INFLUENCE OF RESTRAINT ON AUTOMATIC MOVEMENTS

527 sound arm does not bring back these movements in the unsound arm. Reflexes may be linked so that inhibition of one calls forth the other reflex. For instance, swallowing and breathing are associated reflexes in that one of them must’ be inhibited to allow the other to act. Now, the inhibition of breathing-e.g., in a high wind-calls forth reflex swallowing. One would therefore expect that, in walking, restraint of one of the two limbs functionally associated as already described would stimulate reflexly the action of the other pair of limbs. This has been shown to be true of the arms and is probably true of the legs also, but this is difficult to prove.

INFLUENCE OF RESTRAINT ON AUTOMATIC MOVEMENTS VALUE IN DIAGNOSIS

KOSTA KURTES

VLADIMIR VUJIC M.D.

M D.

Prague

PROFESSOR OF NEUROLOGY AND PSYCHIATRY

Belgrade

CLINICAL ASSISTANT, NEUROPSYCHIATRIC CLINIC

UNIVERSITY OF BELGRADE

THERE is a functional unity in the movements of all four limbs in quadrupeds and man. The fore limb (arm in man) of one side and the hind limb (leg in man) of the other side normally move simultaneously in the same This has been direction during bodily progression.** demonstrated also in’ reflexes obtained in decerebrate animals (Sherrington 1898). Arm-swinging is therefore an automatic accompaniment of walking ; and Wilson (1928) observed in a ,case of largely right-sided parkinsonism that the left arm was always advanced to a distinctly greater extent than usual, and this corresponded strictly to a slower advancement of the weak

right leg." Automatic arm-swinging in walking is often diminished abolished in extrapyramidal lesions-e.g., parkinsonism, -of which it is one of the earliest signs-but this also happens in severe spastic hemiparesis and in slight pyramidal lesions. According to Monrad-Krohn (1938) this movement is’ often absent in pyramidal and or

extrapyramidal lesions.

We have observed that

carrying something heavy

more than when both

arm

in

healthy people walking while in one hand swing the free arms

are

free ; and that

increases the In making this test it that the restrained arm makes no

healthy person restraint of amplitude of swing of the other. a

one arm

is essential to ensure movement whatever. These observations led us to test in various pathological conditions, and we have found that, when a patient with predominantly unilateral parkinsonism walks carrying a book in his sound hand, or with that hand in his pocket or resting on his back, the automatic swinging of the unsound arm returns or is increased. When the sound arm is released, the swinging of the unsound arm is -decreased or disappears. We have found the same thing in encephalitic pseudoneurasthenia, ’

arm-swinging

Sydenham’s

chorea, and hemichorea. (In some cases of encephalitis, and even in some cases of overt encephalitis if the patient can walk, some days may elapse before this phenomenon can be observed.) But in parkinsonism in which the unsound arm shows much hypertonus, in cerebral hemiparesis with spasticity, in unilateral pyramidal lesions without hypertonus, and in flaccid central paralysis of the arm, restraint of the masked

’Exceptionally,

in

simultaneously,

animals, both limbs of as in ambling.

one

side

are

advanced

MOLLISON, MR. CUTBUSH : REFERENCES DeMarsh, Q. B., Windle, W. F., Alt, H. L. (1942) Amer. J. Dis. Child. 63, 1123. Diamond, L. K. (1945) New Engl. J. Med. 232, 447 and 475. — (1947) Proc. R. Soc. Med. 40, 546. Howarth, S., Sharpey-Schafer, E. P. (1947) Lancet, i, 18. Javert, C. T. (1942) Amer. J. Obstet. Gynec. 43, 921. Levine, P., Waller, R. K. (1946) Blood, 1, 143. Mollison, P. L. (1943) Arch. Dis. Childh. 18, 161. Mourant, A. E., Race, R. R. (1948) Med. Res. Coun. Memo. DR.

—

no. 19. London. Parsons, L. G. (1947) Lancet, i, 534. Pickles, M. M. (1947) D.M. Thesis, Oxford University. Ross, J. F., Finch, C. A., Peacock, W. C., Sammons, M. E. (1947) J. clin. Invest. 26, 687. Sadowski, A., Bromberg, Y. M., Brzezinski, A. (1947) Nature, Lond. 160, 192. Vaughan, V. C. (1946) J. Pediat. 29, 462. Wallerstein. H. (1946) Science, 103, 583. Wiener. A. S., Wexler. I. B. (1946) J. Pediat. 31, 1016. Shulman, A. (1948) Amer. J. clin. Path. 18, 141. — —

