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The anosmia may be unilateral or bilateral and is often permanent. Subarachnoid hemorrhage, chronic meningitis, and cranial surgery, in which the frontal lobes and olfactory bulbs are retracted from the ethmoid bone, may have the same effect. The olfactory bulb and tract (second olfactory neuron) may be compressed by a meningioma of the olfactory groove, in which case the optic nerve is often implicated as well. The association of unilateral anosmia and optic atrophy with a...

Anxiety Fear And Depression

These emotional states may occur episodically or persistently with lesions of the medial temporal lobe in the region of the amygdaloid body and its connections with the thalamus and hypothalamus. Williams observed such emotional disturbances as part of a seizure in 80 of 2000 epileptics. Fear and anxiety were three times more frequent than depression. Attacks of anger and rage have been induced by stimulation of the amygdala through depth electrodes, and destruction of the central part of this...

TABLE 391 Classification of the Acquired Metabolic Disorders of the Nervous System Metabolic Encephalopathies

Metabolic diseases presenting as a syndrome of episodic confusion, stupor, or coma, sometimes with seizures E. Hepatic failure and Eck fistula H. Other metabolic encephalopathies acidosis due to diabetes mellitus or renal failure (also inherited forms of acidosis, Chap. 36) Addison disease bismuth toxicity hypercalcemia I. Sepsis, multiorgan failure, and burns J. Hypo- and hypernatremia and hyperosmolality II. Metabolic diseases presenting as an extrapyramidal syndrome A. Acquired...

Petit Mal Absence

The absence seizure consists of a brief lapse of consciousness, which comes without warning, lasts for 2 to 10 s, and is followed by immediate and full resumption of consciousness. Often there is blinking of the eyelids or rhythmic (3-per-second) movement of the arms or fingers. The patient remains sitting or standing and afterward may be unaware that anything has happened. Hyperventilation may induce an attack. This form of petit mal is a disease of childhood, with onset between 4 and 12 years...

Classic or Female Hysteria Briquet Disease

Onset is usually in late childhood, adolescence, or early adult life. Once the ailment has started, various symptoms recur intermittently, though with lessening frequency in adult years. Schooling and later social life, work, and marriage are interrupted repeatedly by violent headaches, simulated seizures, trancelike states, paralyses, intractable vomiting or regurgitation, unexplained fever, blindness, urinary retention, aphonia, and unsteadiness of gait. Typical examples are young women who...

Treatment of Alcohol Addiction

Following recovery from the acute medical and neurologic complications of alcoholism, the underlying problem of alcohol dependency remains. To discharge the patient at this point and to leave him to his own devices practically assures that he will resume drinking, with a predictable recurrence of medical illness. At a minimum, the physician must inform the patient and his family of the medical and social consequences of continued drinking and of the fact that total abstinence represents the...

With Coma of Unknown Etiology

Supratentorial mass lesions 101 Posterior fossa subdural hemorrhage 1 Metabolic and other diffuse disorders 326 Endocrine disorders (including diabetes) 12 Encephalomyelitis and encephalitis 14 Note Listed here are only the patients in whom the initial diagnosis was uncertain and a final diagnosis was established. Thus, obvious poisonings and closed-head injuries are underrepresented. Source From Plum and Posner, with permission.

Approach To The Problem Of Visual Loss Examination for Visual Loss

First one measures visual acuity by means of a Snellen chart or, at the bedside, by a near card, on which the letters have been reduced proportionately, to be read at a distance of 14 in. If the patient reads only the top line of the Snellen chart at 20 ft rather than 200 ft, the acuity is stated as 20 200 or 6 60, in meters. Normal vision is 20 20, or 6 6. If the patient has a refractive error, glasses should be worn during the test. If visual impairment cannot be corrected to 20 20 with...

Disorders Of Conjugate Movement Gaze

Frontal lobe lesion, acute Weakness or paralysis of contralateral gaze eyes deviate to side of lesion temporarily (few days) retention of pursuit and vestibulo-ocular movements. Bilateral frontal lesions Loss of rapid voluntary (saccadic) movements to either side, with retention of visual pursuit and vestibulo-ocular movements (erroneously called apraxia of gaze). Parieto-occipital lesion Loss of pursuit movements to side of lesion loss of slow phase of optokinetic nystagmus to side of lesion...

