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Geschwind accepted Liepmann s proposition that a lesion of a subcortical tract (presumably the arcuate fasciculus) disconnects the parietal from the left frontal cortex, accounting for the ideomotor apraxia of the right limbs, and that the left limb apraxia is due to a callosal disconnection of the left and right premotor association cortices But in a right-handed person there is also the situation of a left limb apraxia from a lesion in the left frontal lobe that includes Broca s area, the left motor cortex, and the deep underlying white matter Clinically there is a motor speech disorder, a right hemiparesis, and this type of apraxia of the nonparalyzed hand, which has been termed sympathetic apraxia If the lesion in the deep white matter separates the language areas from the right motor cortex but not from the left, the patient can write with the right hand but not with the left, or he may write correctly with the right hand and aphasically with the left That such a syndrome is attributable to interruption of a pathway that traverses the genu of the corpus callosum, as depicted by Geschwind, is questionable, insofar as sympathetic apraxia has not been observed in patients with lesions (or surgical sections) con ned to the anterior third of the corpus callosum (see page 395) The disconnection syndromes are discussed further in Chaps 22 and 23 Perhaps surprisingly, there are but a few cases of apraxia of any type with proven prefrontal lesions Of a somewhat different nature is a facial-oral apraxia, which is probably the most common of all apraxias in practice It may occur with lesions that undercut the left supramarginal gyrus or the left motor association cortex and may or may not be associated with the apraxia of the limbs described above Such patients are unable to carry out facial movements to command (lick the lips, blow out a match, etc), although they may do better when asked to imitate the examiner or when holding a lighted match With lesions that are restricted to the facial area of the left motor cortex, the apraxia will be limited to the facial musculature and may be associated with a verbal apraxia or cortical dysarthria (page 418) So-called apraxia of gait is considered in Chap 7 The terms dressing apraxia and constructional apraxia are used to describe certain manifestations of parietal lobe disease These abnormalities are not apraxias in the strict sense of a loss of previously learned behavior but are instead symptoms of contralateral extinction or neglect of the body schema and of extrapersonal space (anosognosia, page 401) Testing for apraxia is carried out in several ways First, one observes the actions of the patient as he engages in such tasks as dressing, washing, shaving, and using eating utensils Second, the patient is asked to carry out familiar symbolic acts wave goodbye, salute the ag, shake a st as though angry, or blow a kiss If he fails, he is asked to imitate such acts made by the examiner Finally, he is asked to show how he would hammer a nail, brush his teeth, take a comb out of his pocket and comb his hair, cross himself, and so forth, or to execute a more complex act, such as lighting and smoking a cigarette or opening a bottle of soda, pouring some into a glass, and drinking it These last actions, involving more complex sequences, are said to be tests of ideational apraxia; the simpler and familiar acts are called tests of ideomotor apraxia To perform these tasks in the absence of the tool or utensil is always more demanding because the patient must mentally formulate a plan of action rather than engage in a habitual motor sequence The patient may fail to carry out a commanded or suggested activity (eg, to take a pen out of his pocket), yet a few minutes later he may perform the same motor sequence automatically One may.

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think of such an ideomotor de cit, if it can be singled out from confusion or a defect in comprehension, as a kind of amnesia for certain learned patterns of movement, analogous to the amnesia for words in aphasia Children with cerebral diseases that retard mental development are often unable to learn the sequences of movement required in hopping, jumping over a barrier, hitting or kicking a ball, or dancing They suffer a developmental motor apraxia Certain tests quantitate failure in these age-linked motor skills (see Chap 28) In the authors opinion, the time-honored division of apraxia into ideational, ideomotor (idiokinetic), and kinetic types is unsatisfactory It is more helpful to think of the apraxias in an anatomic sense, as disorders of association between different parts of the cerebral cortex, as described above We have been unable to con dently separate ideomotor from ideational apraxia The patient with a severe ideomotor apraxia nearly always has dif culty at the ideational level and, in any case, similarly situated left parietal lesions give rise to both types Furthermore, in view of the complexity of the motor system, we are frequently uncertain whether the clumsiness or ineptitude of a hand in performing a motor skill represents a kinetic apraxia or some other fault in the intrinsic organization of hand control A related but poorly understood disorder of movement has been termed the alien hand In the absence of volition, the hand and arm undertake complex and seemingly purposeful movements such as reaching into a pocket or handbag, placing the hand behind the head, and tugging on the opposite hand or other body part; these activities may occur even during sleep The patient is aware of the movements but has the sense that the actions are beyond his control, and there is often an impression that the hand is estranged, as if commanded by an external agent (although the limb is recognized as one s own there is no anosognosia); a grasp re ex and a tendency to grope are usually added Most instances arise as a result of infarction in the territory of the opposite anterior cerebral artery, including the corpus callosum When the callosum is involved, Feinberg and colleagues nd that there frequently appears to be a con ict between the actions of the hands, the normal one sometimes even restraining the alien one Damage in the left supplementary motor area from any cause as well as in the disease called corticobasal ganglionic degeneration (page 928) are associated with a similar alien hand syndrome A form that results from a stroke in the posterior cerebral artery territory with associated sensory loss has also been observed by Ay and colleagues Finally, it should be remarked once again that the complexity of motor activity is almost beyond imagination Reference was made earlier to the reciprocal innervation involved in an act as simple as making a st Scratching one s shoulder has been estimated to recruit about 75 muscles But what must be involved in playing a piano concerto Over a century ago Hughlings Jackson commented that There are, we shall say, over thirty muscles in the hand; these are represented in the nervous centers in thousands of different combinations, that is, as very many movements; it is just as many chords, musical expressions and tunes can be made out of a few notes The execution of these complex movements, many of them learned and habitual, is made possible by the cooperative activities of not just the motor and sensory cortices but integrally of the basal ganglia, cerebellum, and reticular formation of the brainstem All are continuously integrated and controlled by feedback mechanisms from the sensory and spinal motor neurons Even the spinal stretch re ex has connections with the motor cor-.

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