Приложение А.Список посещенных лекций .41

ЛИСТ ДЛЯ ЗАМЕЧАНИЙ

ОГЛАВЛЕНИЕ

1. Отчет……………………………………………………………………4

2. Текст оригинала……………………………………………………….5

3. Текст перевода………………………………………………………...22

Приложение А.Список посещенных лекций……………………………….41

Приложение В. Лекции……………………………………………………...42

1. ОТЧЕТ

Учебная переводческая практика проходила с 11 февраля по 8 марта, данная практика должна была способствовать совершенствованию знаний языка, переводческих умений, обогащению наших фоновых и теоретических знаний. Практика началась с инструктажа по технике безопасности. Инструктаж проводил кандидат филологических наук, доцент Поликарпова Елена Вакифовна. На протяжении всей практики мы посещали лекции в СГМУ, которые проходили на английском языке. Данные лекции способствовали расширению словарного запаса (как общеупотребительной лексики, так и специальной лексики, связанной с медициной). В течение практики я переводила отрывок из учебника под названием «Топическая диагностика заболеваний нервной системы», автором которого является А.П Скоромец. При переводе текста возникали определенные трудности с нахождением эквивалентов. Для этого я пользовалась прямыми соответствиями, указанными в словаре, либо находила соответствия в интернете.

2. ТЕКСТ ОРИГИНАЛА

3. ТЕКСТ ПЕРЕВОДА

This is the case of hyperesthesia, when there’s a pain sensitivity – of hyperalgesia. Sometimes even after transection of the peripheral nerve, on the corresponding skin area sensitivity to pain stimuli can be lost, however in the area of ​​anesthesia pain may be felt – so called anaesthesia dolorosa. Stimulation of the central nerve segment transfers excitation to certain parts of the brain, which is often taken as a pain in the corresponding skin area.

When there is the abruption (lesion) of sensitivity conductors, the symptoms of prolapse develop – the loss of sensitivity (of any kind superficial and deep), which is called anesthesia and its reduction – hypoesthesia. The loss of pain sensitivity is called analgesia, its lowering – hypalgesia.

In the clinic we often have to meet with a peculiar form of pain cacesthesia – hyperpathia. It’s characterized by the increase of sensitivity threshold. A patient doesn’t feel single injections, but a series of injections 5-6 or more) causes an intense and oppressive pain, which occurs after a certain period (suddenly). The patient can’t point out the place of injection. Single stimulation is felt as multiple, the area of these sensations expands. This perception remains even after stimuli are applied (aftereffect). Sometimes the injections are perceived as heat or cold (temperature dysesthesia). Hyperpathia occurs when there are lesions of various parts of the cutaneous analyzer from the peripheral segment to the thalamus and the cerebral cortex.

Two types of sensitivity were singled out: more primitive ‘’protopathic’’, which is caused by rough stimuli, and ‘’epicritic’’, providing the perception of more delicate and differentiated impacts [Head H., 1920]. The modern interpretation of these kinds of sensitivity is mentioned above.

The pain cacesthesia is often accompanied by violation of temperature sensitivity. Its complete prolapse is called thermoanaesthesia, its lowering – thermohypaesthesia.

Occasionally there may be a distortion of the perception of heat and cold – thermodysesthesia. Sometimes the perception of cold and heat can be disordered separately.

Anesthesia, hypoesthesia and hyperesthesia may occur in case with disorders and tactile sensitivity. Qualitative disruptions of superficial sensitivity are connected with distortion of the content of the information received and manifest themselves clinically: by the dichotomy of pain (during the interjection by the needlestick the surveyed at first feels the touch and only some time after feels the pain); by polyaesthesia (single stimulation is perceived as a multiple); by allocheiria (the patient points out at place of stimulation, where it’s not applied, but at the opposite side of body, at a symmetric area); by synesthesia (stimulation is perceived, not only in the area of its application, but in any other area); by dysesthesia (distorted perception of "receptor belonging" of stimulus, for instance, heat is perceived as cold or vice versa, interjection is perceived as a touch of hot).

Disorder of all kinds of deep sensitivity is called bathyanesthesia and is accompanied by sensory ataxia. There are also partial prolapses, for instance, in case with multiple sclerosis sometimes only pallesthesia is disordered. The loss of ability to recognize familiar objects by palpation is called astereognosis.

What symptoms of sensitivity should be used in the topical diagnostics? At first one should pay attention to the location of area of changed sensitivity. This applies not only to the phenomena of prolapse, but to irritation (pain, paresthesia). The area of anesthesia or other kind of cacesthesia may always be attributed to a certain level of disordered afferent route. This is what the topical diagnostics is based on according to the data of cacesthesia. It’s not always that all kinds of sensitivity are affected; some of them can be prolapsed, other can be preserved.

Disorder of some kinds of sensitivity, when other are preserved is termed dissociated disorders. Dissociative anesthesia points to the affected area of ​​the brain, where wires of different modalities pass separately. Especially it is typical for the destruction of the dorsal columns and the front commissure of the spinal cord and also for the centers in the brain stem.

An important criterion of the topic diagnostics is agreement or disagreement of localization between motor and cacesthesia. When there is a half and cross destruction of the spinal cord due to different levels of transition of nerve fibers from one side to the other, we have a peculiar pattern: motor prolapses are developing on one side, and sensitive – on the other - so-called Brown – Sequard syndrome (see Fig. 147).

It’s more appropriate to fix graphically the results of research of different kinds of sensitivity. For this one can use special forms – neural and segmental innervations schemes to which areas of cacesthesia are applied (Fig. 29).