Lumbar Puncture And Examination Of Cerebrospinal Fluid

The indications for a lumbar puncture (LP) are as follows 1. To obtain pressure measurements and to procure a sample of CSF for cellular, chemical, and bacteriologic examination. 2. To administer spinal anesthetics and certain antibiotic and antitumor medication. 3. To inject a radiopaque substance, as in myelography, or a radioactive agent, as in scintigraphic cisternography. If, because of a localized mass, the intracranial pressure (ICP) is very high, LP carries a risk of inducing or...

Aberrant Respiratory Patterns

These are observed mainly in comatose patients and have only an uncertain value in localization (central neurogenic hyperventilation, apneusis, ataxic breathing see Chaps. 17 and 19). Cheyne-Stokes breathing, the well-known waxing-and-waning type of cyclic ventilation, occurs most often with deep, bilateral hemispheral lesions. Centrally driven hyperventilation is known to occur with brain lymphoma, even without involvement of the brainstem. A loss of automatic respiration with preserved...

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Spinothalamic tract sometimes descending sympathetic fibers, with Horner syndrome Corticospinal tract Vestibular nuclei, lateral spinothalamic tract, descending puplllodilator fibers Spinocerebellar and olivocerebellar tracts, medial longitudinal fasciculus Facial and abducens palsy and contralateral hemiplegia sometimes gaze palsy to side of lesion Paralysis of soft palate and vocal cord and contralateral hemianesthesia Avellls syndrome plus ipsllateral tongue paralysis Nystagmus, Ipsilateral...

Headache and Other Craniofacial Pains

Headache is essentially a symptom without a sign. With a few notable exceptions (auscultation of a bruit, palpation of thickened arteries), physical examination of the head during or between headaches yields little useful information. The frequency and multiplicity of causes of headache bring it to the notice of physicians in many specialties. Although usually benign and lacking assignable cause, it is often enough the expression of significant intracranial disease to require consultation with...

Lesions of Single Peripheral Nerves and Roots

With respect to peripheral nerve lesions, the clinical findings will vary depending on whether the affected nerve is predominantly muscular, cutaneous, or mixed. With interruption of a cutaneous nerve, the area of sensory loss is always less than its anatomic distribution because of overlapping innervation from adjacent nerves. Also, for reasons given above, loss of tactile sensation is usually a more accurate measure of a cutaneous nerve lesion than is loss of pain and temperature. Sensory...

TABLE 351 Classification of the Demyelinative Diseases

Multiple sclerosis (disseminated or insular sclerosis) A. Chronic relapsing encephalomyelopathic form C. Neuromyelitis optica (Devic disease) II. Diffuse cerebral sclerosis (encephalitis periaxilis diffusa) of Schilder and concentric sclerosis of Bal III. Acute disseminated (postinfections) encephalomyelitis and myelitis A. Following EBV, CMV, herpesvirus, Mycoplasma, or undefined infection B. Following measles, chickenpox, smallpox, and rarely mumps, rubella, influenza, or other obscure...

The Testing Of Eye Movements

To determine whether the axes of the two eyes are parallel, one observes the eyes as the patient looks straight ahead and fixates on a distant target. If one eye deviates inward (esotropia) or outward (exotropia), covering the normal eye will result in refixation of the deviant eye onto the target, indicating an imbalance of ocular muscle tone (congenital or nonparalytic strabismus) rather than an ocular muscle palsy. Another way of detecting an ocular imbalance is for the patient to focus on a...

Pyridoxine Vitamin B6 Deficiency Encephalopathy

There are two types of B6 deficiency encephalopathy. One is related to an inherited deficiency of the enzyme glutamic acid decarboxylase, of which vitamin B6 is a cofactor this disorder presents as neonatal convulsions. The other is an acquired deficiency of the vitamin, either from simple dietary lack or from the therapeutic use of isoniazid or hydralazine, which forms hydrazone complexes and makes pyridoxal unavailable to the tissues. The latter type is a cause of anemia and polyneuropathy in...