Lescenko’s Phenomenon Other associated reflexes provide similar examples. Reflex blinking of one eye in normal people is strongly linked, and takes place simultaneously, with blinking of the other eye. But Lescenko has shown that if, in some cases of parkinsonism, while the patient fixes his gaze on an object, the demonstrator lowers one of the patient’s upper eyelids and lifts that eyelid again, the uncontrolled upper eyelid of the other eye is automatically lowered ; and, when the controlled eyelid is lowered again by the demonstrator, the uncontrolled eyelid is automatically raised. It seems that, the normal lowering and raising of eyelids (blinking) being extremely rapid, the slower movement of the patient’s eyelids by the demonstrator constitutes a form of restraint. Now, we have shown that restraint on one side causes active movement on -the other. Further, the raising of the patient’s eyelid by the demonstrator restrains its lowering; therefore such restraint provokes lowering of the opposite (uncontrolled) eyelid. In harmony with this finding is the fact that, in normal people, if the demonstrator prevents the subject from closing his eyes, attempts to blink are produced which are more frequent than normal. Abduction of Legs Raimiste (1909) has described how, in cerebral hemiplegia, restraint of active abduction of the sound leg elicits abduction of the unsound leg. According to Walshe (1921) " diverse forms of voluntary movements against resistance may, in certain cases of hemiplegia, always elicit the same response, whereas in other cases the form of the associated reactions could be completely modified according to the form of the voluntary movement of the sound arm." In these latter movements, to which Raimiste’s phenomenon belongs, two facts are important according to Walshe : " (1) in most cases of residual hemiparesis there is considerable voluntary power in the affected leg ; and (2) it is impossible in these circumstances, and even in the normal subject, to adduct or abduct the extended limb without also bringing into action with equal force the corresponding muscles of the crossed leg." We do not agree with Walshe’s first remark, because we have seen Raimiste’s phenomenon even when the leg His second remark, has been completely paralysed. however, is evidence that there is a certain functional connexion between the legs in symmetrical abduction and adduction, probably stronger than in other symmetrical movements of the legs. ,

Movements On the other hand,

Pathological

involuntary pathological

move-

ments-e.g., parkinsonian tremors-can be checked, in some cases by voluntary or other synergic movements. Even tonic muscular spasm which cannot be inhibited voluntarily may sometimes be overcome by synergic movements-e.g., voluntary blinking inhibits oculogyric lateral rotation (Golmann, quoted by Astwazaturow 1929). The automatic upward rotation of the eyeball on blinking inhibits lateral rotation.

528 DISCUSSION we consider the effect of restraint of the sound limb automatic movement of the unsound limb, as already described, Raimiste’s phenomenon, Walshe’s second remark, and the fact that restraint of automatic armswinging on the sound side does not influence that on the unsound side in pyramidal lesions, we can conclude that restraint of either voluntary or automatic movements on the sound side elicits similar movements on the unsound side if those movements have been reduced or lost owing to a lesion of the motor tract (pyramidal or extrapyramidal) controlling those movements and when those movements are functionally connected. Consequently the effect of such restraint is of diagnostic value where it is uncertain’whether diminution or loss of movement is due to a pyramidal or to an extrapyramidal lesion. In pyramidal lesions, whether paresis of the arm is spastic or flaccid, restraint of the sound arm does not bring back the absent arm-swinging. Walshe (1921) found no sign of an associated reaction in arm or leg in flaccid paralysis, and concluded : "Some degree of hypertonus in a case of hemiplegia is an essential preliminary to the development of an associated reaction... the higher the degree of spasticity, the more forceful and the longer lasting will the associated reaction be." In contrast to this, the absence of pronounced hypertonus in extrapyramidal lesions is a necessary condition to enable restraint of the limb on the sound side to bring back movements in the limb on the unsound side. Most workers consider that the disappearance of armswinging represents a primary disturbance. There is no doubt that hypertonus also impedes these movements. Froment and Gardere (1921) consider that even in cases without evident hypertonus there is’latent rigidity. Noica (1936) holds the same opinion and says that, where arm-swinging has been lost and yet hypertonus is not evident, hypertonus will develop later, at first only in walking and only in the proximal parts. The fact that arm-swinging can disappear in unilateral pyramidal lesions with minimal paresis and no evident hypertonus might be regarded as supporting Wilson’s (1928) opinion that arm-swinging is not purely automatic. But against this assumption is the observation that, in unilateral parkinsonism, deliberate swinging of the unsound arm inhibits arm-swinging by the sound This harmonises with the fact that, in normal arm. people, automatic movements are inhibited by attempts at voluntary control, and with our observation that, in unilateral parkinsonism, deliberately increased armswinging on the sound side does not affect arm-swinging on the unsound side. These investigations cannot be regarded as complete. It would be especially interesting to study cases of postconcussional Mann’s syndrome. In unilateral cerebellar lesions Wartenberg (1930), Marburg (1936), and Holmes (1946) find that arm-swinging disappears, whereas Grinker and Levy (1943) seem to think that it increases because of hypotonus. In a patient with a bilateral cerebellar lesion, more pronounced on the left side, we found that arm-swinging was diminished on the left side and that when the right arm was restrained arm-swinging increased in the left arm.

