel stallen en oppassen,

gedurende een week of wat. Hervau stuurt het beest over, en wij
betalen hier. Maar hoofdzaak is, dat wij hem moeielijk op onzen
naam kunnen laten loopen. Arnolds of ik tenminste niet. Wil jij dat
doen?” [175]

„Neen” zeide Boom. „Voor mij is het ook niets. Maar ik weet een
eerzaam winkelier, die wel eens een beetje gokt, en die het wel
voornaam zal vinden. Ik sta voor hem in.”

„Duur?”
„Neen. We mogen hem er geen te groote zaak van voorspiegelen;
anders wantrouwt hij het. Zoo voor de aardigheid, om ook eens als
eigenaar te figureeren en nog een kleinigheid toe te verdienen,
waarvoor hij zoo goed als niets waagt. Want we moeten hem iets
mee laten betalen; anders is het te mooi.”

„Best,” zeide Arnolds. „Zorg jij dan voor je winkelier en de

inschrijving, en wij doen de rest. Ik zal dadelijk telegrafeeren, dan
kan de knol op de volgende courses te Woestduin meeloopen.”

„Maar tegen een onbekend paard zijn geen pari’s te krijgen,”

meende Boom.

„O, hij moet de eerste keer ook niet winnen. Een keer of drie moet hij
meeloopen. Tweemaal zóó verliezen, dat er een hooge côte te
maken is, en de derde maal in een verkoopsren winnen. Zie je, dat is
de manier, om geld te verdienen, en tegelijk de lastpost van het
paard kwijt te zijn. Wacht, ik zal mijn telegram klaarmaken.”

En hij zette zich tot schrijven.

Ruim drie weken later was het drietal vereenigd te Woestduin. Het
was de groote dag, waarop Miss Kate, hun paard winnen zou. In de
volle zekerheid van hun slagen, hadden Arnolds en Viehof zoowel bij
de bookmakers als aan den totalisator hun geld geplaatst, het over
verschillenden verdeelende, om geen argwaan te wekken. Boom
had gewacht. Het was zijn systeem, om eerst te zien wat vóórging,
en zoo laat mogelijk te zetten, in elk geval niet eer men wist of alle
paarden meeliepen. Eindelijk besloot [176]hij het voorbeeld der
anderen te volgen, en verwijderde zich van hen. Eensklaps werd hij
zacht aan zijn mouw getrokken. Het was een gewezen jockey, die
thans het baantje van adviseur uitoefende, en tips gaf. Boom had
hem vroeger eens uit den nood geholpen, en daar werkelijk soms
goeden raad voor ontvangen, de enkele malen, dat hij naar de
courses ging.

„Speelt u Walkyrie” raadde hij.

„Ik was van plan Miss Kate te spelen,” zeide Boom.

„Dat dacht ik wel,” zeide de ander. „Ik heb u zien praten met meneer
Viehof. Die zit in een combinatie.”

„Hoe drommel weet je dat?” riep Boom uit.

„Ik moet wel alles weten, tenminste als er geknoeid wordt. De jockey
is omgekocht, geloof u me gerust. Miss Kate wint ditmaal niet. De
volgende maal.”

Boom begreep, dat daar iets achter moest zitten. Het was een
verkoopsren, en men moest verkoopen, omdat men het financieel
niet langer houden kon. Won dus Miss Kate niet, dan was men
paard en inzetten kwijt.

„Weet je het heelemaal zeker?” vroeg hij.

„Heelemaal zeker,” antwoordde de ander. „Maar ik zou niemand

anders dan u gewaarschuwd hebben. U verklikt me niet?”

„Dankje wel,” zeide Boom. „Kom straks eens bij mij.”

„Neen, meneer, dan zoude men misschien iets merken. Ik kom

morgen avond even bij u thuis.”

Boom volgde den gegeven raad, maar met kloppend hart. Hoewel
de ex-jockey nooit met zekerheid tevoren kon zeggen, welk paard
zou winnen, als elk zijn best deed, kon hij toch daartegenover wel
veilig afraden een paard te spelen, als hij van knoeierij de lucht had.
En daarop was hij uitgeslapen.

