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Show Bilateral Internuclear Ophthalmoplegia with Absence of Convergent Eye Movements Clinicopathologic Correlation* ~1itchell B. Stwminger, B,S., Ernest J. Mincy, M.D., Adele I. Stwminger, tv1.D., and Norman L. Stwminger, Ph.D. ,\ C,lSt' III bil,llt'r,ll IIllt'rnuck',u llphth,'lllluplegl'l ut IUllg ,htr,ltlllil \\'Ith ,1lItll~'~Y Cllllltrlll,ltIUIl i~ replntt'd, TIll' 1ll.l1l1 k,ltures III the ~\Ildrlllllt' Illcluded part'S" ui llluLu ,1ddu([lllll Upl'll 'lltl'lllplt'd I,llt'r,ll g,lLt', hllriLllllt,ll 1l\~t,lgIllUS In the ,1bdu([lllg e\'t', ,llld ,111 absellcl' lli Cllll\ t'rgl~g t'Yt' Illll\l'Illl'llh 'b"llllll1,ltilln lli \\'eil-slained "'C;lll~S revealed Illultlple pl,l'lues III dt'Ill\'elinatilln. The Illedl,ll k)ngltudInal t,l~Clculus \\'a~ dl'm\'elinalt'd bl!. llt'rall\- In the u~'per p''ll~-caudal midbraIn. The lKulllllllltl) r. tfllchlear. and ,ll'ducelb nucleI appeared relat"' elY \\'ell prese[\ed The Internal capsule was severelv damaged. Large c\'st-likt' stru([ure~ were centered in the a~tenllr li~lb bilatt'rall\- and e'\tt'ndl'd c,lud,lllv tu the le\'t> I lli the gt'nu Pla~lu,'~ ui dt'Ill\'t'llI1atllln \~'erl' present bilaterall\' in the pu~tertllr lilllb. The lett ~Idt' ui the IIlternal capsule \\'a~ mllre ~e\'t'rel\' aiie([ed than the nght. It " thought th'll cun\'t'rgenct' in thIS C,No' Ill,1\' ha\t' been ehmInalt'd b\' Interruplilln III tlbers tWill till' Iwntal e\'e iields and l'r uther curtlcal areas III thl'lr descent thrllugh the inlt'rnal capsule. from the Departml'nl ot An,llom", 'lIld 1)"'I'lon lit :"l'lIrll, urgerv (EJ:Yl). Alban" Ml'dlldl (ollq;t', Alb,IIl\', Nt''' )or~ M. B. Stwmlllger I' a membl'r ot Ihl' tid" ot I'IHh, W,I'hll1glllll Lnl\'erSlIV. School of \ll'dllllll'. St LIlUI', \ll""llrl ... Pre.,~nted at the Aml'f1l"dn A.., ... Ulldllllll til An.ltPllll ... h Ml'eltng, Dl'trolt. MIChigan, M,l\' 1'177 Addre." correspondl'ncl' 'lIld rl'prlilt "'qlll'~h 10 I)r ."" I Stromlllger al Anatom\' Dl'Polrtllll'llt, Alb,lIl\' \kdl"" l ollt-gl', Albanv, NY 12208, USA. This study was supported III pM! bv 1'\111 I gr,lIll NS-12211H 57 The results uf numerous experimental and clinical studies shuw that lesiuns lucated in the medial lungitudinal fasciculus (MLF) mav produce disturbances uf conjugate horizontal eve muvement>, which have been referred to as internuclear ophthalmoplegia, Paton (l), in 1921. appear., to be the first to appreciate that disturbances of the \ILF produce "internuclear pabies," The syndrome uf the MLF has been divided into anterior and posterior tvpes (2,3), Accurding tu Lutz (2), the charactt.'ristic features of anteriur internuclear ophthalmoplegia are: (a) paresis llr paralysis of ocular adduction upun attempted lateral gaze with pre.,en'ation uf adducting e\'e movements in ocular cOIl\'ergence; and (b) nvstagmus exclusivelv present l'r most prominent in the abd ucting eve, Vertical eve Inll\'el1lents a re unaffected, Fullowing Lu tz' s descri ptil)Jl, PllS terillr internuclear ophthalmoplegia is characterized bv a pMesis of ocular abductilln This t\'pe would seem difticult to ditterl'nti,ltl' froIll ,m ,1bducens nen'e p,llsy, Whiit.' there ,Hl' sen'r,ll C,lSl'S llf pl1sterillr intl'rnuclear llphth'llnlllpit.'gi'l repl1rtl'd in the liter, lture, nllne h,l\'l' dllcul1ll'nted lesillns innl!\'ing the MLF, ,md till' ,lppwpri,ltl'ness llf the term in this wnte,t has been tjuestilllwd (-1-8). Cllgan (3) proposed ,1 different cl,lssificati'ln in which paresis 01 ocul,H ,ldduction togl'ther with nvstagmus in the ,lbducting l'yl' is ch,H,lCtl'ristic of both ,1nterior ,1I1d posterior intl'rnucleM ophthalmoplegias, with con\'ergl'IKe "bulislwd in the former. The present rq~llrt describes a C,lse of bilateral ,lntl'rior internuclear ophth'lll1loplegia in which OCUIM nmvergence clluld Illlt be elicited . CLINICAL OBSERVAnONS ;\ 52-ye•.H-uld right-handed man was hospitalized fllr evaluation of ,1 recent onset of numbness ;\1 Ii SIR( )MINCU\ IJ AL. ,1Ild tillglillg lIl\oh'illg hi", I'Ight h,llld dlld d conClllllil, lllt 10-lb l\l'ight 10"'''', TIll' ,l.;l'lll'rdl phv",icdl ,11ld Ill'U rologil'd I l'\d Illi 11,11 iOIl \\'d'" UIHl'lll,lrk,lbll' l'\l'l'f't Illr till' prl''''l'lln' 01 d "'Illdll "'Ublll,llldibuldr IYlllfl h Illldl' llil till' right ",idl' dlld pdn'",tlll'",id'" of Ihl' I'Ight h,lIld, ;\11 l'\l'i",iolldl billpW 01 till' IVlllph Illllk rl'\'l',lil'd d plH1rl\' dilll'l'l'lltidll'd l'drcillllllld, :\ priIllM\' Illdl.'" nllild not bl' IllUlld, Sub"'l'LJul'nl Ill'urlllllgiLll tl'",tillg ",lllIwl'd progrl'",,,, illil llt 11ll' righl-h,llldl'd p.lrl''''llll'",id''' ,1Ild d nl'\\', Illild, right-",idl'd hl'lllipan''''I''' wilh upfwr Illlltllr nl'Unln ",ign"" Cl'rebrll",pinal fluid dna!v",i"" CMlltid ,1rll'n' angillgr,lphv. ,1Ild pnL'ullllll'ncl'phdIllgr, lph\' were l'ntirely nllrlll,ll. I'.lrentlll'tic,ll"', it ShllUld bl' nlllL'd th,ll thi", ca",l' preddll'''' cllmpull'riled ,l\i,ll tllnlllgraph\', The p,ltient'", Increasing fllC,ll nl'uwlllgic,ll dl'licits were altribulL'd tll diffuse Il'It Iwmisplll'ric Ilwtasta"'L'S, In till' ab"'L'nce llf .1 d l'm II n '0 t I'a b k m,1 '" '0 k '" ion, the p ,1 til' n I wa '" tre,lll'd with ,1 21-dav Cllur",e of l'llbalt tlll'rap\' (5,000 rad tlltal) tu the !eft hl'misphere, He wa", discharged lln ,1 regimen uf Oilantin and prednisune, TIll' p,ltient's cllndition cuntinuL'd tu dell'rillrall' during the ne\t 13 mllnths, Svmptum", includL'd increasing weaknL'ss un the right side, blurrL'd \'isilln, right retw-llrbital headaches, and cuntinul'd weight Illss, He was ,1dmitll'd tll the "lb,ll1\' \'derans "dministratiun Huspital. The ]\;eurlllogical e\aminatiun shu\\'ed ,1 prufound right hemipkgia grealL'",t in the upper L'\tremitv and a wide-based g,lil. The pupils \\'('rl' equal, rllund, and n',lCti\'L' tu light and ,lccummlldatiun, The patient e\hibill'd a full r,lIlge llt t'\t' mU\'L'mL'nl. Hurizunt,ll nvstagmus was nulL'd In the abducting e\'L' upun lall'ral gaze tll l'itlll'r side, The visual fields wert' int,lcl. Right I,llial asymmetry was ubser\'L'd, with ,1 Illltl'fwd n,lsulabi,ll fold and widened p,llpebral fissure, Otlwr cr,lIli,ll nerves were un,lffected, An elt,ctn1l'nct'ph,1Iugram, radiunucielltidL' brain "'C,lIl, cl'l'\'ic,ll m\'('lllgram, fuur-vessel angillgram, ,lnd repl',lt pneumOL'ncephalugr, lm ",huwed nu pa thulugiC,ll ,litera t ions, 'I' h e cere b I' II '0 pin ,1 I flu id ,1 n ,1 II' '0 i '0 , gastwinll'stinal snil's, intr,l\'l'nUUs p\'L'lugram, thvroid ",can, and ruutinL' blood and urine study re",ults wert' within norm,ll limits, The p,ltient again I\'d'" disch,Hged frum the huspit,ll un Cl1J1tinued Dilantin ,1Ild prednisune tlwrapy, Hi", c1inic,ll course was une llf pwgressive decline and he W,lS re,ldmitlt'd tll the huspit.11 \l1 month", 1<1lL'r. The nl'urolugica! l'\amin,ltiun rt'veakd th<1t Ill' \1',1'0 lethargic but llrienlt'd, The pupils were equdl, round, and reactive tu lighl. For the first time, ,1 bilalt'ral paralysis uf ocular ad-duction was observed both upon attempted lateral gaze (Fig, 1) and cunvergence (Fig, 2), Horizontal nystagmus was present bilaterally in the abd~ cting eye, Eye movements in the vertical plane elicited bilateral upbeat nystagmus, In the primary po"ition, the right eye was exotropic (Fig. 3). Thert' wa" nu evidence of papilledema upon fund u ",co pic exa mination, Corneal reflexes appeared bilalt'r,ll!v diminished. The right facial paresis per", i",lL'd, Till' patient'", "peech was slurred and had a na",al LJualit\" Hi" \'oice was hoarse and his swallowing retarded, An adductor palsy of the left vocal c()l'd wa" documented by direct laryngosCOPY, A righ them iplegia wa s present together with bilalL'ral increased deep tendon reflexes, anklt- clonus, and Babinski signs. The patient could "tand on'" with aid and exhibited a broadbased gait when supported, Ob"tT\'ation", of abnormal e\'e movements were ducumenll'd cinematographicall;, and reconfirmed at frequent Intt'l'\'al", until the patient died of bronchupneunlllnia 15 months later, as confirmed by autop"\,, PATHOLOGICAL FINDINGS At autups\', meta"tatic undifferentiated small cell carcinuma \\'.1" fllund in four of fi\'e peritracheal kmph nude" un the right side of the neck. There \\'.1" nu e\'idt'nct' uf nwtastases to other loci, includmg the brain, The brain, \\elghing 1,120 g, was removed \\'Ithin 2 h afll'r dt'ath and \\'as perfused through cannul.w in"erkd mtll the inkrnal carotid and \t'rtt'br,11 <1rkrit's \\'Ith isutul1lc saline, followed b\' ill', butfered tl1rm,1lm The nwninges and COI1\'Olutil1J1" uf the cerebr,l! cork\. appeared normal. There \\',1" nl' ub\illU" di"culuration or cerebral atroph\', .'