Variants of distribution of cacesthesia. When the peripheral nerve is destructed, cacesthesia coincides with the area of its innervation. All kinds of sensitivity are affected. However, the border area of anesthesia is usually less than the anatomical innervations due to the blocking by the neighboring nerves.

Fig.29. The coincidence of the areas of different types of cacestthesia:

a – loss of pain sensitivity; b - loss of temperature sensitivity; c - loss of deep and tactile sensitivity;

1 - total anesthesia in the area of the right lateral cutaneous nerve of the thigh (neural type of anesthesia - loss of pain, temperature and tactile sensitivity);

2 - dissociative anesthesia in the left-side area of ​​ dermatome 1 (segmental type of anesthesia - loss of pain and temperature, keeping the tactile sensitivity)

The type of distribution of cacesthesia with the destructed nerve stems is called neural. These disorders are accompanied by by paralysis or paresis of the corresponding muscles.

The peculiar pattern of cacesthesia is observed in polyneuritis. Sensitivity is disordered in the terminal sections of the upper and lower limbs. Figuratively such pattern is called anesthesia of "glove, stocking" type. The degree of disorders gradually decreases towards towards the end of the limb to its radix. Such type of distribution of cacesthesia is called distal or polyneuritic (Fig. 30). Fig. 30. Distal (peripheral polyneuritic) type of cacesthesia. Along with numbness and pain, as a rule polyneuritis is accompanied by paralysis and paresis of the limbs with the distal distribution as well.

The destruction of the nerve plexus (cervical, lumbar and sacral) reveals itself by anesthesia or hypoesthesia of all kinds of sensitivity in the projection area of nerve plexus; in the same area pain and paresthesia arise. The destruction of back spinal nerve leads to cacesthesia in the corresponding dermatomes. When one radix is turned off, loss of sensitivity is not detected due to the compensation by the related radixes (dermatomes overlap, as tile plates). On the body dermatomes are located as cross strips, on the limbs as longitudinal strips, on the buttock as concentric semicircles (Fig. 31). Fig. 31.Distribution of cutaneous sensitivity according to the nerves and radixes: a - front view; b - back view; c - scheme of segmental distribution of the sensitivity (side view).

Cacesthesia corresponds to this distribution when the radixes are destructed. Common irritative effects in the form of pain and paresthesias in the corresponding dermatomes are typical for the destruction of radixes.

When the spinal ganglium is involved, in the affected dermatome rash of bubbles may appear – shingles (herpes zoster).

Cacesthesia with destructions of the spinal cord at various levels. Pathological process (trauma, inflammation, tumor) often leads to the cross-destruction of the spinal cord. Afferent wires may then be broken. All kinds of sensitivity below the level of destruction turn out to be weakened (spinal type of conductive disorders of sensitivity). In clinic such distribution of cacesthesia is called para-anesthesia (Fig. 32). In this case, the efferent systems of the patient are also affected, pyramidal fascicle in particular, paralysis of the lower limbs is developing - lower spastic paraplegia. Study of the sensitivity of such patients helps to determine the level of destruction (upper limit of pathological focus). If, for example, the upper limit of pain cacesthesia is located at the level of the umbilicus (Tx segment), then we can say that in this segment of the spinal cord there is also the upper limit of pathological focus. When making the topical diagnostics one should remember the peculiarity of transition of spinal thalamic fibers in the spinal cord from one side to the other. Therefore, the upper limit of the focus is to be moved to 1-2 segments upwards, and in this case to consider it to be located at the Tix or Tviii levels. Determination of the focus limit is very important in localization of tumor, when this is the matter of the operation level. Fig.32. Spinal conductor type of cacesthesia. Conductor disorder with an upper limit on the Tix level.

One should consider the fact that there’s disagreement between the segments of spinal cord and vertebrae, which on the level thoracic and lumbar sections has already 3-4 vertebrae. Let us consider clinical pattern of destruction one half of the cross section of the spinal cord. In this case on a focus side joint-muscle sense is disordered (back white column is being turned off), the spastic paralysis of the lower limbs arises (break of the crossed pyramidal fascicle). On the opposite side of the focus pain and temperature sensitivity is prolapsed according to the conductor type (spinal thalamic tract in the lateral funiculus of spinal cord). Such clinical pattern is called Brown – Sequard’s paralysis.

Conductor cacesthesia can be found in pathological focus in back white columns. Thus joint-muscle and vibration senses are reduced on the side of the focus (thin and tapered tracts are turned off). Sometimes tactile sensitivity is being prolapsed. Disconnection of the back white columns may be observed in dorsal tabes (tabes dorsalis), or in deficiency of vitamin B12, or in myeloischemia that reveals itself by sensory ataxia and paresthesias. Fig.33. Spinal segmental type of cacesthesia. Dissociative anesthesia of “jacket” type in the CIV-Tx area.

When the spinal cords are destructed, the segmental type of cacesthesia can be observed. It takes place in case with the damaged back corn and anterior white commissure of spinal cord. In the dorsal corn second order neurons are located conducting the pulse of pain and temperature sensitivity from the corresponding dermatomes. If the dorsal corn is being destroyed over several segments, in the corresponding dermatomes pain and temperature sensitivity is being prolapsed. Tactile and deep sensitivity is retained its conductors are outside the focus area, and, having entered in the marginal Lissauer’s area they are immediately transferred to the back white column. As, mentioned above, this kind of cacesthesia is called dissociative anesthesia.

When the front commissure of spinal cord is destructed, dissociative anesthesia is also developing, in this case – in several dermatomes on both sides. Genesis of such distribution of anesthesia is clear, because the axons of the second neuron, conducting pain and temperature sensitivity, pass from one side to the other throughout the spinal cord, this is what leads to the bilateral disorder.

