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afferents Corticosteroid therapy enhances this fast tremor A particularly severe form of slower tremor is combined with clumsiness of movement in certain neuropathies that affect large afferent bers, speci cally in the autoimmune, antimyelin-associated glycoprotein (MAG) polyneuropathy and in some cases of chronic in ammatory demyelinating polyneuropathy (CIDP) During action, the tremor may at times be so coarse as to resemble the intention tremor of cerebellar disease Deformity and Trophic Changes In a number of chronic polyneuropathies, the feet, hands, and spine become deformed This is most apt to occur when the disease begins during childhood Austin pointed out that foot deformity is found in 30 percent of patients with hereditary polyneuropathy, and spine curvature in 20 percent In early life, the feet are pulled into a position of talipes equinus (plantar deviation) because of the disproportionate weakness of the pretibial and peroneal muscles and the unopposed action of the calf muscles Atrophic paralysis of the intrinsic foot muscles while the bones are forming allows the long extensors of the toes to dorsi ex the proximal phalanges and the long exors to shorten the foot, heighten the arch, and ex the distal phalanges The result is the claw foot le pied en griffe or pes cavus (high arches) when the process is less severe These changes in the foot are valuable diagnostic indicators that a neuromuscular disease originated in early childhood or during intrauterine development A congenital claw hand has a similar basis In early childhood, unequal weakening of the paravertebral muscles on the two sides of the spine leads to kyphoscoliosis Denervation atrophy of muscle can be considered the main trophic disturbance resulting from interruption of the motor nerves However, there are numerous other changes In particular, analgesia of distal parts makes them susceptible to burns, pressure sores, and other forms of injury that are easily infected and heal poorly In an anesthetic and immobile limb, the skin becomes tight and shiny, the nails curved and ridged, and the subcutaneous tissue thickened ( trophic changes ) Hair growth is diminished in denervated areas If the autonomic bers are interrupted, the limb is warm and pink Repeated injuries and chronic subcutaneous and osteomyelitic infections may result in a painless loss of digits and the formation of plantar ulcers (mal perforant du pied) These are prominent features of the recessive form of hereditary sensory neuropathy, and we have observed them in dominant forms as well In tabes dorsalis and syringomyelia as well as certain familial and other chronic polyneuropathies, analgesic joints, when chronically traumatized, may rst become deformed and then actually disintegrate in a process called Charcot arthropathy (Charcot joint) The pathogenesis of the trophic changes is not fully understood Apart from analgesia, a critical factor may be inappropriate neural regulation of the distal vasculature, which interferes with normal tissue responses to trauma and infection Ali and colleagues relate the ulcer formation to loss of C bers, which mediate both pain and autonomic re exes However, paralyzed limbs, even in hysteria, if left dependent, are often cold, swollen, and pale or blue These are probably secondary effects of immobilization, as pointed out long ago by Lewis and Pickering Erythema and edema, burning pain, and cold sensations surely can be evoked by peripheral nerve irritation, particularly of C and A- bers as discussed in Chap 8 Autonomic Dysfunction Anhidrosis and orthostatic hypotension, two of the most frequent manifestations of autonomic dys-.

These may be divided into four categories: 1 A loss or impairment of the production and/or comprehension of spoken or written language due to an acquired lesion of the brain This condition is called aphasia or dysphasia 2 Disturbances of speech and language with diseases that globally affect higher-order mental function, ie, in confusion, delirium, mental retardation, and dementia Speech and language functions are seldom lost in these conditions but are deranged as part of a general impairment of perceptual and intellectual functions In Alzheimer disease, for example, a gradual impairment of all elements of language without the emergence of any of the classic aphasic syndromes constitutes an important part of the clinical picture (Chap 21) Common to this category are certain special disorders of speech, such as extreme perseveration (palilalia) and echolalia, in which the patient repeats, parrot-like, words and phrases that he hears (see further on) The odd constructs of language and other disorders of verbal communication of schizophrenics and some autistic individuals extending to the production of meaningless phrases, neologisms, or jargon probably belong in this category as well 3 A defect in articulation with intact mental functions and comprehension of spoken and written language and normal syntax (grammatical construction of sentences) This is a

Hemi- or Temporal, quadrantanopia, no infrasylvian paresis including angular and supramarginal gyri Conduction Fluent Relatively preserved None Usually none Supramarginal gyrus or insula Global Scant, non uent Very impaired None Hemiplegia usual Large perisylvian or separate frontal and temporal Transcortical motor Non uent Good Largely preserved Variable Anterior or superior to Broca s area Transcortical sensory Fluent Impaired as Wernicke Largely preserved Variable Surrounding Wernicke s area Pure word-deafness Mildly paraphasic or Impaired Impaired None or Bilateral (or left) normal quadrantanopia middle of superior temporal gyrus Pure word-blindness Normal but unable to Normal Normal Right hemianopia; Calcarine and white (and alexia without read aloud unable to read own matter or callosum agraphia) writing (or angular gyrus) Pure word mutism Mute, but able to Normal None None Region of Broca s (aphemia) write area Anomic aphasia Isolated word nding Normal various sites Normal Variable Deep temporal lobe dif culty

The resulting chart is more of a flexible line chart type Since both axes are values, it s important to be aware of the appropriate scaling factor for the particular values The final result is shown in the next illustration

SOURCE:

Non uent, effortful, agrammatical, paucity of output but transmits ideas Fluent, voluble, well articulated but lacking meaning

Lesion in dominant (left) hemisphere unless noted Adapted by permission from Damasio AR: Aphasia N Engl J Med 326:531, 1992

indicators for the overall economy worldwide The impact of changes in the economy show up well in an average of the 500 top companies Narrow-based indices A narrow-based index covers a small sector or speci c industry such as the Nasdaq Biotech Index which covers biotechnology and pharmaceutical companies Narrow-based indices are useful to investors with interests in speci c industries The indices help them gauge the temperature of the industry rather than the overall economy Many industries do well even in tough economic conditions The chart from McDonald s earlier in the book ( 7, Figure 722) demonstrates that well Narrow indices help investors seeking opportunities to move funds from one sector to another or control risk on certain portions of their assets The components and weighting structure of the indices are published regularly and are readily available on the Internet The major broad-based indices are reported on regularly in television and radio reports as is the overall action of the market, but the reports can be deceiving It is interesting reading to take a look at an index like the S&P 500 and how the components measure up to one another It is not uncommon for the top 10 components of the S&P 500 to represent a signi cant portion of the total index The same is true in other indices where the top few companies represent a sizable percentage As an index investor, it is important for you to know the structure of the index and which companies will cause dramatic changes in the index and which will have minimal effect In managing your portfolio, you should keep track of the weight ratio of these components because, as you invest in either broador narrow-based indices, each component could enhance the effect