Anorexia Nervosa and Bulimia

Anorexia nervosa (AN) is a disease of unknown cause, the core of which is excessive voluntary weight loss. It occurs almost exclusively in previously healthy adolescent girls and young women. Anorexia in boys and men is usually linked genetically and clinically to an endogenous depression hence there is no impropriety in appending the description of the anorectic states to this chapter. AN is culturally predicated, being more prevalent in social groups with free access to food and deeply...

Common Disturbances of Vision

The diverse composition of the eye, containing epithelial, vascular, connective, muscular, pigmentary, and nervous tissue elements, renders it vulnerable to a wide variety of diseases. For this reason, it concerns physicians in several medical specialities other than ophthalmology. To the neurologist, the eyes are the most important of all sense organs. A large part of human motility and numerous reactions to the environment are under visual control. Thus, nature has assigned a large part of...

Uremic Encephalopathy

Several types of encephalopathy may develop in the course of renal failure and dialysis 1. Uremic twitch convulsive syndrome A variety of motor phenomena twitching, tremor, myoclonus, convulsive seizures may be associated with renal failure, sometimes when the patient is still mentally clear and the blood pressure is normal. The BUN is extremely high, but urea is not the responsible neurotoxin. Acidosis, hypocalcemia, and hypomagnesemia are added factors. Dialysis is the only effective...

Common Causes Of Visual Loss Acute Retinal Lesions

Sudden painless loss of vision always suggests an ischemic lesion of the retina or optic nerve due to occlusive disease of the central retinal artery or vein or posterior ciliary arteries. Macular and vitreous hemorrhages and retinal detachment are less common causes. Thrombotic or embolic occlusion of the central retinal artery renders the retina ischemic. Occlusion of the central retinal vein causes engorgement of the retinal veins and diffuse retinal hemorrhages. With ischemic optic...

Symptomatology

Affliction of the peripheral nerves is expressed by a number of motor, sensory, reflex, autonomic, and trophic symptoms and signs, various combinations of which stand as the clinical criteria for diagnosis. Most polyneuropathies are marked by weakness and reflex loss and, if chronic and axonal, by denervation atrophy. The pattern of motor loss varies. The common one is a symmetric involvement of the muscles of the feet and legs, followed by those of the hands and arms, because the largest and...

The Neurologic Examination

This is an integral part of the general physical examination. With most disease states, the neurologic examination is the last part in a comatose patient, it follows immediately upon the recording of vital signs and the cardiopulmonary examination. The type and completeness of the neurologic examination are determined by the nature of the clinical problem. Obviously, it is not necessary to perform a detailed mental status examination in an alert patient with an acute compression of a peroneal...

Postinfectious Postexanthem Postvaccinal Myelitis and Encephalomyelitis

All of these terms refer to a distinctive form of demyelinative disease, which evolves over a period of several hours or days in the setting of a viral disease, after certain vaccinations, or after some infection that often defies identification. The common viral precedents are EBV, CMV, and the exanthems (measles, rubella, chickenpox). Occasionally, ADEM follows Mycoplasma infections. Cerebral, cerebellar, or spinal cases (transverse myelitis) appear acutely, along with a CSF pleocyto-sis. In...

Hypo and Hypernatremia

These are among the most common of metabolic abnormalities encountered. As with other metabolic encephalopathies the degree of CNS disturbance is related to the rate at which the serum Na changes. Extremely high levels cause impairment of consciousness, myoclonus, asterixis, seizures, and choreiform movements. Low levels are accompanied by a decrease in alertness, which progresses through stages of confusion to coma, often with convulsions. Severe hypernatremic dehydration (Na > 155 meq L) is...

Syndromes Caused By Lesions Of The Temporal Lobes

The sylvian fissure separates the superior and lateral surfaces of the temporal lobe from the frontal lobe and from the anterior part of the parietal lobe (Fig. 22-1). The temporal lobe merges posteriorly with the occipital lobe and superolaterally with the parietal lobe. The temporal lobe includes the superior, middle, and inferior temporal, fusiform, and hippocampal convolutions and, on its superior surface, the transverse gyri of Heschl. The latter constitute the auditory receptive area....

The Pineal Gland and Melatonin

The pineal gland, or pineal body, is a small glandular structure that projects from the dorsal diencephalon and lies just posterior to the third ventricle. The identification of the pineal hormone, melatonin (by Lerner in the 1950s) along with the recognition of its role in maintaining biologic rhythms and the modulating effects on its secretion by the circadian light dark cycle revived scientific interest in the gland. Ablation of the gland in humans, with the loss of most of the circulating...