In focus localization in the front commissure of the spinal cord on the level of lower cervical and thoracic segments cacesthesia is developing in the form of “jacket” - spinal segmental type (Fig. 33). Dissociative anesthesia of such localization can be found in syringomyelia (foci of endogenous proliferation of glial cells, sometimes with collapse and formation of cavities in the spinal cord gray matter). The same is observed in vascular diseases and intramedullary tumors.

In cerebral type of cacesthesia due to the brain lesion, conductor anesthesia is always on the opposite side. When the right hemisphere is affected, left-sided hemianesthesia (or vice versa) is developing. Therefore, the boundary of pathology and norm is not horizontal (lateral), vertical - the median line of the body. In organic (destructive) lesions, border area of anesthesia is 2-3 cm below the midline of the body and the head due to the overlapping of related sensitive areas.

As you know, in the back peduncle of the internal capsule thalamocortical fibers, conducting all types of sensitivity, pass as a compact tract. In this section of brain (softening or hemorrhage) affected foci lead to the development of hemianesthesia on the opposite side of the body (Fig. 34, a). Distal sections of limbs are more affected.

In the affected back peduncle of the internal bursa, pyramidal fascicle is involved. Hemianesthesia on the opposite side of the focus will be combined with hemiplegia.

When the area of postcentral gyrus is affected (cytoarchitectonic fields 3,1,2), anesthesia covers not all of the opposite side of the body, but only the area of the focus projection. Cacesthesia is confined to upper or lower limbs. Sometimes anesthesia occupies the distal part of the upper or lower limb with the upper cross boundary – anesthesia of "glove" or "stocking" type. As a rule deep sensitivity is more affected. Pathological focus might include not only the postcentral gyrus, but also the upper and lower parietal lobule (field 5.7). In this case, complex types of sensitivity are being disordered, astereognosis, discriminatory senses appear, the patient doesn’t recognize figures on the skin and other signs, defect of body scheme appears (the patient has a distorted idea of proportion of his body and position of his limbs). The patient may feel that he had an extra limb (pseudomelia) or, vice versa, absence of one of the limbs (amelia). Among the symptoms of the superior parietal area are also: autotopagnosia -inability to recognize one’s own parts of the body; anosognosia – misunderstanding of the defect of one’s disease, for instance, the patient denies his paralysis (usually left-sided).

In cortical pathological focus (tumor, scar, arachnoidal cyst) there are symptoms not only of prolapsed, but also of irritation of the afferent conductors. This may reveal itself by different attacks of paresthesia in the corresponding parts of the opposite side of the body (so-called sensory type of partial seizure). Paresthesia may cover all half of the body end by general convulsions.

Fig.34. Conductor cerebral type of cacesthesia:

a - hemianesthesia, b - crossed hemianesthesia.

When optic thalamus is affected, the whole complex of sensory disorders (cacesthesia). Heterolateral hemianesthesia arises, which often covers the face. On the side of hemianesthesia painful, stabbing and burning pain emerges, which is occasionally intensified and difficult to stop. The slightest touch to the skin, blood pressure, cold make pain attack more severe. The patient can’t point out the area, in which pain is located. Sometimes pain is radiating to the whole part of the body. Sometimes it’s stronger, when the patient doesn’t move, and when moving, it is reduced. In the study one can observe reduction of superficial sensitivity with the symptoms of hyperpathia, disturbance of deep sensitivity is expressed more strong, which leads to sensitive ataxia.

Within the limits of the right and left half of the midbrain operculum and brain spinal-thalamic and bulbo-thalamic tracts go. Lesion of the conductors causes anesthesia on the opposite part of the body. Spinal-thalamic tract, conducting pain and thermal impulses, can be damaged in isolation. It happens in vascular disorders in the basin of the lower and upper cerebellar arteries. In this case, hemianesthesia has dissociated character – pain, temperature sensitivity are prolapsed and deep and tactile sensitivity are preserved.

In the focus in the lateral section of the operculum of medulla oblongata except spinal thalamic tract, spinal tract and nucleus of trigeminal nerve are involved in the process. Their lesion leads to the anesthesia of face on the homonymous side. A peculiar distribution of cacesthesia arises: anesthesia of face on the focus side and dissociated hemianesthesia on the opposite side. This pattern is called alternating anesthesia (Fig. 34b).

When there is the microfocal lesions of the reticular formation, especially in mesencephalic brain sections and also in the cerebral hemispheres there are various types of hypoesthesia maculosus.

Functional (hysterical) hemianesthesia is characterized by the prolapse of all kinds of sensitivity or pain sensitivity mainly on one side of the body with the border, passing strictly on the midline. In case with functional paraanesthesia the upper border is more horizontal, than the corresponding dermatome,the border of which, on the dorsal side of the body, is always higher than on the ventral.

Thus, depending on the location of the lesion in the nervous system, there are three types of distribution of cacesthesia. When the spinal radixes or peripheral nerves are affected, one of the variants of the peripheral type of cacesthesia is developing: neural – disorder of all kinds of sensitivity in the area, supplied by the affected nerve; polyneuritic - disorder that occurs symmetrically in the distal limbs; radicular – disorder of all kinds of sensitivity in the area of ​​the corresponding dermatomes.

