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However, it is only relatively recently that a chronic infective-in ammatory disease of the spinal cord due to the retrovirus HTLV-I has been discovered and the connection made to tropical myelitis The implications of this discovery are broad and extend even to the demyelinative and possibly the degenerative diseases Spinal cord disease of this type has been reported from the Caribbean islands, southern United States, southern Japan, South America, and Africa The clinical picture is one of a slowly progressive paraparesis with increased tendon re exes and Babinski signs; disorder of sphincteric control is usually an early change Paresthesias, reduced vibratory and position senses, and ataxia are the usual features A few patients have had an associated polyneuropathy, as in Cruickshank s early cases The upper extremities are usually spared (except for lively tendon re exes), as are cerebral and brainstem functions..

This problem arises frequently in connection with both hysteria and sociopathy and the physician should know how to deal with it It is not a medical diagnosis except under the rare circumstances in which a patient is caught in the act of producing a sign of disease or confesses to having done so The term malingering refers to the conscious and deliberate feigning of illness or disability in order to attain a desired goal It does not appear as an isolated phenomenon, and its occurrence must be interpreted as a sign of a serious personality disturbance, often one that prevents effective work or military service, as a means of obtaining recompense for an alleged injury, although noteworthy exceptions to this statement can be found.

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In cases of suspected disc herniation or tumor in ltration of the spinal canal, one generally proceeds directly to MRI Although these imaging procedures have largely replaced conventional myelography, the latter examination, when combined with computed tomography (CT), provides detailed information about the dural sleeves that surround the spinal roots, at times disclosing subtle truncations caused by laterally situated disc herniations and at times revealing surface abnormalities of the spinal cord, such as arteriovenous malformations Administration of gadolinium at the time of MRI enhances regions of in ammation and tumor Injection of contrast medium directly into the intervertebral disc (discogram) is practiced in very few institutions and is more dif cult to interpret than CT myelography and MRI; it carries the risk of damage to nerve roots or the introduction of infection.

Discography is indicated only in special circumstances and should be undertaken only by those who are specialized in its performance Isotope bone scans may disclose tumors and in ammatory processes such as osteomyeltitis, but these are also evident on CT and MRI Nerve conduction studies and electromyography (EMG) are particularly helpful in suspected root and nerve diseases, as indicated further on, in the discussion of protruded lumbar discs However, as for all the aforementioned tests, they must be interpreted in the context of the history and clinical examination; otherwise they are subject to overuse and overinterpretation..

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In the malingerer one may observe pain, hyperesthesia, anesthesia, limping gait, tremor, contracture, paralysis, amaurosis, deafness, stuttering, mutism, amnesia, pseudoconvulsions and fugues, unexplained gastrointestinal bleeding, and unexplained skin lesions in short, the same array of symptoms and signs, singly or in combination, as in the patients with compensation hysteria Certainly there is a similarity between hysteria and malingering, but the nature of the relationship is nebulous, and there may be great dif culty in establishing a clinical differentiation As Jones and Llewellyn have observed: Nothing resembles malingering more than hysteria; nothing, hysteria more than malingering In both alike we are confronted with the same discrepancy between fact and statement, objective sign and subjective symptom the outward aspect of health seemingly giving the lie to all the alleged functional disabilities.

Once the operation is complete, take a backup copy of the 4 original database and move the newly compacted database to the original database location.

One or several intracerebral hemorrhages may be apparent immediately after head injury, or hemorrhage may be infrequently delayed in its development by several days (Spatapoplexie). The bleeding is in the subcortical white matter of one lobe of the brain

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