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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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Figure 26-2 The parasympathetic (craniosacral) division of the autonomic nervous system Preganglionic bers extend from nuclei of the brainstem and sacral segments of the spinal cord to peripheral ganglia Short postganglionic bers extend from the ganglia to the effector organs The lateral-posterior hypothalamus is part of the supranuclear mechanism for the regulation of parasympathetic activities The frontal and limbic parts of the supranuclear regulatory apparatus are not indicated in the diagram (see text) (Reproduced by permission from Noback CL, Demarest R: The Human Nervous System, 3rd ed New York, McGraw-Hill, 1981)

Hair follicle muscle (pilomotor)

Sweat glands (sudomotor)

S1 Vasomotor fibers to lower extremity CX Preganglionic neuron Postganglionic neuron Sympathetic trunk