When the spinal cord is affected, several variants of spinal cacesthesia are developing: segmental – dissociated sensitivity disorder (the prolapse of pain and temperature cacesthesia, when pain and tactile cacesthesia are retained) in the same areas as in case with the radixes, when they are affected (in the zone of dermatomes), conductor type - cacesthesia of the whole body below the level of lesion (paraanesthesia). When the brain is affected cerebral type of cacesthesia is developing: conductor type - cacesthesia on the opposite part of the body (hemianesthesia, sometimes alternating), cortex type - the zone of hypesthesia varies depending on the location of lesion in the postcentral gyrus (more often monoanesthesia).

Chapter 4

Movement - the universal manifestation of life, providing an opportunity for active interaction of constituent parts of the body and the whole body as well with the environment. All human movements can be divided into reflex and voluntary.

Reflex motor reactions are unconditional and take place in return to pain, light, sound and other stimuli, including stretching of muscles. Apart from these so simple reflex motor reactions there are also complex reactions representing a series of consecutive purposeful movements. Reflex mechanisms play an important role in providing motor functions and regulation of muscle tone. The basis of these mechanisms is the simplest reflex to stretching - myotatic reflex (See ch. 2).

Voluntary movements arise as a result of the programs, formed in motor function systems of CNS. These movements are realized in contraction of agonist muscles and synergist muscles and simultaneous relaxation of antagonist muscles. This way not only movements of the limbs are provided but also more complex motor acts: walking, exercising, oral and written language, etc.

Effector parts of any motor systems are represented by many anatomic structures. The most direct tract from the periphery to the cortex consists of two nerve cells. The body of the first neuron is in the cortex of the precentral gyrus. It is traditionally called a central (upper) the motor neuron. Its axon serves to form synapse with the second - peripheral (lower) motor – neuron. This two-neuron tract, connecting the cortex of big hemispheres of the brain with the skeletal (striated) muscle is called by clinicians cortico-muscular tract (Fig.35). The set of all the central motor neurons is called pyramidal system. Sum of the elements of the second link i.e peripheral neurons constitutes the motor effector part of the segmental apparatus of the brain stem and spinal cord. Through the segmental apparatus and muscles the pyramidal system brings CNS into effect. When the program is repeated, voluntary movement may become stereotyped and turn into automatic, changing from the pyramidal system to extrapyramidal (See ch. 5).

Phylogenetically pyramidal system - a young formation, which developed mainly thanks to humans. Segmental apparatus of the spinal cord appears early in course of evolution, when the brain is just beginning to develop, and the cortex of big hemispheres is not yet formed. By the pyramidal system we mean the complex of nerve cells with their axons, through which the connection between the cortex and the segmental apparatus is formed. The bodies of these cells are located in V layer of the precentral gyrus and the paracentral lobule (cytoarchitectonic field 4), they are of big size (40-120 mm) and of triangular shape. In 1874 they were first described by Kiev anatomist V.A Betz, they are called giant – pyramidal neurons (Betz’s cells). There’s a clear somatic distribution of these cells. The cells located in the upper part of the precentral gyrus and paracentral lobule innervate the lower limb and body, located in its middle part - the upper limb. In the lower part of this gyrus the neurons, that send impulses to the face, tongue, pharynx, larynx, masticatory muscles, are located. Effector cortical centers of the limbs, face and neck are located in the precentral gyrus in the reverse order of body scheme, i.e the cells controlling the movements of the head, face are represented below, above - the upper limbs, and in the upper and medial sections - the lower limbs.

Fig. 35. Scheme of cortico-muscular tract.

1 - central motor neurons (giant – pyramidal neurons of the cortex of the precentral gyrus of the brain), 2 - the core of the facial nerve (peripheral motoneuron to the lower facial muscles), 3 - cortico-spinal tract (pyramidal system), 4 - peripheral motor neurons (a-motor neurons of the anterior corns of the spinal cord), 5 – lumbar enlargement segment, 6 – cervical enlargement segment, 7 - the medulla oblongata, 8 – pons cerebelli, 9 - cortico-nuclear tract (pyramidal system), 10 – cerebral peduncle.

Another feature of the motor areas of the cortex is that the space of each of them depends not on muscle mass, but on the complexity and subtlety of their function. The space of the motor area of the hand and fingers of the upper limb, especially the large one, and also of the lips and tongue, is particularly large (Fig.36). Fig.36. The projection of the motor sphere in the precentral gyrus of the cerebral cortex [Penfield W., Rasmussen Th., 1948]. Recently it was proved that giant – pyramidal neurons are not only in the precentral gyrus (field 4), but in the back segments of the three frontal gyrus (field 6), but also in other fields of the cerebral cortex. The axons of these neurons go downwards and inwards, approaching each other. These nerve fibers constitute a radiate crown (corona radiata). Then the pyramidal conductors form a compact bundle, making a part of the internal capsule (capsula interna). By this we mean a narrow plate of white substance, which is located between the head of the caudate nucleus and the lenticular nucleus (anterior peduncle of the internal capsule). The fibers of the pyramidal system form a knee and an adjacent part of the back peduncle (Fig.37). The knee is formed by the fibers, going directly to the motor nuclei of the cranial nerves (cortico-nuclear), back peduncle – by fiber bundles to the spinal segmental apparatus (cortico-spinal), the bundle for the upper limb lies ahead, the bundle for the lower limb lies back. From the internal bursa, axons of the giant – pyramidal neurons go into the base of cerebral peduncle, occupying its middle part. Cortico-nuclear fibers are located medially, cortico-spinal – laterally. In pons cerebella the pyramidal fascicle goes through its base and split into separate bundles. Within the brain stem, the part of cortico-nuclear fibers passes on the opposite side, then they form synapses with neurons of the motor nuclei of the corresponding cranial nerves.