Het leek een spannende strijd. Na eerst in een klomp te [177]hebben

geloopen, drongen reeds na de eerste hindernis twee paarden
vooruit. En ofschoon de achterblijvers hoe langer hoe meer distantie
kregen, die twee bleven als aan elkaar hangen.

„Hij houdt Miss Kate in,” zeide Arnolds zacht tegen de anderen. „Dat
is zeer verstandig. Dan kan hij haar krachten voor het laatste vlakke
eind bewaren. Het gaat goed.”

Maar een oogenblik later uitte hij onwillekeurig een kreet.

Bij den sprong over de laatste hindernis was Miss Kate teveel op de
voorhand neergekomen, en had door den schok zijn vaart verloren.
Het scheen zelfs een oogenblik of hij vallen zou, zoo wankelde de
rijder. Zich onmiddellijk weer herstellende schoot het paard echter
weer vooruit, zichbaar den voorsprong inhalende, dien Walkyrie door
dat korte oponthoud gekregen had. Maar telaat. Met een neuslengte
was Miss Kate geslagen!

„Weg centers!” riep Boom, onverschilligheid voorwendende.

Hij had mooi in de angst gezeten. Toen hij het geval bij de laatste
hindernis zag, begreep hij dat dit een gewilde misstap was, doch
later twijfelde hij weer. En minder goed gezicht op de paarden
hebbende, daar de tribune eenigzins schuin tegenover den winpaal
stond, dacht hij een oogenblik dat Miss Kate tòch weer voor was
gekomen. Doch neen, en weldra weerklonk het geroep: allright!
waarmee de overwinning van Walkyrie een feit werd.

Arnolds en Viehof stonden met bleeke gezichten te kijken.

„Ik moet eerst wat drinken,” zeide de laatste, waarmee de ander
instemde.

„En ik moet wat versche lucht blijven inademen,” zeide Boom. „Is me
dat een toestand! Ik kom straks ook aan het buffet.”

Zoodra zij daarin verdwenen waren, ging hij zijn winst

[178]realiseeren. Eerst bij de bookmakers, waar het van uit het buffet
meer in het gezicht kon loopen, en toen bij den totalisator. Daarna
vervoegde hij zich bij de anderen.

„Geen prettig bericht voor Hervau,” begon Boom.

„Voor ons is het erger,” antwoordde Arnolds. „Hoeveel heb jij gezet?”

„Duizend pop.”

„’t Is jammer. Ik wou dat die vervloekte knol de beenen gebroken

had. De jockey heeft z’n best gedaan. Het scheelde nog maar een
haartje.”

„Gévédé!” liet Viehof los.

„Kom, er is niets aan te doen,” meende Boom. „Laat ons

opwandelen, en aan het hôtel nog iets pakken. Die champagne
begint me tegen te staan.”

En zij zetten zich in beweging, langzaam opwandelend naar de door

Boom voorgestelde plaats, om van daaruit de komst van den trein af
te wachten.

Thuisgekomen dacht Boom zijn vrouw te verheugen met al het geld,

dat hij gewonnen had. Doch dat was een misrekening. Wel nam zij
het hem af, maar diende hem een ongezouten standje toe. Ten
eerste omdat hij de duizend gulden, waarmee hij gespeeld bad, niet
had afgedragen, en voorgewend, dat hij die de vorige week niet had
kunnen innen. En voorts, omdat hij die gewaagd had, en zeker kwijt
zou geweest zijn, als niet toevallig die jockey hem had ingelicht.
Enfin, het was gebeurd, en nu gelukkig afgeloopen; maar hij moest
het niet weer wagen. Neen, nooit meer. Want ze hadden genoeg, om
met voorzichtig uitzetten van te leven, en gingen gaandeweg zelfs
vooruit. Er was dus geen enkele reden om van die gewaagde dingen
te doen.

„Het was niet gewaagd,” wierp hij tegen. „Geknoei kan niemand
verhelpen.” [179]

„Spelen is altijd gewaagd,” besliste zij. „En ik wil het niet meer
hebben, hoor je!”