\ slight tu mllderate degree of atherosclerllsis W,l '0 nlltt'd, m,1 inh' invoking the basilar artl'n' and circle uf \\'illis, The br<1in \\'<1S cut intll 0.5- to 1-cm blocks trans\' t'rSt' tll the longitudinal ,nis of the brainstem, i\l.lCwscopic e\.amination of serial slices revealed th,lt tht' I,lteral \'entricks were enlarged approxim, ltt'h' one and one-half times normal and the septum pellucidum was dilated. Multiple cavitatillns and art'as of softening were present in the subcortical white matter, beginning rostral to the It'\'e! of tilt' head of the caudate nucleus. Large necrotic lesions were centered in the anterior limb of the internal capsule on both sides at different levels and extended into both the caudate nucleus and putamen, Destruction extended caudallv to the level of the anterior commissure (Figs. 4 -and H/LAID\/\I. /Nrtl\i lIl'll .\1\ (l/'//rt /,.\1 Mtl/'l.tC/iI 59 FIG.1. Failure of ocular adduction is documented upon attempted lateral gaze to the left (A) and right (B). 5). The lateral segment of the globus pallidus was im'oh'ed here bilateral"'. Bilateral areas of pitting, involving the dorsomedial nucleus and to a k'ssl'r e:\tl'nt the intr,llaminc1r nuclear grou p, were the mo..,t pn1m i(wnt grl I..,,, pathological changes in the thalamus. In addition, therl' Wl're Sllnll' discrek Meas llf sllfkninh in the lateral nuclt'M group. PMenchymal destructillIl appec1red less se\'ere in the br,linskm. NlImer(1l1S structurt'S clmtained f(1cal dis(L1Il1l',lti(1n ,1I1d sllftening. incilidinh the inferillr colliotlus, superillr clnd middle cerebellar FIG. 2. Bilateral paralysis of ocular adduction is documented upon attempted convergence Note pencil (0) in foreground. I C/I/I Ncltro-tll'htJwl,,/tlf, Vol. 6, No 1. 1986 ()(I M, H ST/,()MINCL/, ET At FIG. 3. Exotropia in the right eye is documented with the eyes in the primary position, pedunlll''', dt)r",ll penh pt till' p.tr,l Illl'd 1.11 pllntinl' kgnll'n tu 111 , ,1I1d thL' Illl'di,ll Ielllnl"cu", I he Illl'dull, l .1~1Pl\Hl'd rl'i,lti\'l'I\' un,lltl't'll'd, An'.l" pi di,,culuratH1I1 ,lbll t,ccunL'd in till' t'l'rl'bl,jlulll, A bluck thruugh till' uppl'r plln";-C,llIdcll midbr, lin \\',lS sectiulll'd ,1t 20 f-lm un ,1 irl'l'/ing micnltuml', Sl'ctiun" "t,linl'd with llll' ;'\;,Hllc1-C\'g,1' (L)) ,lIld buth \'Mi,lIlh ui till' Fink-Hl'inlt'r (l()) techniques iailed tu ducunll'nt thl' prl'''l'IKl' ui degenerating a,llns, The remaining bluck-., ui brain \H're l'mbeddl'd in celluidin and sectioned at 20 f-lm, A minimulll ui e\'erv tenth seLtilln thwuglwut the br,1in \\',1" stained bv the \VeilmL'thlld and \\'ith cre"vl viulet Selected sectiuns were staim,'d with Crl'S\,j \'itl]L'tluxol iast blue ,1Ild hem,llu:",lin-l'usin, FIG. 4. Brain slice shows cyst-like structures centered in the left anterior limb of the internal capsule and involving the pulamen laterally and the head of the caudate nucleus medially, Cumpll'k br/atl'r,ll dL'm\'l·linatilln was documented in thL' mL'dial Illngitudinal iasciculus (\1 LF) in till' u ppt'r pI ,n ,,-ca uda I mid brain at levels abp\,\, thl' ,lbducl'n" ,1nd c,ludal tll the trochlear nucleu" (Fi,~, h), IIll' \ILF \\.1"; intact adjacent to thL' truchlear ,1Ild uculllnwtur nuclei; it contained p,ltchec, oi lh'mn,lination at medullan' le\'els, Ll1\\'lT ml1tpr neurl1n" lli the abducens, trochlear, and Undlll11l1tl1r nuclei appeared largeh- intact (Fig, 7) All ui these nuclei pl1ssibh' exhibited a small reductitln in cell Clll11pkment, but this is difiicult tll dllcument. It should be emphasized that the ucuklnwtllr cllmplex \\'as relati\'ely well preserved thwughllut ih wstr'lcaudallength, TIlt' majl1r pllrtitlll t1i the antt'ril)r limb of the in- FIG. 5. Brain slice at the level of the anterior commissure shows cyst-like structure centered in the right anterior limb of the internal capsule involving the putamen laterally and the head of the caudate nucleus medially Similarly located softening is present on the left Side, but at this level it is less severe, IW:\/U,,\1 INIII,i\JUl '11,\ I, (ll'lll1 /,·\I,A]( JI'IJCIA 6/ FIG, 6, Well-stained section documents bilateral demyelination of the medial longitudinal fasciculus In the tegmentum of the upper pons Note other plaques of demyelination In the tegmentum and In the basilar region ternal capsule \\'a~ den1\'elinalt'd bllakrelliv (Fig. S), Dem\'elinatiun e,knded intu till' curLlna 1',1dlata immediatelY adjacent tu the internal C,lp"Ull' bilateral!