If

on

SUMMARY

Restraint of automatic arm-swinging on one side in normal people reinforces arm-swinging on the opposite side. Restraint of arm-swinging on the sound side in unilateral extrapyramidal lesions-e.g., incipient parkinsonism, chorea minor, and encephalitic pseudoneurasthenia-brings back the arm-swinging on the affected side if there is not much hypertonus. *

In unilateral pyramidal lesions such restraint has no such effect, regardless of the state of muscular tone. This test is of diagnostic value where it is doubtful whether loss of arm-swinging on one side is due to a pyramidal or to an extrapyramidal lesion. REFERENCES

Astwazaturow, M. (1929) Dtsch. Z. Nervenheilk. 109, 252. Froment, J., Gardère, C. (1921) Rev. neurol. 37, 1077. Grinker, R. R., Levy, N. A. (1943) Neurology. Springfield, Ill. Holmes, G. (1946) Introduction to Clinical Neurology. Edinburgh. Marburg, O. (1936) in Bumke, O., Foerster, O. Handbuch der Neurologie. Berlin ; vol. v. Monrad-Krohn, G. H. (1938) Clinical Examination of the Nervous System. New York. Noica, D. (1936) Rev. neurol. 65, 812. Raimiste, J. (1909) Ibid, 17, 1366. Sherrington, C. (1898) in Selected Writings of Sir Charles

Sherrington.

Walshe,

London, 1939.

F. M. R. (1921) Brain, 46, 1. Wartenberg, R. (1930) Neurol. Zbl. 57, 566. Wilson, S. A. K. (1928) Modern Problems in Neurology. New York.

PRIMARY CARCINOMA OF THE LIVER IN A BOY AGED 15

A. E. BEYNON M.R.C.S. MEDICAL DIRECTOR AND

PHYSICIAN, CHEST RADIOGRAPHY CENTRE, NOTTINGHAM

ratio between primary and secondary carcinoma liver has been estimated as between 1 : 20 and In 18,500 necropsies at Guy’s Hospital (Hale 1908) 24 cases (0-13%) of primary carcinoma liver were found, and the incidence in - 6000 necropsies at the General Infirmary, Leeds (Stewart 1922) was the- same. Data from several American and European hospitals revealed 144 cases (0-21%) in 65,501 necropsies, and reports collected from Asia and Africa give 416 cases (1-05%) in 39,701, and from a Singapore hospital 134 cases (0-76%) in 17,664 necropsies. Berman (1940) estimates that primary carcinoma of the liver is over forty times more frequent in some of the pigmented races than in the European. The disease occurs mostly in or after middle age, and is said to be rare before 40 years of age. The earliest recorded case was in a baby girl aged 5 weeks (Langmead 1912). Berman (1940), in a series of cases in Bantu natives, found that 82-6% of the patients were 40 years of age or less, while the highest incidence was in the age-group 21-30. Steiner (1938), in a critical review of the literature, found 77 proved cases in children up to--16 years of age, 53% of them in children under the age of 2 years. This disease is seen more often in men than in women; and of affected children Steiner (1938) observed that

THE of the 1 : 40. White of the

’

68% were boys. Symptoms.—There are no characteristic symptoms. Dull pain is a frequent feature and is referred to the liver region. Usually there are gastric upsets-i.e., anorexia, nausea, vomiting, diarrhoea, or constipation. Jaundice and ascites are uncommon. The average duration of life after the onset of symptoms is four months. No recovery has yet been reported. The incidence of symptoms in Berman’s (1940) 42 cases was abdominal pain in 90%, asthenia in 86%, and dyspnoea, especially on exertion, in 26% ; but this was a late

symptom.

,

Physical Signs.—Most patients do not lose weight before admission to hospital but when bedridden lose weight rapidly. The liver is always enlarged and tender. Jaundice was noted in 43% and ascites in 55% of 34 cases (Berman 1940). Dilated superficial abdominal veins and oedema of the ankles and legs are found less commonly, and hæmatemesis rarely. Usually the temperature is either normal or subnormal, but

patients early stages high colour,

some

febrile. The urine is unaffected in the but later is diminished in amount and of are