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ular level is conjoined (loss of pain and temperature sense due to spinothalamic tract damage, and loss of vibratory and position sense due to posterior column involvement) Also, in bilateral disease of the spinal cord, the bladder and bowel and their sphincters are usually affected These abnormalities may be due to an intrinsic lesion of the cord or to an extrinsic mass that narrows the spinal canal, both types of lesion being evident on MRI In peripheral nerve diseases, motor loss tends to involve the distal muscles of the legs more than the proximal ones (exceptions are certain varieties of the Guillain-Barre syndrome and certain types of diabetic neuropathy and porphyria); sphincteric function is usually spared or impaired only transiently Sensory loss, if present, is also more prominent in the distal segments of the limbs, and the degree of loss is often more for one modality than another For clinical purposes it is helpful to separate the acute paraplegias from the chronic ones and to divide the latter into two groups: those beginning in adult life and those occurring in infancy The most common cause of acute paraplegia (or quadriplegia if the cervical cord is involved) is spinal cord trauma, usually associated with fracture-dislocation of the spine Less common causes are hematomyelia due to a vascular malformation, an arteriovenous malformation of the cord that causes ischemia by an obscure mechanism, or infarction of the cord due to occlusion of the anterior spinal artery or, more often, to occlusion of segmental branches of the aorta (due to dissecting aneurysm or atheroma, vasculitis, and nucleus pulposus embolism) Paraplegia or quadriplegia due to postinfectious myelitis, demyelinative or necrotizing myelopathy, or epidural abscess or tumor with spinal cord compression tends to develop somewhat more slowly, over a period of hours, days, or longer Epidural or subdural hemorrhage from bleeding diseases or warfarin therapy causes an acute or subacute paraplegia; in a few instances the bleeding has followed a lumbar puncture Paralytic poliomyelitis and acute Guillain-Barre syndrome the former a purely motor disorder with mild meningitis (now rare), the latter predominantly motor but often with sensory disturbances must be distinguished from the acute and subacute myelopathies and from each other In adult life, multiple sclerosis and tumor account for most cases of subacute and chronic spinal paraplegia, but a wide variety of extrinsic and intrinsic processes may produce the same effect: protruded cervical disc and cervical spondylosis (often with a congenitally narrow canal), epidural abscess and other infections (tuberculous, fungal, and other granulomatous diseases), syphilitic meningomyelitis, motor system disease, subacute combined degeneration (vitamin B12 de ciency), syringomyelia, and degenerative disease of the lateral and posterior columns of unknown cause (See Chap 44 for discussion of these spinal cord diseases) In pediatric practice, delay in starting to walk and dif culty in walking are common problems These conditions may indicate a systemic disease (such as rickets), mental de ciency, or, more commonly, some muscular or neurologic process Congenital cerebral disease due to periventricular leukomalacia accounts for a majority of cases of infantile diplegia (weakness predominantly of the legs, with minimal affection of the arms) Present at birth, it becomes manifest in the rst months of life and may appear to progress, but actually the disease is stationary and the progression is only apparent, being exposed as the motor system develops; later there may seem to be slow improvement as a result of the normal maturation processes of childhood These disorders fall under the heading of cerebral palsy, as discussed in Chap 38 Congenital.

The incision is created horizontally through conjunctiva and lid retractors overlying the area of fat herniation, usually halfway between the inferior fornix and inferior tarsal border Since the lower lid retractors may fuse with the orbital septum as low as 2 to 3 mm below the inferior tarsal border, the orbital fat does not extend superiorly beyond this point and the incision should be made below this level A battery-operated disposable hot cautery, Colorado needle, RF device, or CO2 laser may be used to achieve hemostatic cutting Once the conjunctiva and

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Loss of function of the anterior pituitary gland may result from disease of the pituitary itself or from hypothalamic disease In either event, it leads to a number of clinical abnormalities, each predicated on the de ciency of one or more hormones that depend on the pituitary trophic factors described earlier The condition of panhypopituitarism represents the more serious illness in that it requires supplementation with multiple hormones Hypopituitarism may have its onset in childhood, either as an inherited process that affects individual or multiple hormones or as a secondary process due to a destructive lesion of the pituitary or the hypothalamus from tumor, eg, craniopharyngioma Later in life the causes vary, but the most common are pituitary surgery, infarct of the gland from a rapidly growing adenoma (pituitary apoplexy, page 577), involutional changes that occur at the end of pregnancy (Sheehan syndrome), cranial irradiation for cerebral tumors other than those in the pituitary fossa, lymphocytic hypophysitis, and granulomatous and neoplastic invasion The clinical features of pituitary failure vary, but impairments of thyroid function tend to be more prominent than those of adrenal failure The neurologic accompaniments of pituitary failure depend on the underlying cause; Lamberts and colleagues have reviewed the endocrinologic aspects

Suppose the vector = ( 0 , 1 , , M 1 ) is periodic with period k and with no offset (that is, the nonzero terms are 0 , k , 2k , ) Thus,

Apart from diabetes insipidus and SIADH, there are a variety of other special clinical phenomena resulting from disease of the hypothalamus These usually occur not in isolation but in various combinations, comprising a number of rare but well-characterized syndromes Precocious Puberty This term refers to the abnormally early onset of androgen secretion and spermatogenesis in boys and of estrogen secretion and cyclic ovarian secretion in girls It is associated with the premature development of secondary sexual characteristics The occurrence of precocious puberty always calls for a neurologic as well as an endocrine investigation In the male, one searches for evidence of a teratoma of the pineal gland or mediastinum or an androgenic tumor of the testes or adrenals In the female with early development of secondary sexual characteristics and menstruation, one seeks other evidence of hypothalamic disease as well as an estrogen-secreting ovarian tumor

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