\', Sume cell ILl"S uccurrt'd bllakralh' in the head of the caudait' nucleu" elnd tu a ll'"ser e,tent in the putamen Although diffuse demvelinatiun was present in the thalamus, perikan'a appeared mainh' intact. The genu and pustl'rior limb uf till' inkrnal CelPSUllO had val' ia b Ie amLl un hut d t' nl\' l' jill el t illil , which was greate... t un till' It'lt "Idl', A pclrtlell Ill"" of cells occurred in the putelnll'n elnd gillbu" p'll! idus bilaterallv at thal,lmic ll'\'t'l " , [hl' "ubth,llamic nucleus, substantia nigra, and rt'd nucll'u" were essentially unaffeckd. Cun"idl'rabIL' cell dl'pletion occurred in caudal pclrh ut the pl'ri\'t'ntricular gray matter "urruunding thl' third vl'ntricle. The cerebral peduncle" Wl'rl' pclrtiellh' dl'mVl,jinated. Other small plaque" Wl'rl' IUCclll'd within till' pontine and medullary tl'gnll'n tu III , including till' area of the medial ll'mni"cu". The bel"il,lr plln" ,llld the inferior culliculu" al"u Wl'rl' ,lttt'ded TIll' ml'dulla had fewer art',lS uf dl'lllVl'lineltilln than did more cephalic subdivi"iuns (If the br,lin, 11ll' p\')'amids appeared well myl'linakd ,lt Sllllle Il'vel" but at others were cumpldelv dl'm\Tlinelll'd bilelterally, Several plaques uf demVl'linelti(ln Wl'I'l' present in the medullary substancl' ut the (nl'- bt'llulll, but pl'l'lkan'el uf the deep nuclei and curk, \\'ert' undam,lged, Samplt'" uf ct'rebral curk, abu appt"lred nurlllaL DISCUSSION The prest'nt C,be cunforllls tll the definitilm llf anteriLlr inlt'rnuclear uphthalmllplt'pa as pl'llpused bv Cugan (3) in th,lt therl' \\'as a 1L,SS uf llCul, lr Clll1\'t'rgenn' tugt'tlll'r \\'ith till' c!,lssic,11 signs II t bi I,lll' I' ,11 in ll'rn UCll',l r llp h t h.ll n1l1pll'gi.l, i, t', , p,Hl'"i" III u(ul,lr ,lddu(tiun Uplln .ltkmpll'd 1,1lt'ral g,l/t' in bllth dirl'diun" .llld n\'"t,lgrllu" in the ,lbdUeling l'\'l', :\ ~ll'l'"i"tl'ncl' l11 llclilelr Cl)J1\ergence W,b rl'purll'd in IllUSt prt'\'IUU" dinic.ll studies llf inkrnude,lr uphth'1Inll1plt'gi'1 (11-32). :'\ecwps\' fi nd ing" h,l \'l' ducu n1l'n It'd th,l t im p,lirments of Jelkr,lJ g,l/e St'l'n in inkrnudeclr uphth,11mllplegia drl' ,lttributdble tll le"lllns Il1\uhing the t\ILF wstr, ll tll till' ,1bdu(l'lh nut'il,j (13~ Ih, It', 19,212,1,2')), Chri"tult t't elL rq,urkd ,1 CelSt' with a uni1,1 tl'r,ll 1\ Ill, Il'"iun in \\'hich cun\'t'rgence ine,plicelblv l'lluld nut be l'licikd despill' sparing of the U(UIUnl\ltur l'lllllpil" (ILJ). F\pl'rinll'nt,ll studil'" in nwnkt'ys with discrete MU: Il'siun" pl'llduCl'd sll'reotelelicallv stwnglv "uggl'"t th,lt the lll'lIr,ll p,lthwavs mediating conVl'rging l'\'t' IlW\'l'ml'nts dLl nllt involve the MLF, /e'/I// .\ICllrtJ-ophtlIllIIllOI, \\1/.6. No.1, 1986 M. H. SnWMINCLR LT AL. " .. , ." . , ", .. .; .. . , ., . , It: ~. '" .• ~ :I •. ill" . . .. t .~ ., . " , • - _. '; ~~ 'I. I ~ I ."'•. ,I" I • ••• .: III r ~ ~ .'''''''' • .... ~..':, ~ . ....... ... ..,. ( .. ~ .. ~J .. ~I"'" ." . FIG. 7. Photomicrographs of Nissl-stained material demonstrate the relative intactness of the oculomotor complex (A), trochlear (B) and left (C) and right (D) abducens nuclei Note Intactness In A of oculomotor roots and medial longitudinal faSCiculus fibers at this level, shown With luxol fast blue counterstain. since this function was preserwd (33<1b), In the present case, degenerative changes within the oculomotor complex, abducens nuclei, and trochlear nuclei were at most slight MId thus the s\'ndrome was not a lower motor neuron type of paralysis. That the oculomotor complex was essentiallv intact throughout dl'serves emphasis, The etiology of internuclear ophthaln1llplegi,1 is variable. While most patients present with del11\'elinating disease (13-15,18,20,22,37,38) inkrnuclear ophthalmoplegia also has been obsen'ed after head traum,l (11,12,17,27-31). vasculM disease (14,16,18, ISl,21 ,2h,32,37,38), svphilis (37). glioma (3Sl,40), and lymphoma with intrathecal chemotherapy and cranial irradiation (41). Ac-cording tl) Smith and Cogan (18), the bilateral form l)f the syndwn1l' usuallY is associated with . . demwlinating disease, whereas unilateral inter-nucleM l)phth,llml)plegia generally is a result of \'asculM ,Kcident. Since the patient reported here l'xhibikd bilateral den1\'elination of the MLF between the abducens and oculomotor nuclei, the pMesis l)f oculM adduction upon attempted lateral gaze and nystagmus in the abducting eye most certainly was due to this lesion, The paresis of ocular adduction seen in the ipsilateral eye after unilateral MLF lesions rostral to the abducens nucleus in monkeys was generally attributed to interruption of the vestibulo-ocular retlex arc. Such lesions elicited ascending axonal RILAITI\/I/ INIIl\Nllt'1/,11\ (ll'lllI IIIUv1( )[JIJCIII 63 FIG. 8. Well-stained section shows bilateral demyelination of the anterior limb of the internal capsule also involving the caudate nucleus and putamen. degeneration, \\"hich \\'<lS differentiallv but not exclusivel\' distributed tl) the ventral nucleus Llf the oculomotor complex (}h), a