Another part of the cortico-nuclear fibers remains on its part, forming synaptic connections with the cells of the nuclei of the same part. Thus, bilateral cortical innervation of the oculomotor, the masticatory, upper mimic muscles, muscles of the pharynx and larynx, is provided. Cortico – nuclear fibers to the muscles of the lower part of the face and tongue muscles almost completely pass on the opposite side (these two muscle groups receive innervation only from the cortex of the opposite hemisphere).

Cortico-spinal fibers of the pyramidal system at the level of the caudal section of the brain approach each other and on the ventral part of medulla oblongata form two macroscopically visible cushions (the pyramids of the medulla oblongata). Thus, we have such term as "pyramidal system". On the border of the medulla oblongata with spinal fibers of the pyramidal fascicle they pass on the opposite side, and decussation of pyramids (decussatio pyramidum) is being formed.

The greater part of the fibers, which has passed to the other side, goes down in the lateral funiculus of spinal cord, forming lateral or crossed pyramidal fascicle. A small part of the pyramidal fibers (about 20%) remains on its side and goes down in front funiculus (direct pyramidal fascicle).

Fig.37. The scheme of horizontal slice (according to Flechsig) through the center of the right hemisphere of the brain.

The structure of the internal capsule:

1 - head of the caudate nucleus, 2 – knee of the internal capsule (tr. corticonuclearis), 3 – back peduncle of the internal capsule (tr.corticospinalis), 4 – thalamus, 5 - optic radiation, 6 - calcarine sulcus of the occipital lobe, 7 - back third of the back peduncle of the internal capsule (tr. spino – bulbo – thalamo-corticalis), 8 - external capsule, 9 – claustrum, 10 – lenticular nucleus, 11 – front peduncle of the internal capsule.

The proportion of the crossed and direct fibers of different parts of the body is not equal. In the upper limbs crossed innervation predominates.

In the spinal cord, diameter of both pyramidal fascicles is gradually decreasing. The fibers pass from them to the segmental apparatus (to a-motoneurons of the front corns and the intercalated neurons). Peripheral motor neurons of the upper limbs are located in the cervical intumescence of the spinal cord, motor neurons of the lower limbs - in the lumbar intumescence. There are cells of body muscles in the thoracic part. Axons of motor neurons of the spinal cord go to the corresponding muscles composed of the front radixes, then followed by the spinal nerves, plexus, and finally, the peripheral nerve stems.

Fig.38. The study of the strength of the finger flexors of the hand with the help of a dynamometer.

Each moto neuron innervates several muscle fibers, which form the "motor unit."

So, the cortico - nuclear fibers of the pyramidal system move to the opposite side on different levels of the brain stem, and cortico - spinal - at the border of the medulla oblongata with the spinal cord. As a result, each of the hemispheres of the brain controls the opposite part of the segmental apparatus, and consequently by the opposite part of the muscular system.

As it was mentioned before, part of the pyramidal fibers is not involved in decussation and comes into contact with the peripheral neurons of the homonymous side. Such peripheral neurons receive signals from both hemispheres. However, bilateral innervation is unequally represented in different muscle groups. It’s more evident in muscles innervated by cranial nerves, except the lower part of the mimic muscles and tongue. Bilateral innervation is preserved in the axial musculature (neck, body), and in a less degree – in the distal segments of limbs. This long cortico-muscular tract in various diseases can be interrupted on any area. This leads to the loss of voluntary movement in some muscle groups. Complete loss of voluntary movement is called paralysis, its weakening – paresis. Paralysis or paresis occurs in lesions of both central and peripheral neurons, but the symptoms of paralysis are different.

Clinical study of voluntary movements includes a number of methodological approaches. At first, one should find out whether the patient can flex the limbs of the joints, whether he can do it properly. In determining the restrictions, the doctor does passive movements to exclude local lesions of osseous - articular apparatus (ankylosis, contractures, etc.). Immobility of such type doesn’t belong to the category of paralysis or paresis. It’s not difficult to discover paralysis. In identifying paresis one should pay attention to the decrease of active movement, for instance during flexion and extension of the limb of any joint. However, this method has only approximate value and doesn’t determine the degree of paresis. Another way to identify paresis is the study of contraction force of different muscle groups. This way one can get an idea of ​​the degree of paresis and formula of its distribution. This method has been widely used in the clinic.

There are various devices that can be used for quantitative measurement of the force of contraction of some muscular groups, but the dynamometer, that measures the force of hand grasp, when the arm is straightened (in kilograms), is usually used (Fig. 38). The force of contraction muscular groups can be defined manually. Confronting some elementary reflex movement done by the patient, clinician determines the force, which can stop the movement. There are two modifications of this method. According to the first one, the doctor makes an obstacle to the patient in different parts of the body and limbs, in a certain direction (during the active movement, produced by the the patient). The task of the clinician is to determine the force of resistance, which can suspend the movement, for example, when flexing the upper limb of the elbow joint. In most cases, another modification is used. The patient is offered to produce some active movement and hold the limb in this new position with the full force. The clinician tries to move in the opposite direction and pays attention to the degree of effort, which is necessary for this. For example, the force of the forearm flexors is defined at full active flexion in the elbow joint. The patient is asked to resist with the active flexion of the upper limb. The clinician grasps with his right hand the lower part of forearm and, setting his left hand against the middle part of the patient’s shoulder, tries to unbend the upper limb of the elbow joint (Fig. 39).

Fig.39. The study of force of biceps muscle.