Spinal Sensory Syndromes

The lesions giving rise to these syndromes are shown diagrammatically in Fig. 9-4. A complete transverse lesion of the spinal cord abolishes all motor and sensory functions below the level of the lesion. In a narrow band at the upper level of the analgesic zone, where loss of sensation is only partial, pressing or rubbing the skin lightly may be painful. A lesion of one side of the cord results in a contralateral loss of perception of pain and thermal sense, beginning one to two dermatomes...

Disorders Of The Corticospinal And Other Upper Motor Neurons

Corticorubrospinal Tract

The motor cortex is defined physiologically as the electrically excitable region from which isolated movements can be evoked by stimuli of minimal intensity. Anatomically, this cortical region lies in the posterior part of the frontal lobes and comprises three areas the precental (area 4), the premotor (area 6), and the supplementary motor, on the medial surface of the superior frontal and cingulate convolutions. The descending motor pathways that originate in the motor cortex are designated as...

Differential Diagnosis

Once it has been ascertained from existent symptoms and signs that there is disease involving many peripheral nerves, three questions must be answered (1) Is the disease in question a polyneuropathy, a radiculopathy or a polyradiculopathy, or a random affection of multiple nerves (mononeuropathy multiplex) (2) What is the time course (3) Is the deficit predominantly due to demyelination or to axonal degeneration The features that distinguish polyneuropathy from mononeuropathy multiplex have...

Cluster Headache Migrainous Neuralgia Hortons Histamine Cephalalgia

This type occurs nightly, less often daily, for many weeks to months (a cluster) and then disappears as mysteriously as it came. It occurs predominantly in young men (male-female ratio of 5 1). The pain is intense and nonpulsatile in and around one eye and is accompanied by one or more of the following features tearing, conjunctival congestion, rhinorrhea, mild ptosis, and sweating and flushing of the forehead and cheek. It lasts for 20 to 30 min and subsides rapidly. A common pattern is abrupt...

Electrodiagnostic Tests

Muscle weakness and atrophy may be due to a primary disease of muscle (dystrophy or a myopathy of metabolic, toxic, traumatic, or inflammatory type) or to denervation (from disease of anterior horn cells or peripheral nerves), and the two can be readily differentiated by electro-diagnostic methods. The two standard procedures are (1) the demonstration of fibrillation potentials and changes in the size and shape of motor unit potentials (MUPs) by the insertion of needle electrodes into muscles...

Electroencephalography

This is an essential technique for the study of patients with epilepsy and those with suspected seizure disorders. It is also helpful in evaluating the cerebral effects of toxic and metabolic diseases, in studying sleep disorders, and in identifying subacute spongiform encephalopa-thy (Chap. 32). The instrument for recording electrical activity of the brain, the electroencephalograph, comprises 8 to 16 or more separate amplifying units capable of recording from many areas of the scalp at the...

Alcoholic Cerebellar Degeneration

This term refers to a common disorder in alcoholics characterized by a wide-based stance and gait, instability of the trunk, and ataxia of the legs. Arms are affected to a lesser extent, and dysarthria and nystagmus are distinctly uncommon. The pathologic changes consist of a degeneration of the neurocellular elements of the cerebellar cortex, particularly the Purkinje cells, restricted to the anterosuperior vermis and, in advanced cases, to the anterior parts of the anterior lobes. These...

Clinical Approach To Syncope

If on the scene of a common vasovagal faint, one need only ensure that the patient remains recumbent until the vasodepressor inadequacy has corrected itself. For the patient who reports one or more faints and is normal when seen, one must ascertain, from the descriptions of the episode, that it was a faint and not a seizure or an attack of anxiety, transient ischemia, or hypoglycemia. Having satisfied oneself on this point, one attempts to determine the mechanism of the faint and the likelihood...

Deficiency Amblyopia

This is a relatively rare syndrome of subacutely evolving bilateral, but not necessarily symmetric, central visual loss with pallor of the optic discs (optic atrophy). In the past, alcohol and tobacco were thought to be causative (tobacco-alcohol amblyopia), but the disease is now known to be due to B vitamin deficiency. It overlaps the Strachan syndrome, in which the amblyopia is associated with a painful and predominantly sensory polyneuropathy and orogenital dermatitis. The latest outbreak...

