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poral lesions or seizures, polyopia (one object appearing as two or more objects) more frequently with occipital lesions (it also occurs in hysteria), and palinopsia (perseveration of visual images) with both posterior parietal and occipital lesions Visual eld defects are present in many of the cases In all these conditions the anatomic correlates are imprecise It is likely that an element of cortical vestibular disorder underlies the metamorphosis of parieto-occipital lesions The vestibular and proprioceptive systems are represented in the parietal lobes of each side and the lesions there are probably responsible for misperceptions of movement and spatial relations (The illusion of tilting of the environment or upside-down vision is known to occur with parieto-occipital lesions but occurs more often with abnormalities of the vestibular system) Visual Hallucinations These phenomena may be elementary or complex, and both types have sensory as well as cognitive aspects Elementary (or unformed) hallucinations include ashes of light, colors, luminous points, stars, multiple lights (like candles), and geometric forms (circles, squares, and hexagons) They may be stationary or moving (zigzag, oscillations, vibrations, or pulsations) They are much the same as the effects that Foerster and Pen eld obtained by stimulating the calcarine cortex in a conscious patient Complex (formed) hallucinations include objects, persons, or animals and infrequently, more complete scenes They are indicative of lesions in the visual association areas or their connections with the temporal lobes They may be of natural size, lilliputian, or grossly enlarged With hemianopia, they appear in the defective eld or move from the intact eld toward the hemianopic one The patient may realize that the hallucinations are false experiences or may be convinced of their reality Since the patient s response is usually in accord with the nature of the hallucination, he may react with fear to a threatening vision or casually if its content is benign The clinical setting for the occurrence of visual hallucinations varies The simplest black-and-white moving scintillations are part of migraine Others, some colored, occur as a seizure aura Often they are associated with a homonymous hemianopia, as already indicated Frequently they are part of a confusional state or delirium (Chap 20) Similar phenomena may occur as part of hypnologic hallucinations in the narcolepsy-cataplexy syndrome In the peduncular hallucinosis of Lhermitte, the hallucinations are purely visual, appear natural in form and color sometimes in pastels, move about as in an animated cartoon, and are considered by the patient to be unreal, abnormal phenomena (preserved insight) Ischemia in the territories of the posterior cerebral arteries is the usual cause In our material, hallucinosis of this type (erroneously called peduncular insofar as that term refers to the cerebral peduncle) has been associated mainly with high mesencephalic ischemia, which obviously may also implicate the occipital lobes As indicated above, the hallucinations in this disorder are purely visual; if hallucinations are polymodal, the lesion is always in the occipitotemporal parts of the cerebrum A special syndrome of ophthalmopathic hallucinations occurs in the blind person The visual images may be of elementary or complex type, usually of people or animals, and are polychromic (vivid colors) They may occupy all of the visual eld (in the totally blind person) in the eld of one eye Moving the eyes or closing the affected eye has variable effects, sometimes abolishing the hallucinations A similar phenomenon in elderly patients with partially impaired vision has been called the syndrome of Charles Bonnet,.

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following his description of visual hallucinations in a sane person The topic of senile hallucinosis has been reviewed by Gold and Rabin, and 60 such patients were reported in detail by Teunisse and colleagues The latter authors found that 11 percent of older persons with reduced vision experienced these phenomena at one time or another In the majority of their cases the hallucinations lacked any personal meaning and were not distressing, but the patients were greatly relieved to hear that they did not have mental disease Curiously, there are reports of improvement in the symptoms with the use of anticonvulsants such as gabapentin (Paulig and Mentrup) Further comments are to be found on page 220 It has been traditionally taught that the lesions responsible for visual hallucinations, if identi able, are situated in the occipital lobe or posterior part of the temporal lobe and that elementary hallucinations have their origin in the occipital cortex and complex ones, in the temporal cortex However, the opposite may pertain; in some cases, formed hallucinations are related to lesions of the occipital lobe and unformed ones to lesions of the temporal lobe (Weinberger and Grant) Also, as emphasized by these authors, lesions that give rise to visual hallucinations, simple or elaborate, need not be con ned to central nervous structures but may be caused by lesions at every level of the neuro-optic apparatus (retina, optic nerve, chiasm, etc) The hallucinatory phenomena of delirium are nonlocalizable, as pointed out in Chap 20, but sometimes the evidence points to an origin in the temporal lobe The Visual Agnosias Visual Object Agnosia This rare condition, rst described by Lissauer in 1890, consists of a failure to name and indicate the use of a seen object by spoken or written word or by gesture The patient cannot even tell the generic class of the object presented Visual acuity is intact, the mind is clear, and the patient is not aphasic conditions requisite for the diagnosis of agnosia If the object is palpated, it is recognized at once, and it can also be identi ed by smell or sound if it has an odor or makes a noise Moving the object or placing it in its customary surroundings facilitates recognition In most reported instances of object agnosia, the patient retains normal visual acuity but cannot identify, match, or name objects presented in any part of the visual elds; if misnamed, the object is used in a fashion that re ects the incorrect perception Amazingly, one encounters patients who have lost the capacity to recognize only one class of objects eg, animals or vegetables suggesting that, in the human, stored information is grouped and classi ed in a way that is necessary for visual perception (we are unable to corroborate this from our own material) Lissauer conceived of visual object recognition as consisting of two distinct processes the construction of a perceptual representation from vision (apperception) and the mapping of this perceptual representation onto stored percepts or engrams of the object s functions and associations and he proposed that impairment of either of these processes could give rise to a defect in visual object recognition As indicated in Chap 13, visual object agnosia is usually associated with visual verbal agnosia (alexia) and homonymous hemianopia Prosopagnosia (the inability to identify faces; see further on) is also present in most cases The underlying lesions are usually bilateral, although McCarthy and Warrington have related a case to a restricted lesion of the left occipitotemporal region (by MRI) Two of our patients with visual object agnosia had an incomplete amnesic syndrome from a left-sided inferior occipital and.