Maar later bleek zij toch niet zoo kwaad, daar zij Boom honderd
gulden meegaf, om Arnolds en Viehof, als die thans zonder geld
zaten, elk wat te geven. En hij mocht dien avond alleen naar Central,
om het hun te brengen. Want sedert zij getrouwd was, kon ze
moeielijk meer daarheen gaan, met de kans de maîtresses der
anderen te ontmoeten.

Zoo slenterde Boom na den eten naar het bewuste Café, hoewel hij
nauwelijks verwachtte de anderen daar te vinden. Zeer verwonderd
was hij dus hen te zien niet alleen, maar blijkbaar hadden zij met Fifi
en Leda goed gedineerd, en waren in vroolijke stemming.

„Goed bericht!” riep hem Arnolds toe, zoodra hij hem bespeurde.
„Een telegram van Hervau. Hij seint het paard nog aan te houden,
en een volgenden keer te laten loopen. Hij zal stalgeld vergoeden en
dubbel onze inzetten, die er vandaag bij ingeschoten zijn.”

„Begrijp je dat?” voegde Viehof erbij.

„Nogal eenvoudig,” zeide Boom. „Hij heeft tegen zijn eigen paard
gespeeld, en zelf gezet op Walkyrie.”

„Bliksems! Wat heeft hij daaraan?”

„Om tweemaal te winnen. Door onze hooge inzetten leek het, of

Miss Kate nu liep om te winnen. Dat depreciëerde de côte van
Walkyrie, waardoor hij op dat paard zettende, meer won. Den
volgenden keer denkt men, dat het wéér zoo gaan zal, en slaan we
onzen slag met Miss Kate. En dan is het uit.”

„Waarom liet dan de jockey Miss Kate zoo gevaarlijk ophalen?”

„Om een disqualificatie te ontgaan. Daar zijn ze bier tegenwoordig

zoo bijster vlug mee. We hebben hem dadelijk [180]teruggeseind
hoeveel stalgeld en inzet is. Voor jou ook.”

„Je hebt er toch wat opgelegd?”

„Neen, zeker niet. Onder elkaar eerlijk, hè?”

„Natuurlijk,” zeide Boom, even kleurende. „Ik maakte ook maar

gekheid. Kom, dat is een goed bericht, en ik geef er een dozijntje
oesters op, bij Hoek.”

Dat denkbeeld vond de noodige instemming, en men maakte zich

langzamerhand op, om de uitnoodiging te volgen.

Toen Boom dien avond naar huis ging, aarzelde hij, of hij zijn vrouw
mededeeling zou doen van het extra fortuintje, dat hem te beurt viel.
Zij had gelijk, het was wagen geweest. Maar het zou zonde zijn de
volgende keer, als Miss Kate werkelijk won, niet weer mee te kunnen
doen. Heelemaal niets zeggen, durfde hij ook niet. Hij moest toch
eenigen uitleg geven, waarom hij de honderd gulden niet aan de
anderen had behoeven te geven, maar er van had gesoupeerd met
hen. Als het nu niet zoo laat was geworden, en hij kon ergens het
meerdere geld bergen, was het wat anders. Ook deed zich de
moeielijkheid op, zoodra hij de twee mille van Hervau in zijn zak had,
te maken, dat Helene er de lucht niet van kreeg. Zij ledigde zijn
zakken, en borstelde dan zijn goed af. Inslikken kon hij het toch niet!
Ha, hij wist iets! Hij kon haar wijsmaken, dat Hervau hem duizend
gulden restitueerde, in de meening, dat hij die verspeeld had, en de
andere duizend gulden om voor gezamenlijke rekening den
volgenden keer te spelen. Zoo was elk tevreden, en de volgende
maal zou hij de helft afdragen, en de andere helft quasi aan Hervau
moeten zenden. Tegen dien tijd zou hij er wel een geschikt plekje
voor vinden, waar zij niet bij kon.

Het was lastig, zoo’n vrouw, die overal haar neus instak. En toch kon
hij niet buiten haar. Reeds hadden, toen hij [181]pas thuis was, een
paar oude schuldeischers geprobeerd hem aan het kleed te komen,
maar ze moesten onverrichterzake afdeinzen, omdat alles van háár
was. Hij had zich toen gehaast dit zooveel mogelijk bekend te
maken, om geen herhaling te krijgen. En bij slot van rekening zorgde
zij toch goed voor hem, en was het in zijn eigen belang. Alleen, lastig
was het.

