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ALLOCHIRIA.1 Hysteria, and Is of No Value in Diagnosis." How Inexact Is This Account of the Condition Will Be Seen Presently

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ALLOCHIRIA.1 Hysteria, and Is of No Value in Diagnosis. 830 DR. E. JONES: THE CLINICAL SIGNIFICANCE OF ALLOCHIRIA. had been dead at least 48 hours, and post-mortem changes the female sporonts, with hyaline cytoplasm which stains had taken place, but was not considered to have suffered very faintly or not at all and rarely contains vacuoles. from "grouse disease the form of epidemic disease The nucleus is considerably larger than in the macro- described by Professor Klein in the grouse. No fresh blood gamete. films were examined but only dry films stained either with The parasites are contained in oval or spindle-shaped Leishman’s or Giemsa’s stain. elements with the extremities usually drawn out into fine long The protozoal organisms found were fully grown and threads not unlike flagella. The nature of these elements is sexually differentiated sporonts of a leucocytozoon. They not quite clear; they appear to be blood cells greatly altered were fairly abundant but in a state of degeneration and by the parasites they inclose. They present a deeply stained FIG. 1. Leucocytozoon lovati; figures from drawings by A. J. E. Terzi. Macrogamete. (x about 2000.) FiG. 2. Fry. 3. Normal red corpuscle of grouse. (x about 2000.) Leucocytozoon lovati, microgametocyte. (x about 20CO.) B stained badly. The following is a brief provisional descrip- I nucleus pushed to one side and flattened by the parasite tion : Macrogametes of an oval shape, more or less elongate, which entirely occupies the short diameter of its host-cell; 19 A to 25,u in length by 12 p, to 16 A in width. The cyto- at either extremity are numerous chromatoid granules. This plasm has a coarse alveolar structure, stains intensely blue, leucocytozoon of the red grouse appears to differ from the and usually presents one or more clear spaces or vacuoles. leucocytozoa parasitic on the turkey and guinea-fowl Nucleus either rounded or oval and placed as a rule about described by Laveran and Lucet and by Neave respectively, the middle of the parasite. It stains very faintly and con- and since we consider it to be a hitherto undescribed species tains as a rule near the periphery a compact, deeply staining we propose to call it Leucocytozoon lovati after Lord Lovat, chromatin mass. Microgamatocytes slightly smaller than chairman of the Commission upon Grouse Disease. cutaneous stimulus to the corresponding contralateral point; THE CLINICAL SIGNIFICANCE OF it occurs in a large number of diseases, notably tabes and ALLOCHIRIA.1 hysteria, and is of no value in diagnosis." How inexact is this account of the condition will be seen presently. BY ERNEST JONES, M.D. LOND., M.R.C.P. LOND., The symptom first described by Obersteiner under the ASSISTANT PHYSICIAN TO THE LONDON SCHOOL OF CLINICAL MEDICINE, name of Allochiria refers to two entirely different conditions, DREADNOUGHT SEAMEN’S HOSPITAL. which hitherto have not been differentiated from each other writer. The which be called" false allo- DURING the two I have had the of by any one, may past years opportunity is an instance of the localisation defect known as of some cases of chiria," making a detailed investigation allochiria, allosesthesia. The for which I have the a of which will be other, proposed complete study shortly published, together .. is an instance with a full discussion of the of the designation " Dyschiria " or Dyschirognosis," pathogenesis condition. of and three distinct The fact that this is therefore a psychological disaggregation comprises paper merely preliminary of which true allochiria is one. In addition to communication a of the results of the varieties, containing summary these the terms "electromotor allochiria " and reflex allo- above is advanced as an of any appearance study explanation chiria " have been Weiss to conditions in which a of in the remarks that follow. the clinical applied by dogmatism Only unilateral stimulus evokes either a bilateral or contralateral of the condition will be considered, as the significance subject motor There is no reason whatever the term of would need a response. why pathogenesis lengthy exposition. " allochiria " should be used in this connexion and I shall In of Professor Janet’s remarkable which has spite essay, not mention the conditions further. One as not received the attention it it be said might just soon yet deserves, may call the consensual reaction of the to that the views held on the most pupil light allochiria, subject by neurologists if the direct is as can be summarised in the which is taken particularly response abolished, happens following statement, in lesions of one third nerve. from the most modern text-book we complete have-namely, I shall first a brief of false and true und " Allo- give description Nothnagel’s" Specielle Pathologie Therapie": allochiria with their characteristics and shall chiria is a defect in a refers a distinguishing localisation, whereby patient then consider their clinical significance. In allosesthesia there is erroneous localisation of cutaneous which 1 A paper read at the International Congress of Neurology and stimuli, are to more or less distant. Psychiatry, Amsterdam, on Sept. 5th, 1907. referred by the patient points DR. E. JONES: THE CLINICAL SIGNIFICANCE OF ALLOCHIRIA. 