Diagnosis Of Paralytic States

The term monoplegia designates a paralysis of one limb hemiplegia, paralysis of an arm and leg on the same side paraplegia (sometimes referred to as diplegia), paralysis of both legs and quadriplegia or tetraplegia, paralysis of all four extremities. Bulbar paralysis, or palsy, refers to weakness or paralysis of the muscles innervated by the motor nuclei of the lower brainstem (i.e., muscles of the face, tongue, larynx, and pharynx). The paralysis may be atrophic and flaccid (i.e., lower motor...

Herpes Simplex Encephalitis

This, the most serious of the viral encephalitides, occurs sporadically throughout the year, in patients of all ages, and in all parts of the world. It is caused by type 1 herpes simplex virus, very rarely by type 2 (genital herpes). The symptoms, consisting of fever, headache, confusion, stupor, and coma, evolve over a period of several days. Additional symptoms in some patients include olfactory and gustatory hallucinations, temporal lobe or motor seizures, changes in personality and...

Syndrome Of Herpes Zoster

This well-known disorder (also called zona or shingles) is caused by the varicella-zoster (VZ) virus. It has an overall incidence of three to five cases per thousand patients per year and is considerably more frequent in the elderly and in those with malignancies, particularly lymphoma and Hodgkin disease. Herpes zoster probably represents a reactivation of varicella virus infection that has been latent in sensory ganglia following the primary infection with chickenpox. Clinical features The...

Hypoglycemic Encephalopathy

The brain is largely dependent on glucose for its metabolism and has only a limited glucose reserve (1 to 2 g or 30 mol 100 g of tissue). This reserve will sustain cerebral activity for only about 30 min once no blood glucose is available. In conditions such as insulin overdose, islet cell tumor, severe hepatic destruction, acute nonicteric hepatoen-cephalopathy (Reye syndrome), glycogen storage disease, or an idio-pathic state in infants, the blood glucose may fall to a critical degree. When...

Alzheimer Disease

This is the most frequent of all degenerative diseases. It occurs in late life and the senium, and its prevalence in persons between the ages of 60 and 69 years of age is less than 1 percent but it increases strikingly to 11 percent in the eighties. The disease is familial in some 15 percent of cases and runs a progressive course that spans 5 to 10 years. The neuronal loss is mainly in the association areas of the frontal, temporal, and parietal cortices of both hemispheres the primary motor,...

Ancillary Procedures

Sciatic Notch Tenderness

The selection of laboratory tests depends on the nature of the back problem and the degree of one's suspicion of the presence of disease. Helpful measurements include complete blood count, sedimentation rate, FIG. 11-1 (1) Costovertebral angle (renal pain). (2) Spinous process and interspinous ligament. (3) Region of L5-S1 articular facet (facet joint pain). (4) Dorsum of sacrum. (5) Region of iliac crest. (6) Iliolumbar angle. (7) Spinous processes of fifth lumbar to first sacral vertebrae...

Spasmodic Torticollis And Lingual Facial Oromandibular And Manual Spasms Focal Dystonias

These are involuntary spasms of a particular group of muscles. The spasms may be persistent or intermittent and tonic or irregularly clonic, resulting in a turning and retraction of the head, a forceful grimace, closure of the eyelids, protrusion of the tongue, strained voice, pursing of the lips, or writer's cramp. Like all involuntary movements, they are worsened by excitement and emotional upset. Some are observed only with a particular volitional and usually automatic movement, such as...

States Of Persistent Fasciculation Continuous Muscle Activity Myokymia Neuromyotonia And The Stiffman Syndrome

A few fascicular twitches occurring in muscles that are otherwise normal are very common and nearly always benign. These are frequent in the orbicularis oculi, abductor pollicis brevis, quadriceps and ster-nomastoid and are mistaken by anxious patients (particularly physicians) for serious disease. Fasciculations that persist for hours or days in one muscle (live flesh) represent a benign state that usually appears and disappears without explanation. Only if weakness and atrophy of muscle are...