Reeds den volgenden avond kwam de remise van Hervau. Dat was
wat men noemde coulant! Men deelde, en gaf den winkelier te wiens
name het paard liep, de voorgeschoten stalgelden terug. En deze,
die al bang geworden was, dat men hem erin had laten loopen, en
met een deurwaarder in overleg was getreden het paard in beslag te
nemen, verheugde zich in den goeden afloop.

„Ik wist wel, dat ik u kon vertrouwen, meneer Boom,” zeide hij; „maar
het loopt toch in de papieren. Ik heb er zelf vierhonderd gulden op
gezet en verloren. Ik zal de volgende maal mijn inzet moeten
verdubbelen, en dan willen we er het beste van hopen. In elk geval
weet ik, dat ik een renpaard heb gehad.”

„Maak u maar niet ongerust,” zeide Boom. „Het was een toeval, dat
het paard ditmaal heeft verloren. Aanstaanden Zondag zal het wel
beter gaan.”

En deze voorspelling kwam uit.

Mooier dan ditmaal Miss Kate liep, had nooit eenig paard geloopen.
Hands down werd de ren gewonnen, Vroolijker dan de vorige maal
gingen nu ook Arnolds en Viehof naar huis.

„Ik ga er een beetje vandoor,” zeide de eerste. „Ga je mee?”

„Waarheen?”

„Forest, Namur, of zoo. En als we geluk verder.” [182]

„Top,” antwoordde Viehof. „Gauw wat inpakken, en met den

avondtrein tot Brussel?”

„Best!”

„Wat zijn jelui toch dom,” meende Boom. „Nu heb je wat geld, en
kunt met een beetje beleid er van leven, en af en toe nog eens een
slagje slaan. Doe zooals ik, en blijf hier. ’k Weet van tevoren, dat
jelui sans le sou terugkomt.”

„Ik heb toch eens tachtigduizend francs gewonnen,” merkte Arnolds

op.

„Ja, en die heb je er in een maand doorgelapt,” zeide Boom. „Op die
manier heb je er niet veel aan.”
„Het komt er niet opaan,” zeide Arnolds. „We hebben dan tenminste
plezier gehad. Wat heb je hier?”

„En,” vond Viehof, „als we terugkomen, en het is op, dan zoeken we

maar wéér wat op.”

„Ik houd me aanbevolen,” verklaarde Boom.

Zij deden zooals afgesproken, en spoedden zich naar hun kamers,

om hun koffertje te pakken, en de meisjes wat geld te geven. Maar
deze lieten zich daarmee niet afschepen, en het gevolg was, dat zij
zoolang aandrongen tot ze mee mochten.

Even voorbij de grens hadden zij hun gewone bezigheid hervat, als
ze reisden, te weten Arnolds en Viehof kaart te spelen, de meisjes te
kijken en te babbelen, toen zich in de deur van den coupe, die ze
voor den rook hadden opengelaten, de figuur van Wiechen
vertoonde.

„Zoo, heertjes,” zeide hij, „éérste klasse en de dames mee?”

„Kom bij ons zitten,” noodigde Arnolds. „Waar ga jij heen?”

„Naar Parijs,” zeide Wiechen. „Neen, ik kom niet binnen. Ik heb

tweede klasse, en als een conducteur komt.…”

Zij drongen aan, maar hij bleef weigeren, vertellende van een koopje
dat hij eens gehad had door dat te doen. [183]En bovendien was hij
niet alleen. Een dame, die hij wegbracht.

„Blijf je lang?” vroeg Arnolds.

„Ik weet het nog niet. Eens kijken, of ik er iets van mijn gading
vinden kan. Nu, we zien elkaar in de wachtkamer te Brussel wel. Of
gaan jelui niet door?”
„Vannacht blijven we te Brussel. Bonjour!”

„Ik moet toch zien wie hij bij zich heeft,” verklaarde Arnolds, toen
Wiechen verdwenen was. „Neen, één voor één, asjeblieft,” ging hij
voort, ziende dat ook de anderen opstonden.

Hij bleef maar kort weg.