831 I These stimuli are referred usually to points on the same side out the movement correctly. This phenomenon has been of the body but, for a reason that we cannot consider here, given the name of "allokinesia," rather unfortunately, as I a certain number are referred to the corresponding point on think, for so doing serves only to create an artificial separa- the opposite side. The symptom of false allochiria does not tion between two aspects of what is essentially the same need any special designation other than the general one of condition. Allochiria is neither a motor nor a sensory phe- allosesthesia, for its significance and pathogenesis are nomenon, but a psychical phenomenon that has both motor identical with those of the latter condition. It differs and sensory manifestations. Thirdly, the chirognostic sense clinically from true allochiria in respect to seven precise is altered as follows : In a bilateral case the patient can con- features. 1. In allosesthesia only a certain number of ceive of a given feeling of "sidedness" " only when the the stimuli are referred to the contralateral side, usually opposite side is moved or stimulated. In a unilateral case he less than 50 per cent. of them ; in allochiria the stimuli can conceive of the feeling of "sidedness" " of an affected are invariably referred to the contralateral side. 2. In part only when he moves the corresponding part on the a1loae&bgr;tbesia the symptom in question is merely an instance of opposite side under the impression that he is moving the the erroneous localisation that takes place in every direction, so part in question ; if he really moves the affected part, or if that the error in transverse localisation bears an exact rela- this is stimulated, he invariably gets the feeling of " sided- tion to the error in vertical localisation ; in allochiria there ness " of the opposite part. is no error in localisation apart from the mistake in the side. The third variety has been given the appropriate name of In allosesthesia a touch on the inner side of the ankle might " Synchiria by Janet. The three manifestations of it are as be referred to the outer side of the ankle, to any point on the follows. First, a sensory stimulus evokes two simultaneous foot or leg, or to the opposite ankle ; in allochiria such a sensations, which are referred to the corresponding points on touch would invariably be referred to the inner side of the both sides of the body. Secondly, when the patient is asked opposite ankle and nowhere else. 3. In allosesthesia there to carry out a movement on the affected side he does so on are disturbances of common sensibility - particularly both sides, though in so doing he gets only the feeling of hyposesthesia—which are important factors in bringing about " I sidedness of the affected part. Thirdly, the patient is the erroneous localisation ; allochiria bears no relation to any unable, either spontaneously or when cutaneous stimulation " defect of cutaneous sensibility, though such defect may is applied, to conceive the affected feeling of I sidedness sometimes be present independently. 4. In alloaesthesia alone apart from the feeling of the corresponding opposite there may be hypoaethesia or parsesthesia but there are side, though he can conceive it when he moves both limbs never present the peculiar attributes that we shall consider under the impression that he is moving only the affected one. in connexion with allochiria under the name of Phrictopathic On the introspective side there are many interesting Sensation. 5. In alloaasthesia hallucinatory sensations and matters in connexion with dyschiria, but the above-mentioned polysesthesia frequently occur; in allochiria this is not so. clinical features are sufficient to enable the condition to be 6. In allosesthesia there are no corresponding motor recognised. As regards the distribution of dyschiria it may manifestations, except perhaps ataxy ; in allochiria motor be general and bilateral, it may be unilateral, or it may manifestations are at least as prominent and characteristic concern only certain regions of the body. In a given part it as sensory ones. 7. In allosesthesia there are no correspond- may relate to all the functions of the part or to only some. ing mental symptoms and the patient’s error is due solely to Thus in the allochiric stage only painful sensations may be the fact that, on account of the peripheral defect, the mind referred to the opposite side and not other sensations. These receives imperfect information about the stimulus; allochiria, three varieties of dyschiria are three grades of the same on the other hand, is essentially a mental manifestation in pathological process, achiria being the most severe and which there is a deficiency of the power of apprehending the synchiria the least.
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