Dysarthria and Anarthria

With pure disorders of articulation (dysarthria or anarthria), language functions are intact. The only exception occurs with a restricted left frontal lesion and little Broca aphasia (see above) with recovery from mutism, elements of both aphasia and dysarthria can be recognized. This aphasic dysarthria is distinguished from nonaphasic (upper motor neuron) dysarthria by its variability and normalization in the pro nunciation of automatic words and phrases. Defects in articulation are of several...

Striatonigral Disorders

As indicated in Figs. 4-1 and 4-2, the prefrontal, premotor, and supplementary motor cortices send fibers to the caudate nucleus and putamen (together referred to as the striatum), as do other parts of the cerebral cortex. It is estimated that in each cerebral hemisphere there are 110 million corticostriatal neurons (compared to 1 million corticospinal neurons). The striatal neurons are of many types and sizes and project to the lateral and medial parts of the pallidum the lateral, or external,...

Distal And Proximal Of Nerve Fiber

Well Diagram Wallerian Degeneration

With these anatomic facts in mind, one can conceptualize the various targets of diseases affecting the PNS. Each type of nerve cell has its special susceptibilities, as do the myelin sheaths, axoplasm, Schwann cells, blood vessels, connective tissue, and spinal-cranial lepto-meninges and CSF. The following are examples of disease in which each of these elements is affected predominantly Poliomyelitis Herpes zoster Shy-Drager syndrome Autonomic polyneuropathy syndrome diphtheria Heavy metals...

Other Varieties of Headache

Postlumbar puncture headache Characteristic of this type is the occurrence of headache and pain in the neck and upper back within a few minutes after sitting up or standing and relief on lying down. A rent in the spinal arachnoid dura permits CSF to seep into the epidural tissues for hours or days after the lumbar puncture. The low CSF pressure, which is further reduced in the upright position, leads to caudal displacement of the brain and traction on dural attachments and sinuses. Once the...

Clinical Varieties Of Aphasia

Despite the complexity of language mechanisms and the bewildering nomenclature that surrounds this subject, most instances of aphasia will be found to constitute a relatively small number of recurring, identifiable types, tabulated below. Moreover, more than 80 percent of all aphasias fall into the first (major) group. An overlapping of syndromes is frequent, and their localization, which has preoccupied neurologists for more than a century, is not altogether precise. B. Minor, or restricted...

Additional Reading

Devinsky O, Feldmann E Examination of the Cranial and Peripheral Nerves. New York, Churchill Livingstone, 1988. Jannetta PJ Posterior fossa neurovascular compression syndrome other than neuralgias, in Wilkins RH, Rengachary SS (eds) Neurosurgery. New York, McGraw-Hill, 1985, pp 1901-1906. Jannetta PJ Structural mechanisms of trigeminal neuralgia Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neu-rosurg 26 159, 1967. Karnes WE Diseases of the...

Subacute Combined Degeneration SCD and Pernicious Anemia see also p 410

Long-standing deficiency of cobalamin (vitamin B12) has two major effects (1) a macrocytic megaloblastic (pernicious) anemia and (2) a degeneration of the posterior and lateral columns of the spinal cord (and sometimes of brain and peripheral nerves), which may occur independently and precede the hematologic effects. The neurologic disease has been traced to a failure of a cobalamin-dependent enzyme methyl-malonyl-CoA mutase, which is essential for the maintenance of myeli-nated fibers....

Main features

Ptosis upper eyelid (paresis of Muller's muscle), miosis, apparent enophthalmos (narrowed palpebral fissure) ipsilateral anhidrosis and warmth of face Blurred vision, enlarged pupil, anisocoria, more common in women, knee and ankle jerks often absent pupil dilates only slowly to strong maximal stimulation, dilatation sustained, sensitive (constricts) to 0.1 pilocarpine Pupils small, irregular, unequal do not react to light, but near response is intact no response to mydriatics iris atrophy...

Degenerative Diseases of the Retina

Macular degeneration of late life and retinitis pigmentosa (RP) are the most common members of this group. RP is a hereditary disease in which the outer receptor layer of the retina degenerates, allowing melanin of the pigment epithelium to collect in the thinned retina. The melanin deposits resemble bone corpuscles. The disease begins in adolescence and progresses slowly over years. The peripheral parts of the retina are first and more severely affected, constricting the visual fields and...

