New York Neurological Society and New York Academy of Medicine, Section of Neurology and Psychiatry

Abstract

Doupe's theory may explain why this is so. He believes that causalgia is the result of stimulation of sensory fibers by efferent impulses in the sympathetic fibers at the site of the nerve injury in some cases, but possibly at a distal site near the termination of the fibers in others. The theory is based on the demonstration by physiologists that interaction between nerve fibers may occur as the result of injury. Doupe's hypothesis is not incompatible with Livingston's, and the two mechanisms may be operating in the same case. There is one objection to Doupe's theory. Although interaction between nerve fibers can be produced in the laboratory in an injured nerve, as Adrian showed long ago (Proc. Roy. Soc, S. B., London 106:596, 1930), it is hard to visualize how this interaction would remain sustained for any length of time. Inflammatory reaction and interstitial fibrosis are usually set up at the site of injury, and the fibrosis would be expected to insulate or separate interacting fibers. Actually, this may explain why in many cases of causalgia improvement is gradual. A 14 year old boy was admitted to the neurologic service of Bellevue Hospital in status epilepticus. For one year he had undergone physical changes consisting in deposition of fat in the face, shoulders, back and abdomen. For several months before admission he complained of muscular weakness, pain in the back, epigastric pain, right supraorbital headache and polydipsia. Physical examination revealed hypertension (blood pressure of 155 systolic and 120 diastolic) ; mild hypertrichosis over the back; dusky, plethoric skin with an acneform eruption on the face; kyphosis of the upper thoracic portion of the spine, and a small nodule in the conjunctiva of the right upper lid. Laboratory studies revealed mild diabetes with decreased sugar tolerance and moderate resistance to insulin; low creatinine excretion (258 mg. per twenty-four hours) ; osteoporosis, particularly of the spine, with hypercalcinuria ; mild erythrocytosis (5,500,000 red cells), and moderate elevation of the 17-ketosteroids. The combination of clinical and laboratory fea¬ tures was typical of Cushing's syndrome, satisfying Albright's criteria. Sudden death followed an episode of acute intestinal obstruction.Pathologic study revealed a retroperitoneal sympathicoblastoma in the region of the celiac axis, with secondary tumors in the liver, right adrenal gland, lungs, bronchus to the middle lobe of the right lung, pancreas, thyroid, thymus, lymph nodes, vertebral column, skull bones, dura, conjunctiva and retina (clinical). Crooke's changes were found in the basophil cells of the pituitary gland. Other conditions observed included a large abscess in the lesser peritoneal sac, acute fibrinopurulent peritonitis and slight hyperplasia of the zona fasciculata of the adrenal cortex. This case is recorded because of the concurrent development of clinically established Cushing's syndrome and a pathologically confirmed sympathicoblastoma Downloaded From: http://archneurpsyc.jamanetwork.com/ by...