The results of the study are estimated according to the 6-point system:

muscular strength to the full extent - 5 points, slight decrease of strength (compliance) - 4 points, moderate decrease of force (active movements to the full extent under the influence of gravity on the limb) - 3 points, the possibility of movement to the full extent only after the elimination of gravity (the limb is placed on a support) – 2 points, stirring is preserved (with slightly visible muscle contraction) - 1 point. In the absence of active movement, if the weight of limbs is not considered, the studied muscular strength is taken as zero. Muscular strength equal to 4 points indicates mild paresis, 3 points - moderate, 2-1 – deep.

In the study of muscular strength by manual method subjective estimation is possible. Therefore, in one-sided paresis one should compare the index of symmetrical muscle groups. In lesion of the upper limbs hand dynamometer is used (if possible – the reversible dynamometer, allowing to accurately measure muscular strength - flexors and extensors of the forearm and the crus).

The study of muscular strength is usually produced in the following order: head and cervical part of spine (flexion of the head forward, backward, left, right, turning sideways), upper and lower limbs (from proximal to distal), body muscles. Muscles involved in movements and their innervation is presented in Table 2.

The results of the study of the muscular strength of the upper limb are put down in the medical card, which helps to define the extent of movement disorders (the results of the survey of the patient A.):

Muscular strength

on the right on the left

Flexion in the elbow joint 5 5

Extension in the elbow joint 5 1

Flexion in the radiocarpal joint 5 5

Extension in the radiocarpal joint 5 1

Flexion of the fingers of the 5 0

the interphalangeal joints

Bringing of fingers 5 5

Separation of fingers 5 5

Supination of the forearm 5 1

In the given example one can observe a sharp decrease of strength of the muscles (deep paresis), which are innervated by the radial nerve. In some cases additional analysis is necessary: identification of electroexitability of muscles and nerves, electromyography, etc.

Table 2

Segmental innervation of muscles and their functions

Движение	Мышцы	Нервы	Сегменты спинного мозга
Bend of the head forward	Mm. sternocleidomastoideus, rectus capitis anterior etc.	Nn. accessorius, cervicales I- III	и ядро n.accesorii
Bend of the head backward	Mm. splenius capitis, rectus capitis posterior major et minor	Nn. cervicales	–
Turn of the head sideways	M. sternocleidomastoideus etc.	N. accessorius	и ядро n.accesorii
Bend of the body forward	Mm. rectus abdominis, obliqus interius abdominis	N. thoracici VIII-XII	-
Extension of the body	Mm. longissimus thoracis, spinalis thoracis	Rami dorsales n.thoracici	-
Bend of the body sideways	M. quadratus limborum	Nn. spinales lumbales	- -
The diaphragm movement	Diaphragma	N. phrenicus
Lifting of shoulders (shrug)	M.trapezius	N. accessorius	и ядро n.accesorii
Outward rotation of the upper limb of the shoulder joint	Mm. teres minor, supraspinatus et infraspinatus	N. suprascapularis	-
Inward rotation of the upper limb of the shoulder joint	Mm. teres major, subscapularis	N. subscapularis	-
Lifting the upper limbs up to the horizontal plane	M.deltoideus	N.axillaris
Lifting the upper limbs above the horizontal plane	Mm. trapezius, serrains posterior superior et inferior	Nn. axillaris, accessorius, thoracicus longus	-
Bending of the upper limb of the elbow joint	M. biceps brachii	N. musculacutaneous	-
Extension of the upper limb of the elbow joint	M. triceps brachii	N. radialis	-
Supination of the forearm	M.supinator	N. radialis	-
Pronation of the forearm	Mm. pronator teres et quadratus	N. medianus	-
Bending in the wrist joint	Mm. flexor carpi radialis et ulnaris	Nn. medianus et ulnaris
Extension in the wrist joint	Mm. extensorcarpi radialis longus et brevis, extensor carpi ulnaris	N.radialis
Bending of the fingers at the interphalangeal joints	Mm. interossei palmares, flexor digitorum profundus et superficialis	Nn. medianus et ulnaris	-
Extension of the fingers at the interphalangeal joints	M. extensor digitorum	N. radialis	-
Bringing and separation of fingers	Mm. interossei dorsales et palmares	Nn. ulnaris
Bending of the main phalanx of fingers, while middle and terminal phalanges are extended	Mm. lumbricales, interossei palmares	Nn. medianus et ulnaris
Bending of the lower limb of the hip joint (bringing of hip to the abdomen)	M.iliopsoas etc.	N. femoralis	-
Extension of in the hip joint	M. gluteus maximus	N. gluteus inferior	- -
Bringing of the lower limb of the hip joint	Mm. adductor longus, magnus et brevis	N. obruratorius internus	-
Separation of the lower limb of the hip joint	Mm. gluteus minimus	N. gluteus superior	-
Rotation of the lower limb of the hip joint	Mm. gluteus medius et minimus	N. gluteus superior	-
Outward rotation of hip	Mm. gluteus maximus, pyroformis, gemellus superior et inferior, obruratorius internus	N. gluteus inferior, ischiadicus, obruratorius internus	- ,
Bending of the lower limb of the knee-joint	Mm. biceps femoris, semitendinosus, semimembranosus	N. ischiadicus	-
Extension of the lower limb of the knee joint	M. quadriceps femoris	N. femoralis	-
Extension of the lower limb of the ankle joint	M. tibialis anterior	N. peroneus profundus	-
Bending of the lower limb of the ankle joint	M. triceps surae	N. tibialis	-
The foot abduction	M. peroneus longus	N. peroneus superficialis	-
The foot bringing	Mm. tibialis anterior et posterior	Nn. tibialis, proneus profundus	-
Bending of the toes of the metatarsophalangeal joints	Mm. flexor digitorum longus et brevis	N. tibialis	-
Extension of the toes of the metatarsophalangeal joints	Mm. extensor digitorum longus et brevis	N.peroneus profundus	-
Walking on toes	Mm. triceps surae, flexor digitorum longus etc.	N. tibialis	-
Walking on heels	Mm. tibialis anterior, extensor digitorum longus et brevis etc.	N. peroneus profundus	-

Determination of strength of individual muscle groups is supplemented with observation of patient’s motor function in general (walking, moving from a lying position to a sitting position, getting up from a chair, etc.).