subdi\'isiLln that inner\' ates the medial rectus. It \\"as assumed that the critical fibers took Llrigin frLlm the cLlntralateral vestibular complex, since this is the SLlurce of the majorit\, l)f fibers in the i\lLF in thl:.' upper pLlns and because of the impLlrtance llf the \'estibuIM sYstem in the contwl Llf eve mlWemt'nl. HLl\\"e\'t.'r, it is note\\"orth\' that large lesions pwduced in the vestibular complex dLl nLlt cause dissLlciated eve movements. ),,'ystagmus in the abducting e\T during attempted lateral gaze \\"as regarded as an expression of weakness in con twl of the la teral rectus (35,36). It was postulated that this \\"as due to interruption of descending fibers in the MLF fwm the interstitial nucleus of e11al to tlw vestibulM complex, thus interfering with a circuit from tlw \'estibular complex to the Llppo..,ik dbducens nucleus (36). The basis for Cllnsidering ..,uch circuitry to be of importance was the observation that discrete unilateral MLF lesions in monh'ys elicitcd nystagmus in the contralakral abducting eve, tLlgether with an ipsilateral pML'..,is of oculM adduction (36). However, with the advent of axonal transport techniques, numL'rou.., an,ltomic,ll and physiological studies have demonstr,llt'd the presence of internuclear neurons in both the ,1bducens nucleus and the oculomotor complL'x that emit axons that travel in both directions bdwL'L'n the two via the MLF (42-55). Abducens inkrrwuwns decussate immediately and terminate in the contralateral oculomotor com plex, pa rticula rI y the part that innervates the medial rectus. I\HL'ntlwtically, it should be noted that Buttner-Ennever and J\kert (54), Llsing rdrograde transport methods, SI1llWl'd thdt the medial rectus in monkeys is innl'rv, ltl'd by neuron.., in two separate cell groups of the oculomotor compil'x, in addition to the ventral cell culumn a.., dL'..,cribed eMlier by WMwick (56). Then' i.., evidencl' to "'Uggl'..,t that one of these cell group'" m,lV bL' of importdncL' in mediating ocular cllnvl'rgl'nCl'. Oculomotor interneuron.., are bilaterdl. Thi.., tlwrL'forL' enable.., reciprocal inhibition dnd l'xcitdtion for conlugalL' horizontal gaze, and inlL'rruption of thL'..,l' tiber.., v."ould ..,eem to account for the adducting p<1rl'..,i.., a.., wl.'II a.., the nystagmus. The deficit in ocular convergence is more difficult tLl explain. Since experimental MLF lesions do not affect convergence, damage elsewhere must be responsible, Of the bilateral cases in the literature in which necwpsy studies have been done, this function has been retained. Electrical stimulation studies have shown that the frontal, parietal, and occipital eye fields are important for conjugate eve mLlvements (57,58). Vergence movements have been elicited bv stimulation of the frontal eve field and other cortical areas such as 19 and 22 of Bwdmann in the preoccipital region (58,59). Similarlv, cortical units in Mea 18 of the macaque ha\'e been found that respond tLl binocular depth (60). Hubel and Wiesel consider that one function of this cortical area is in elaboration Llf slereLlscopic depth mechanisms (60). Thus, the damage to the anterior limb of the internal capsule present in this case ma\' have interrupted corticofugal fibers fwm the frLlntal eve fields, Additionallv, exlensi\'e lesions im'ol\'ing Llther pMts of the internal capsule or even the tegmentum l)f the pons and midbrain ma\' be responsible fLlr the impairment in l)cular CL)J1\'t'rgence b\' intcrrupting cLlrticLlfugal fiber path\\"1\'s fwm posterillr cortic,ll regiLlns tl) the medial rectus cell columns of the LlculLlmLltl)r cLlmplex. Thesl:.' must relay thwugh internwdi,lte neuwns, since there Me no direct fibers fwm the cLlrlex tl) the oculL)mLltLlr nuclei. Recent electwplwsiological e\'idence suggests that neurons in pwximitv to the oculomotLlr cLlmplex identified ,1S "convergence cells" may be a pMt of the relav (bl). In this context, the patient reported bv ChristLlff t't al. had severe unilaler, ll cerebral swelling and sLlftening; this may have been responsible for the abolition of converging eve mOVt'ments (19). The prest'nt case resembles wall-eyed bilateral inlt'rnuclear ophthalmoplegia or "Webino," This tl'rm was introduced by Lubow (see ref. 62) to describe a variant of Cogan's anterior internuclear ophthalmoplegia with exotropia present in the I Cl", NCllro-ol'hthall1lol. Vol. 6, No. 1. 