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The extrapyramidal motor syndrome as we know it today was rst delineated on clinical grounds and so named by S A K Wilson in 1912 In the disease that now bears his name and that he called hepatolenticular degeneration, the most striking abnormality in the nervous system was a bilaterally symmetrical degeneration of the putamens, sometimes to the point of cavitation To these lesions Wilson correctly attributed the characteristic symptoms of rigidity and tremor Shortly thereafter, van Woerkom described a similar clinical syndrome in a patient with acquired liver disease (Wilson s cases were familial); in the acquired form also, the most prominent lesions consisted of foci of neuronal degeneration in the striatum Clinicopathologic studies of Huntington chorea beginning with those of Meynert (1871) and followed by those of Jelgersma (1908) and Alzheimer (1911) related the movement disorder as well as the rigidity to a loss of nerve cells in the striatum In 1920, Oskar and Cecile Vogt gave a detailed account of the neuropathologic changes in several patients who had been af icted with choreoathetosis since early infancy; the changes, which they described as a status brosus or status dysmyelinatus, were con ned to the caudate and lenticular nuclei Surprisingly, it was not until 1919 that Tretiakoff demonstrated the underlying cell loss of the substantia nigra in cases of what was then called paralysis agitans and is now known as Parkinson disease A series of observations, culminating with those of J Purdon Martin and later of Mitchell and colleagues, related hemiballismus to lesions in the subthalamic nucleus of Luys and its immediate connections

The terms hypokinesia and akinesia (the extreme form) refer to a disinclination on the part of the patient to use an affected part and to engage it freely in all the natural actions of the body There may, in addition, be slowness in the initiation and execution of a movement In contrast to what occurs in paralysis (the primary symptom of corticospinal tract lesions), strength is not signi cantly diminished Also, hypokinesia is unlike apraxia, in which a lesion erases the memory of the pattern of movements necessary for an intended act, leaving other actions intact Clinically, the phenomenon of hypokinesia is expressed most clearly in the parkinsonian patient and takes the form of an extreme underactivity (poverty of movement)

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Unilateral plastic rigidity with rest tremor (Parkinson disease) Unilatral hemiballismus and hemichorea Chronic chorea of Huntington type Athetosis and dystonia

Contralateral substantia nigra plus ( ) other mesencephalic structures Contralateral subthalamic nucleus of Luys or luysialpallidal connections Caudate nucleus and putamen Contralateral striatum (pathology of dystonia musculorum deformans unknown) Ipsilateral cerebellar hemisphere; ispilateral middle or inferior cerebellar peduncle; brachium conjunctivum (ipsilateral if below decussation, contralateral if above) Usually bilateral in tegmentum of upper brainstem, at level of red nucleus or between red and vestibular nuclei Ipsilateral central tegmental tract, with denervation of inferior olivary nucleus and nucleus ambiguus Neuronal degeneration, usually diffuse or predominating in cerebral or cerebellar cortex and dentate nuclei

As already indicated, the lumbar puncture is an indispensable part of the examination of patients with the symptoms and signs of meningitis or of any patient in whom this diagnosis is suspected Bacteremia is not a contraindication to lumbar puncture If there is clinical evidence of a focal lesion with increased intracranial pressure, then CT scanning of the head or MRI, looking for a mass lesion, is a prudent rst step, but in most cases this is not necessary and should not delay the administration of antibiotics In an attempt to determine the utility of the CT scan performed prior to a lumbar puncture, Hasbun and colleagues were able to identify several clinical characteristics that were likely to be associated with an abnormality on the scan in patients with suspected meningitis; these included a recent seizure, coma or confusion, gaze palsy, and others The more salient nding in our opinion was that only

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