In detection of paralysis or paresis of muscle groups the question of the topical diagnosis of the lesion focus arises. In determining the localization of the pathological focus, distribution criteria of paresis (and accompanying condition of the muscles) is used. In case with central and peripheral paralysis they change - in the opposite directions. Estimation of the phenomena accompanying paralysis, starts from the muscular tone. It is identified by palpation of the muscles and identification of the degree of their elasticity. Apart from that, muscular strength, occurring in passive movements in the corresponding joints, is being investigated, also the degree of topical muscular tension is being estimated. In a normal tone this tension is small, but clearly perceptible. During palpation of muscle elasticity is easily identified. In severe muscular hypotonia the passive motion is produced without resistance. Their size is increased. For example, when there’s a sharp muscular hypotonia, the lower limb of the coxal joint can be flexed until the hip touches the front abdominal wall: in flexion of the upper limb in the elbow joint, the wrist and hand can be brought to the shoulder joint. In palpation the muscle is interpreted as hypotonic.

When the muscular tone is increased, passive movements have considerable resistance, sometimes even insurmountable. It is revealed only in the beginning of the passive flexion and extension, then the obstruction is removed, and the limb moves freely (clasp-knife sign). It is clearly identified if the passive motion is quickly produced. In case with spastic paralysis, the lower limbs are straightened, they can be flexed only under a great exertion. Paralyzed muscles are palpated by the thicker ones.

In the studies of some physiologists it is said that in the pyramidal tract there are a great number of axons which are not those of giant-pyramidal neurons, but some other neurons (of cortex and subcortex) [Brodal A., 1961; Byosi P., 1964]. The authors believe that the increase of muscular tone actually is not connected with the lesion of the pyramidal fibers, but with their satellites, cortico-reticular fibers, in particular (they come from the cells of the premotor zone of the cortex to the reticular formation of the brain stem and then to the y-motoneurons of segmental apparatus of the spinal cord). Therefore the term "pyramidal hypertension" is not exact, obviously, we should call it increase of tone by muscle spasticity.

For the "pyramidal" hypertension, increase of tone in certain muscle groups is typical. On the upper limbs these are pronators and flexors of the forearm, hand, fingers, on the lower limbs – extensors of crus, flexors of foot. In unilateral paralysis of limbs due to increase of muscular tone, a typical posture with a typical look - Wernicke – Mann posture takes place. Changes in muscular tone are also observed in lesions of extrapyramidal and cerebellar systems.

In maintaining muscle hypertonicity, under central paralysis, neuropeptides (oligopeptides), which are called posture asymmetry factor, play an important role [Di Giorgio A., 1929]. If a healthy experimental animal is injected endolumbally with the liquor of the patient, affected by hemiplegia (due to vascular, traumatic, tumoral lesions of one hemisphere of the brain), then this recipient animal has a rapidly developing disorder of movements in the limbs of the same side as the patient had. Neuropeptides, evidently, influence the synaptic membrane of motor neurons of the segmental apparatus of the spinal cord and serve as synapse-modifiers. Improvement of synaptic transmission may be a consequence of increased sensitivity of receptors to the neurotransmitter or changes in the metabolism of the neurotransmitter [Klusha V. E., 1984]. The dynamics of the activity of these neuropeptides is being revealed in the course of the disease – they are being detected in 1-3 days after the development of pathological focus in the brain. This activity lasts for 1-3 weeks and then it goes down.

Thus, neuropeptides are involved in the formation of neurological syndromes. The activity of the neuropeptides of liquor may be brought down, which is of great importance for the development of treatment methods of neurological patients.

5. ЛЕКЦИИ

Лекция 1

15.02.13

Mental Health:

Risk factors and prevention.

-what is health

-health levels

-sciences studying mental health

-mental and narcological diseases

Health-a state of complete physical, spiritual and social well-being, state of activity. Harmony with nature and oneself. A human being becomes unprotected from diseases if he keeps away from nature and eases to listen to his body.

Medical-social factors determining health: biomedical, psychological, ethnic.

Health levels

1.individual health-of a separate person

2.group health- of social and ethic group

3.regional health-of population of administrative territories

4.public health-of population in general

Health at individual level

-physical-laws of processes of physical and physiological functioning

-social-adaptation to new social situations

-mental- perceptible good health

Mental health-a state of an individual described by integrity and coordination of all mental functions of his organism securing a feeling of mental comfort.

An angry, frustrated, emotionally unstable person in good physical condition is not necessarily heathy.

Mental functions

-perception

-memory

-thought

-affect

-intellect

Mentally ill person- a person with significant deviations from standards of his community.

Sciences studying mental health:

-psychology

Subdisciplines of psychology:

-social

-clinical

-legal

-pedagogical

Social psychology- studies human behavior in a group

Clinical psychology- studies states that are borderline between norm and pathology.

Mental disease-brain disease occurring in thought disorder and conduct disorder.

Narotics-are substances able to change work of brain.

Term narcotic substance includes three criteria-medical, social- non-medical use of substance is so wide that it becomes socially significant, legal- the authorized echelon recognizes this substance as narcotic substance.