„Gordijntjes dicht,” vertelde hij. „Door de reet zag ik oen knap

snoetje, maar onbekend.”

De overigen schenen het nu niet meer de moeite waard te vinden,

en men ging door met spelen en praten. [184]
[Inhoud]
 HOOFDSTUK XVII.

Ella Wiechen had haar eindexamen met goed gevolg afgelegd.

Zoolang zij daarvoor werkte, had men het geraden geacht het
engagement nog geheim te houden, teneinde haar geen te groote
afleiding te geven. Nu zij er door was, wilde men haast maken met
het huwelijk. Carel kon elken dag zijn orders krijgen, om naar Indië
te vertrekken, en hoe vlugger alles afliep, hoe beter, naar de
betrokken partijen voorkwam.

Zelfs Wiechen werkte mee. Want hij vreesde elken dag voor een
beslag, en wilde zien vóór dien tijd weg te komen. Een paar kleine
vonnisjes had hij afgedaan, doch een der groote hing er teveel in.
Tot overmaat van ramp had de advocaat van van Vleuten, met hoop
op een verstek, maar ineens gedagvaard, en daar Wiechen geen
kosten meer wou maken, was de toeleg gelukt.

Van Marie van Groningen had Ella antwoord gekregen, waarbij deze
haar hartelijk geluk wenschte. Als Ella trek had, haar eens op te
zoeken, dan kon dit nu geschieden, daar zij bij haar oom en tante
Slot was ingetrokken.

Gaarne gaf Ella nu aan die uitnoodiging gehoor, en nam ook

dankbaar Marie’s aanbod aan, om haar met haar uitzet te helpen,
zoodat zij geen onbruikbare dingen meenam.

Ten huize harer aanstaande schoonouders was zij in het [185]eerst

met eenige koelheid ontvangen, doch ook die week weldra, en al
heel spoedig was Ella maar zelden thuis te vinden.

Het begon er ook ongezellig te worden. Haar vader had, behalve op

het kantoor, dat nog zijn gewone uiterlijk behield, overal ingepakt, en
veel de deur uitgezonden. Tot haar had hij gezegd, dat hij
onmiddellijk na haar huwelijk naar Parijs zou vertrekken, en dus op
de meubels na, alles wilde hebben opgeruimd en opgezonden. Zoo
ging dan het een vóór, het ander na, de deur uit, en kreeg het
eigenlijke huis den indruk of het voor een verkooping klaargemaakt
was.

Op den Zaterdagmiddag, vóór den Zondag, waarop Wiechen naar

Parijs spoorde, had hij Ella met een groot envelop naar Marie van
Groningen gezonden, dat zij onmiddellijk moest overhandigen, en er
haar bij gezegd, dat hij even heen en weer naar Parijs ging, en zij de
gastvrijheid van Marie maar moest inroepen. Daarop had hij haar
een hartelijken afscheidskus gegeven. Dit laatste herinnerde zich
Ella pas later, toen Marie haar had verteld, wat er nader in den brief
van haar vader stond.

Het was geen „even heen en weer”, maar een vertrek voor goed. En
hij vroeg zijn vroegere vriendin, die toch zooveel van Ella hield, of zij
haar bij zich wilde houden, en voor het verdere zorgen. Een acte van
toestemming voor Ella’s huwelijk, was in den brief vervat. Die had hij
doen opmaken, omdat, afgezien van zijn vertrek naar Parijs, hij bij
de huwelijksvoltrekking niet tegenover die trotsche menschen wou
staan, die niet eens zijn kennis wilden maken. Hij zou nog niet zoo
spoedig gegaan zijn, als niet Maandag een beslag in zijn huis
verwacht werd, en hij daar Ella niet in kon laten zitten. Hij verzocht
Marie van dit alles aan Ella enkel het hoognoodige te willen
meedeelen.

Ella schreide haar oogen rood, en zoo vond haar Carel, [186]die haar
kwam afhalen, om bij zijn ouders te gaan eten. Hoewel hij hartelijk
blij was, dat hij Wiechen, die hem tegenstond, niet zou ontmoeten
voorshands, gevoelde hij toch groote deelneming met zijn aanstaand
vrouwtje, en stelde haar voor haar komen voor heden af te gaan
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