Clinical Aspects Of Pain

Activation of the nerve endings in various tissues and organs induces different types of pain, distinguishable by their quality, location, temporal attributes, and aggravating and alleviating factors. Skin pain is of two types (1) pricking pain, transmitted by A-8 fibers, and (2) stinging or burning pain, transmitted by the slower conducting C fibers. Deep pain from visceral and skeletomuscular structures is aching in quality, occasionally knife-like or burning (as in heartburn), and poorly...

Tropical Spastic Paraparesis TSP

This spinal cord disorder, which is endemic in many tropical and subtropical countries, also occurs sporadically in the Western world. Originally thought to be infectious or nutritional, it is now known to be due to the human T-cell lymphotropic virus type 1 (HTLV-1). The clinical picture is one of a slowly progressive spastic parapare-sis, with increased reflexes, Babinski signs, and a disorder of sphinc-teric control. Paresthesias, reduced vibratory and position sense, and sensory ataxia are...

Sleep Disorders Insomnia

Strictly defined, insomnia is a chronic (more than 3 weeks) inability to sleep at times when sleep normally occurs, but the term is commonly used to designate any short- or long-term disturbance in the depth, duration, or restorative powers of sleep. There may be delay in falling asleep, easy awakening during the night, or early-morning awakening. Apart from pseudoinsomnia, in which an individual expresses dissatisfaction with his sleep despite its normal depth and duration, there are two major...

Nuclear And Infranuclear Disorders

Uncrossed Diplopia

Oculomotor (third nerve) palsy Paralysis or weakness of superior, medial, and inferior rectus muscles, levator palpebrae, and usually of pupillary light and near reactions. With complete lesions, there is pto-sis of eyelid, deviation of the eye outward and slightly downward (due to unopposed actions of abducens and superior oblique), and dilatation of the pupil. With incomplete lesions, strabismus is less and pattern of diplopia on ocular movement conforms to that in Fig. 14-2. Compres-sive...

Treatment of Alcohol Withdrawal Symptoms

Minor withdrawal symptoms The main considerations are replacement of fluids and electrolytes and the judicious administration of sedative drugs. In depleted alcoholics, the use of parenteral glucose solutions carries a special danger, namely the precipitation of Wer-nicke disease, and should always be supplemented by B vitamins. A variety of sedative drugs are equally useful in allaying tremor, nervousness, and insomnia. In general, phenothiazine drugs should be avoided because they reduce the...

Examination of the Back

Much information can be obtained from simple inspection of the back, buttocks, and lower extremities as the patient assumes various positions. When the patient is standing, the presence of an excessive curvature of the normal dorsal kyphosis or lumbar lordosis , a gibbus from vertebral fracture , a step deformity from lumbar spondylolisthesis , a pelvic tilt from a lateral prolapsed disc , and a sagging gluteal fold from an S1 root lesion are all helpful diagnostic signs. The patient is then...

Clonus Myoclonus And Polymyoclonus

Clonus, myoclonus, and polymyoclonus are symptomatic of a large number of diverse neurologic disorders. Precise usage of these terms is essential if they are to be neurologicaUy meaningful. The following definitions are in common use. Clonus refers to a series of rhythmic, uniphasic undirectional contractions and relaxations of a group of muscles. These movements involve only an agonist group of muscles and thus differ from tremors, which are diphasic bidirectional and involve both agonist...

Placidity And Apathy

A quantitative reduction in all psychomotor activity is the most common behavioral alteration in patients with cerebral disease. There are fewer thoughts, fewer words, and fewer movements per unit of time psychomotor asthenia . That this is not a pure motor deficit is disclosed in conversation with the patient, who shows a lack of ongoing psychic activity, a slowness in thinking, and a diminished perceptivity, inquisitiveness, and interest in his surroundings. Depending on how one views this...

Neurosyphilis

Treponema pallidum is the recognized cause of a wide range of neurologic syndromes, which include acute syphilitic meningitis, meningo-vascular syphilis, syphilitic meningoencephalitis general paresis or paretic neurosyphilis , syphilitic lumbosacral radiculitis tabes dor-salis , meningomyelitis, and optic neuritis. The incidence of these late forms of syphilis has decreased dramatically during the past 3 to 4 decades. However, there has been an increase in reported cases of early syphilis in...