1986 /VI. H. SI/,()MINGU, cr AL. REFERENCES prim,H\' pusitiun, I,uhll\\' bl'lil'\'l'd lhdl till' '>1'11dl'\ lnlL' \\'.lS l\lUSl'd bv Il',>iul1s ill\'lll\'illg till' MLI' hil,lll'l',llh' ill llll' midbrdill tllgdllL'r with llll' 1lH'di, ll rl'dus SUbIlU,'Il'i ,II till' ,lddIlIlH.lllr l'llillpll''\, III thi'> ,\l'>l' ,',\ulrllpid 11'.1'> ,1pp,lrl'1l1 ill llH' right lTl', but till' ml'lti.1i I'\'du,> sublludl'i III llll' Ild"l" IlHlt,lr nUl,ll'us Wl'I'\' in I,ll' I. rhl'rl' hd\'l' bl'l'n llnlt· .I ll'\\' rl,,'l'nt publi'>lll'd rl'pllrh ,II till' VVl'!'lllll ,>\'11' drllllll', UIH' ,',lSl' \Yd,'> l'dU,'>l'd bv .1 tulwr,ulll'>I'> gr,lIlUIUIll,l in llll' midbr,lill th.lt pn'SI1I11.lhh' ill \,\Ih'l'd thl' ILf ,1Ild nll'didl rl'du,> subllulll'i III Ill,· IIClIlllillutur Clllllpil''\ h\' m,lS'> dtl'd (h I). I'llur Lltlll'r p,ltiL'nls Wl'rl' di.1gIlUsl'd .1S h.l\·illg lll',lu'>I\'" ''.lscul.lr disl"lSl' ur Illultipil' '>cil'rtl'>i'> (h~) I Ill' dU' thIll's ,1ttriblllt'd till' s,'ndl'llnlL' tll Il''>llln'> dtll"tlll,~ thl' p,lr,lIlll'di,ln pUlltillL' rl'licul.lr tllrm,ltHln .11ld the MLF, but this \\',lS spl'clIl.1tilln unsuppllrlt'd b,' p.lthlllugic,ll findings. "'Vl' ((lnsidl'r it f" lssibll' th,lt lesil)ns in IllIHl' th,ln Llnl' lucu'> Ill,1\' hl' rl',>~lIlIlSihk iLlr eliciti ng thL' \\' l'bi nu S,'Ild ruml' In ,1dditiul1 tu UCUIM dvsfundilln, thl' mllrl' '>l'" ere degenl'r,ltilln ut till' puslt'riur limb ,II till' Internal capsuiL' L11l the Idt "l'r'>us till' right '>idl' I'> cllnsistent with thl' finding L1f right llL'mipMl'sis, R, I Inkrnucll'.H c)phthalnw., 'I ': l )1,: .. :I/,1/ 1nl'/. 13: b7'1-67:;, [ntl'rnudear ophthalmoplegia: tvpical and l),'"I""IIII<" 84: 583-589, 1970, l-t, C"g.Jn, D, C, Kubik. C. 5" and Smilh, ). L: Unilateral inIl'rtllldv,] f "phlhalnHlplt'gi,l: r,'port of K c1ini(al ca,e, with 1 p",I-nlPrlc'Jl) 'Judv, lInk Ul'ht/wllll"l. 44: 7K3-796, 1950. I; C",hlgn·n. ,,-,. ,md ilotman-Bang, E,: A ca~t' of internuclear "phlh,i1nlllpl,'gld (BiL'kh"w,kv) with alllop'y, Ada Psy'// 1,,1 N"I'" 25: -t2lJ--t1J. IY'iU. , .. (.h'· "', "rei, "I Ilw \1.I"ac-hu't'lh Gener.:ll Hospital: Cast' \"r.r \ 111-.:/ 1 ,\".of 249: 77o-7Im, 1953 17 (,1''''. ( VI.i1'''''lt,h, /1" and B"ulad. Ophth.:llmoplegie in- 1"""",1,,.,,1',' hildll'r,i1,' p",Hrdlimati'lut', R"", Ulol1['/lrooph1,,/,/ 1,,1 2'1: -t1;- -t1cl, I CI;7 IX '-olllllh. I I . "nd ("gdn, I), C, Int,'rnudL'M ophthalmo"),-,;,., .J n"'"'''' "I ;X ,.1'V' ..11''-'' UI'ht/lI1ll11ol. 61: 61l7-69-t, II ";11 .' I ICI (IHISI,,'I. ,\. , And"r,,,n, r,) .. !\athan'on, M., and Ilt-nclt-r. \1 B I'n'l'lt-m' In anatomIC analvsis oi lesions oi Ih,' IIll'dl,d l"ngllu,lInal l.:l,(](ulus, .·ir,-h, .\'['111'01. 2: 2q~ 1fl~, ll..Jhll 211 (11'1",,,",. I' o.,l"m'''I. f' . ,'nd WOjtuwicz, 5. Biel- ,h"" '''I -I utI -( "~dn ,,'ndn'me: '\/1/ 1 UI"II"all1/[11. 59: ~ I h - -l11 J, Iqh; . . 21 II"rrll1l.;I .. n, I~ B 11 .. llt-nl'"r'1. f, W. and Saver. G. P.. L nd,ltl'r.d J11h'rnu\ k,lr \l~'\hth,dnlll~')kgid, rt.:pl)rt llt a case Inlllldll1~ ~,.dhldll'~" I',:: ',./fr.,; 15: ~y-)~, lYhb. f....llf'kr, ( "nd l, 'C;,1/1, I' L nJl"I"r,,1 "f'hthalm"plegia. '.,,: I I: ," .. ,.. 1 75: -l -l--l ....\'. )4h,.., ~) I,ll'-,.... .llh1 {It·\h ·r. \\ 1.... ld.1lt-,d ... \-ndr\lmL' L1f tht' I11t'dl,t1 I, Ilh,:l!lJdll1,li 1.1"'\'I~ LIlLI'" In /11,111, ,In ..1tlIJ111lal con fir- Jll,llllll) I, 15: ~II-:;-~I); ]L1hh ~-l \ ,Ill ·\Jkn \1 \\ I .d\:r.d "':'.l/t· ,lIh1 ltln\ l'rt..:\.'nle In Internth. ktlr t ,~')I)l h.dlllt 1~')1t:~1..1 .1 Ih ItL' tin l,\. ..lnlln,l·tl\ln .\·l'ltrllltl'lI 16: 1t,~ ~ ~t'). !4t-.,n .. 2; CII~,Hl. D lJ ,1I1d \\ r,1\ .... H Jntl'rnu\.-ll',H "'lphthalrnLlt'\ lt'.~I,l ,1'" .111 t',Hh "'1~1l \d l-"r.Hn ... tl'ln tUlntlr ..\·l'llItl/t1,(1I 20: h24_1')_1~. 14:-"11 2,., G,'Il' c',l f BJI,'ll'r.l1 In lvrnlicil',H t'f'hlhalml1plegla .. \,<1, \,'"",;, 31: 1",,>- J ;-,; 1";-.. RICh, I R l,rc',~"rJlI', F f.... "n,j Hc:pil'r. R S Bilateral 1I1ll'fI1uck.H "f'hth,dmc'f'il'gl.l ,1ttn tr.ll1m.l, ,-Irch, Ol'h: It,lllJ/I'! q2: hf'\-h~. IlI:-"~ 2~, S,ll,'. l)" ""~'t,L f.... l)cl"c,(h",) l't .II Lt',ion c)f lhe medl, lll ll)n~ltudlndl t,h('llU]U'" t\)llll\\ In.~ he,lJ injun' .\'cUrl)· ,;""" ';:,' 17: l-t 1- l-t" 1";--t ' 2l.1 T\.,hr,1. ~ l, 1...1)\\ ,Hlh..lT1I.ir.l. ~.•lT1J D..lnlble. \1.. Bilat- ...·Lli Ilh'dl,ll rt'\.-tll'" F',ll ... \· l.illl' tl l 1111L1e..lf In\ t..lh·ement in cl,,,vc1 Ilt',hi Illlun ,1 ,',hc' rC'f,,\rt 1",1 I l)/'hlh'71"",! 2-1: 2~-~t.." }...,:--" _111 B.l!,"'r R ~ Inkrnullt'.H \It-.,hth.llnh1t",!et:1 ..1 tl)II,)\\'ing head Ir.llllll.l. I \\':.1,1.<1'\ 51: ~:;2-:;:;:;. lq:-q. .. 1'<,,", [;:, \\ ,)Ihi \lc,,"It'r, f'\C'.