Narcotics:

Opium preparations

-cocaine

-preparations of Indian hemp

-psychostimulants

-hallucinogens

-hypnotics and sedative drugs

Лекция 2

19.02.13

Assessment of a pediatric patient with respiratory problems

Subjective date

1.presenting problems

-cough (dry, hacking, moist, barking, productive with different color of sputum)

-respiratory difficulty-rapid, slow, shallow, deep respirations, retractions, wheezing, hoarseness

-sore throat and rhinorrhea (or congestion)

2.history of presenting problems

-onset-sudden or gradual

-duration-length of time present

-frequency-constant, intermittent, completely absent for a time and then present

Progression-better or worse than when first noted, better or worse when combined with activity, at night, at daytime, better or worse with change of position (sitting, lying, anxious)

-associated symptoms-pain, cyanosis,pallor, intoxication (anorexia, vomiting, stool’s disorders), decreased fluid intake (dry mucous and lips, depressed fontanel, decreased urination), change in behavior-irritability, restlessness, fatigue

Anamnesis vitae

-pre-intra and postanal periods

-previous

· Respiratory problems (frequent colds, pneumonia, respiratory distress syndrome, broncopylmonary dysplasia)

· Allergis (asthma, hay fever)

-immunization status

-family history (respiratory problems,allergis)

Objective data (examination, palpation, percussion, auscultation)

1. General appearance

-vital signs and level of consciousness

-physical growth and its disorders

-development and its disorders, irritable, lethargic

2. skin and mucous membranes (lips, nose, eyes, ears, mouth)- color, turgor, rash, irritation, dryness

3.lymphatic nodules (swollen, tender, pain)

4.throat (mucous membranes, swollen tonsils)

5.respiratory system-respiratory pattern-rate, depth, rhythm

Respiratory system:

-percussion-resonance, dullness

-auscultation-decreased breath sounds, abnormal breath sounds

-prolonged inspiration or expiration

6.heart

7.gastrointestinal system-anorexia, vomiting, stool’s disorder

8.urinary system-decreased urinary output

Лекция 3

21.02.13

Methods of human genetics

The genealogic method

Is based on researching of any attribute in a number of generation with the indication of related connections between members of a family tree. Genealogy, in wide understanding of a word-a family tree of the person.

Data gathering begins with a proband-persons for whom the family tree (is made by him) can be sick or healthy person- carrier of any attribute). Brothers and sisters a proband refer to sibs. The method includes two stages-gathering of data on families, drawing up of a family tree and the genealogic analysis. For drawing up of a family tree make short records about each member of a family.

-drawing up of a family tree of generation it is possible to designate in the Roman figures from top to down (to the left of a family tree)

-the posterity of one generation (sibs) settles down in one horizontal number (line) by way of birth (from left to right)

-within the limits of one generation each member of a family tree if designated by the Arabian figures. Each member of a family tree can be designated by the corresponding code.

-the genealogic method will be more informative if there Is more than authentic data on presence of concrete attributes at relatives of proband. At gathering genealogic data and their analysis it is necessary to mean, that the attribute can be shown with different expressivity and incomplete penetration

-after drawing up of a family tree the second stage- the genealogic analysis which is the establishment of genetic laws begins

Pedigrees

· A pedigree is a diagram showing the ancestral relationships and transmission of genetic traits over several generations in a family

· Square symbols are almost always used to represent males, whilst circles are used for females.

· Pedigrees are used to help detect many different genetic diseases.

· A pedigree can also be used to help determine the chances for a parent to produce an offspring with a specific trait.

Types of inheritance

-autosomal dominant

-autosomal recessive

-x-linked dominant

-x-linked recessive

The genealogic method allows to establish:

· Character of inheritance of an attribute

· Type of inheritance

· Zygous of proband and other members of a family tree

· Probability of occurrence of an attribute of proband, his future children

· Expressivity and penetration of an attribute

· On what line (father or mother) the attribute is transferred

Autosomal-dominant type of inheritance is characterized by the following attributes:

1. The attribute is observed in family tree on a vertical. At father plenty sibs-and across.

2. Male and female individuals can be sick equally.

3. One of parents of the sick child, as a rule, is sick.

4. The probability of display of an attribute at descendants makes 50%-100%.

The x-linked recessive the type of inheritance is characterized by the following attributes:

1. The attribute is observed in a family tree across and verticals, frequently through generation, native sibs are sick, relatives on the mothers side

2. Mainly men are sick. The pathological gene is shown in hemisygous state.

The x-linked dominant type of inheritance is characterized

1. The attribute is equally shown at men and at women

2. The attribute is shown in a heterozygous state at women, at men in hemizygous state.

3. One of parents of the sick child is sick.

4. To the patient the man transfers a mutant gene to all daughters.

5. The pathological heredity is traced and on a vertical, and across.

Y-linked inheritance

1. Occurs when a gene, trait, or disorder is transferred through the Y chromosome.

2. Since Y chromosomes can only be found in males, Y linked traits are only passed on from father to son.

Study of twins

One of classical methods of studying of genetics of the person.

Among twins allocate 2 groups: monozygotic twins and dizygotic. Demographers have calculated, that on the Earth lives about 50 million pairs twins.

Лекция 4

04.03.13

Protein properties

Molecular mass of proteins

5000: millions Dalton

Insulin – 5 711 Da

Solubility of proteins

1. Hydrophilic proteins – are soluble in water and salt solutions (hemoglobin, meyoglobin, amylase, pepsin)

2. Hydrophobic proteins – are soluble in non-polar solvents (membrane proteins are soluble in membrane lipids)

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