<:I'l .llkr Iw"d t1',111111,1 I"~I 12 f...."mmcTc·II, l, L"d"tc'r,ll 1I1Ic'rIluclc'dr C\f'hlh,'lmoplegia: Till' 1.1," "I ,"ll1ht"" 111\ ,'),<,nwnl III nwd"ll re(IU~ mu~de .h.-tl\lt\· !I:;',· .. t L):,,' .. :;:,;,·n:I'I· \':~. ~t'l .21: 3l.j2-~44, 1981 ," BC'l1ch-r \1 I, .1I1d I\C'II1'tc'ln. E .-\ .. Ett,'d~ "f ~timlliation ,111d IC"'c\11 ", till' Ilwd',ll 1,'n~ltlld,nal t,,,(iculu~ in the ])h'])""" ,\"" \,':",'[ /','II,I",II/'I/ 52: ILlb-I13. 19+!, ,-t BC·'hit-r. \1 H.. ,mel S(h,ll1h'r.' S .. (kult)mc)lor pathwavs d\'t])ll'd I", c'kdfl',l! ,til11ul,1ti"n ,lI1d le~i"ns in the bra';n ,kill pt Ilh'I1"c", In TI,,- (\'1/1.'"','1,'1' SI/';(,-I/I. 1\1. B. Bender, F~d Ildrf'c'r'" R,\,\. :,\:,,\\, ) c\r". 14b-t. pp, SI-I-tO, 1~ l,lrpl'ntl'r \1. H.. ,111...1 7\ll-~l..l~ter~, R, E.: Disturbances of c"'"lug,Hc' IWflb'nt,ll c:\',' I11cl\'eml'nt~ in the monke\' II I'h",,\lc1gl(,lll'lt"(h ,1I1~j ,1I1,1I,)m;(al degeneration restil;ing tr,'\111 1t''iC\I1' 111 tilt' medi,ll IL1n~itudinal fas(iculus, Ardl. ,\1'/11'1 1/. 8: 304:--,)b~. l\.)(:l3. Cnp\'nll'r. 1\ I. B, .•lI1d Slwminger, N. L.: The medial lonS'ludln, ll I,b(i(ul", ,1I1d di~turban(e~ of (Onjugale horiIl\ nl,11 l',',' n1l'\'t'nwnt~ in monke\·. I, e'"III'. :Vel/wi. 125: -t 1-(11,. jLJh;, . C,>g,ln. D, G.' ,It\pi(,ll. ..\,,11 ,-, _1/. I )Il' illlll'r\'.ltlilll dl'r Illu"'(uli rl'dl Illtl'1'1l1 H,'I fl"/lh, l, ('I,"t/,,,I I,,', 30: Ih-t 1;-1. II r,llon. L lLJ21 2 Llil/ . .-'\ L'l'l't'r dll' [',Ihn"n d,'r ['lld,"c'ndlln~ lind dvrvn .Jj ......l)Llil'rung: .'\,: ...·b.... t nlilh:dllng l'Jlll' .... t.1Jll''' \'llJl tlphth.ll· n111pleghlllllt.'rnudl'.lri ... ~H)ll'rior in \"t.'rbindung 1111t dl .......p· /Iil'run.g dL'f bllgl'ng,ll·ngl'. k/Ul .\ flllJdt ...N "\/I'~'t'llltt'lt.tf 70: 21 :1-23:1. ILJ~3 . 3, (og,ln, D, C,' .'V"/I/"'/"S '/ ,'I III,' 11,'/1/," ,\I/I,d,·,. 2nd vd, ChMIt', C [h"m,l'. "pringllvld. I";" -t, LMmandv. A, \1. L.J pM,'!I',,,' '"f'r,lnlll"',l1rC' du \'! Id,lv "phla!m"pil'siv Intc'rnllc'k,lIn' f',"I,'r"'lIrv! ,',eI, l '/,1, 11111111/(" ({'Ill"') 29: ;21-;311, 1%", ~, Rclthsteln. T, L.. ,lI1d :\!I'''rd. C f . II', 1'<"tcTI,'r II1tl'rnu· (il'M "phlh,llmop"'gi,l, "\1',1" .\','//1',,1 24: 11/1-202, 11/;-1 h, K"mmvrl'il. C,' Inll'rnudc',lr "f,hlh,lllll"f,I,'gu "I ,l['du,·· tlll11: i.... llldtl·d Inl~).llrnlL'nt III phd ..·.]l tllULn nhlt~lr ,ldl\-jt\ 111 "'upr,lflull"',lr Il"·dllll"'. :\llh t)/,hthlllllll/. q3: ;."'1 ;1.+. l"l:--; 7, ("IIMd. 1\1 . fb,·r. A, 1\1 '-oln',dll'r. L1 .. ,lIld 1{"llIlh I Dt It· ... pp.... lt.·f!\'r intt.'rnlll.:lt..',lr \ 'phth,tlll'h 1~11t.·~1,1 l·\I .... t \ l"t," pl1rt un l'11'\'l'J) Ll .... l·.., .lnd till' rl"''lulh tIl 1l1..-uh1hr,lvdn !'t', ''!','//I'"I, (/',,1'1') US: 21/~~12. 11/;-'1 ,., '["pil"". II, IV 1'<"tvl'I,'r II1Ic'rnll,lv,H "phlh,lIIl1"I'lvgl,1 "I I.utl ..\/1/1 ('1,"111"111,,,1, 13: 221 22;. I""" 'I, N,wt." W, I I I.. ""d (;\'g,l\. I' :\,: ~,!I"'r IInl'r"gn"t'''11 "t dq.':'l·nl'r,lltl1g d\tlrh III till' ll'lltr.d Ill'r\'tlll"" .... \· .... tl'Ill-.1 11111l1l( It,d Ivch"lc, ... 1",// 1,'eI,,",1 2'1: 1/1 "1.11/;-t Jll, !-t"". R, I' . ,l1ld I "',nwr. I I",,, Ilwlh"d, '''I' ,,'1",1,\'1' lin, prt'hll.l(ltlll til dl'gl'l1l'f.lttng ,\\tlll'" tI,,,,,.1 tlll'lf ... ,'n.q'lh: l'ndlng'" 111 till' 1t.'n1LII Ill'r\PU'" ... \ ... tl'1ll I"d/l/ 1,( ... 04; ~hl) In. 1%7 11Il,I"h"\\,",,. 1\ dl ... ",",jtl·Il\\·"·ndl'r. I C/1l2, 12, 1,Il"h,h. I' i\, IIIl"'lllh " 'upr,lnll"I'''lfC' n1l'dl"II'f',Hc"". 1\1/11, ,\1",",/,/>{ "\/lXo'I,I,,',II.,1 73: -t71--t;-h, IlJ24, I~, C,pilkr, W, (;, ()l'hth"lm"l'lt-gi" mlt-rnudc"J1'" "nlc'o,,1': ,l l',I"'l' wilh Ill'\:rnp"'\,. Hnll1/ 47: Jo4; - 1:;;, Iq~-l. HIL/UD\/\L IN I/I\NLlc'll ,\1\ (J/'/11l I/\IA)( )f'LLC//1 65 ~S. ('r,1I1<'. r 1\ ) l'l'. I, I). 1\,II1lh." 1\' ,1I1d Ilt-f,I"I. " " An.11" .... \.... pI dl.H.ldl'rl .... tll l'\'l' llhl\Tllll'llt ,lbllt11'l1l,dllll"-' III inkrnll,k,lI l'f'hlh,dll1l'f'k.>;I,' \" II ('1,11111.11'/1,,; Illl: 211,,· 2111 Iq~., ~4 1:'nl..'\.- ......\.)11 r IIltl'rIHh.ll,,11 tl~'hth.J1rlltl~lk.~~l,1 ,Ind ~',II'.Ih""I'" l't Ihll"ll\ll1t.ll ~.llt· L!d l l,t/ltlid/IIII'/ -11: hq~ ~l)~ !1I,,-, ~l) Trlll)s!. H \ \ l.nl/l1<'1 I \1>1,1 I \ ,lIld Ilvl, ". I, l L'f'I"',,1 11I'1,1~lllt" ,Ind /l11.'IIlLII k,1I "f'hlh,1I1l1"f,I".I;I.I \I IIh br,lIn ... tt.'ln ~ltl)I1l.1 "t/: \('Iill'/ .'1'7: -tl\ -I-'ll IllSl) ~l Lt'f'11ll' I I ,lIhi \'1"l'IlI,I.,1 \1 H,l.lln,1I /111<'1111111".11 l)f'hlh,IIIl"'I)k~", ,111<'1 /llll,llhl",1I ,h\'IlI\'II"'I'I['1 ,lilli, 1.1 nl,lllrr,hil.llllll1 '".' I l );':.'tl:,/,'II,I,< 4:!: ,'-\;1 S;\ IllS] ..C l~r,l\l"'H.'l \ \1 .11hi I tnt\\ Il'~ I ...... \lllll' .l!kH'lll 1\111- [,ll'dh l l1'" 1'1 the IllUll11ll11h11 Itllll~'ll" III till' l,ll .11l t'\~1l'rl1nt'I1t. ll "'(lId, \\ 1111 (1,lll'1 (I'\, hlllqlH''''' I~/III!/ f\l" HI: :;.+:,\_ ;;\ \\.1-,+ ~.' H,I~\'I " ,1I1d 11I>;h'I\'l/l -. \1 1'111 ""1,,.>;11,11 IdvIlIIII"Itl1.. 111 llt Intt'r1h'lIt"I. 1 n..., ,lJlli Illll(l.lIlt'lIf(ln..., In tht' ,Ibdll\..l'n..., nll\... lt'lI'" l~'.;:': !'l'" ql: ~q~ ~ljS Iq~; ~~ \I.1'1t'" 1(/ I, I "'Int'~" l ,,-. 111.>;h'lt'/ll. -. ~1 .llld Etl~t'r I, \ h'q'lh)~'h\"'lllIl,l.L.Il·,ll Ind Il',lth In I, d III tl'rlll'lI fl, 111"" III tht' l.)l"tt!('llhltllr 1l1l(k,1I .... th.lt prll]t'I..-t t(l thl' .1bdllll·ll .... flU( leu .... In tlh' (,It f~I,IPI 1\(· ... qo: '1U-t':::;, Iq-;:::; ~; BUltlwr-Fnnt'l t'r. I .-\ ,Ind Ikllil \. All ,,"I"r,ld,"- ~r"f'llI' ,Iu,h III 111<' [,.llh".lI' Irll/11 111<' f'"nll/1<' rt'll,ul,1f tl1fm,ltlll n 1[1\ lll\ t'l..i In h1.11"l/1,111t.ll L'\T I1ltl\t'l1lt'nt .... f-!t/i/lil R," 108: I;; - I "~ 1q71' -tt' BJ~l.'r R -\n,ltI.I111Il",11 ,lnd ~'h\""ll,lll.~ll-,d llry"ll1l/,ltlllll .... llt br,1In ... tt'm ~,.lth\\,l\'" undt'rIYlny, tht' (llntflll I,lt .~.l/t', In L,"::'\', ", L~.i':t' i'll ji'.lu,· ... tt"U\t'/Ul l !/-. f\. Ba"l'r, .llld A Berth"l Ed, E.I't'l !l'r \','rlil Ih,ll,llld BIIlIl1<'d",,1 I'rv". .-\m'-tt'rd.ln1, 1I..J:--:-- F'~" 2(C-~~2 r Cacek R R L"'.1II"" III h"l11 ,It'/11 Ilt'Urllll' f'rllil"1111.>; III the ll(tJlllmllttlr nu(lt,lI .... In the l'.lt l. 'I' \(/1/(1/ 57: -2:; - - -lq p.~:-- ~s Cralblt'l -\ \1 l)r.>;.1I1I/,IIIIlIl III "'-llllllllllll'r 1',llh",lIs /11 the (at ,1nJ rht· .... u .... n1llnh.L'\ In L~,ll/tili/ 1),1 l~ll::l' 1111 }~IIIII/ ... ft'll/ \'-"""1' R BaJ..t'r.•1I1el.-\ Ilt-rlhll/. hi, EI"'IIt'r \'Ilrlh H"lland HI"lllt'dJ<'.lI Prl''' ..'\Il"lvr,1-\l11 jq;,;,. f'f' ;''I-,S;~ -ly Hl,'t::;h .... tt'ln ~_ \1 .-\bdul,l'n .... dlld Pl"tdlI11111tl1f Inh..TnuLll\H neuflln...,' felatltln hI .~a/l· In l-Illlfrll! (II l~I1:t' Ill/ }1/i1 11/';' ft'll/ \·(I<r"",. R BaJ..t'r. and A Bt'rth,,/, Ed, EI"'I'It'r i\:llrlh Holland B",m~d/(al rr~"..-\J1l,lt'rdaJ1l. 1'1;';'. f'f' I ;,-Ih~ ;(1 Steiger. H I and Buttnl'r-Ennt'Il'r. I Rl'lal,,'n,hlf' bl" t"·een ml..ltllr neurun.;, dnd \nterneUfl1n .... in thl' abduLl'n..., nucleus. a dl'ublt, rl'lrl)gradt' Ira't'r ,llILh In 11ll' ,al Hr,I//1 Re" 1~8: ],s;]-h" ]'1;,,,' -, I 1\"I1\"'r, tv1 II Ih,/ln I lIlllr,,1 lit '''IlIUgdll' l1<IrI/IlIlI,1I dnd \t'rtlt,lIl'\'l'llltl\t'l1lt'llh /:/(/11/ 10,1: 2'1 hl1, JlJ,''';(1 -,~ l '''I'''IlIl'!. \1 I', dlhl 11,111' '11, "I, III .·\hdull'lls InlnIHII It'dI' 11I·tlrll/l"" dlltl Iht'lf fltlt' III llln)U,~,ltl' hUfl/llntal ,>;,11" I l ""11' .\"111"/ lii'l: I'll - ~II'I_ IlI,S;1I -" Nd~,'lI c, ,1I1d ",""~I," I" 11.11"[\' Illl'lIl IrllJ1l Inkr111' 111"1111"" III Ilw .lhdlltt'Il"" Illlllt'll .... III ll1l'dl.l1 rl'l..tu"" J11tdtl111' 111111'" Int·tll,lIlllg t IIl1JlI,~.tll' ht11"1/11I11,d 1l\'...,Llgmu..., In thl' 1,,1 1'1' UI,IIlI I,,' 1'1:~, ,2. I')SII -,~ 1l/lIIIlVr-IIlIl.'II·r. I 1\ "Ild '\~,'rl. I<. .\1t-d",j rt'<'Iu' sub.~ nItJ~)"" Itt tIll' III Ullllllldllr Illltll'lI .... .Inti Ihl'lr clbdull'n .... InItTlllllk, ll" IIlf1111 III tht, mClnkl'\ (1 11111 1 '\/"IIII'! 197: I;' ~,S;, I'1,S; I <.. drpl'lltl'l", ~1 H .Illtl ( ,Iflt,tllll, l-, <.. (llnl~'clrl""(ln lJ! \.l' .... tlhlll.!!' dntl dbtltllt'l'" Illlt'flllll..ll'df f'nljl'( t]tln .... til tht' I1ll'dldl rl·(tll"" .... ubdl\I .... llJll lil till' lIt IIllll1),lIllr nUllt.'lI"" In thl' l11"Il~"I' UI,IIlI /,," 27~: I~~- I~ll. Ill,,', ~h \\'.ll'\\ll".l\ l\t'f1rl' ....t,llldtH1n tll thl' l'\trdl)( lILlr l11u ....lk.... In tilt· IllUltll11tJtlif 1l1ltll'l (I! thl' 1111 Hlk.l'\ I ("1.111/ 1 ·,I."url'/ 98: -t-tq ;II~. 1'1" :::;7 \\'dhlnan, I Ii 1'\·l' Illtl\l'l1ll'nt .... lndllll'd b\" "Il'dncal .... 111111I1dtllln lit thl' \..l'fl'brUIll In Jl1lJnh.l·\·..., dnd thl'lr rl'lc1tH)n .... hl~' tIl blld\' rl1ll\'l·Jlll'nt..." In flit' 1.)( II/I IIII/Iti l l ~lI ... ft'lIl ,\1 B Ikndl'f. Ed Harpl'r & [,,,,,. \'t'" )"rk. ]'Ih-t. pp 1s;-''I ", Rllbll''''''. D.-\ "Ild Iud" ..-\ E Elt' nll'l~mt'nh l'\'{lh.l'd D\" .... t1ll1ulcltHll1 lit tfllntall'\"l' held.... \ ('lIrfIJlI/ll';'11 1/ 32: h';' - h~~. IlJh'l :::;q 1<lJ11~11'1. R ~ (1111\l'fhl'l1ll'. dl\'l'ry,l'ncl' ~-'upl!]Jr:' rt'a(tHin .... and ,lCllIJ11J11tld,ltltln lIt tht' l'\·l· .... tfll111 tdr,ldl( ,::,tlnll1]Jtllll1 ut tht' 11l.11<lljUl' bf<lIl1 I l-IIiIlJl \l'/lI'II/ 115: 371-,lYY, l'Ihll hll Hubt'l. D Hand 1\1t,,,,1. T \, c,t,'rv"""f'I' \I"I"n In 111,1',lljUt' I11l1n~\'1 \/JIIII,' 225: ~I-~~. 1'1711 hI \1.1\...... L. E .'\l'ural ltlntnd (1t \l'fy,l'nl..-t' t·\·l' I1lt l\eml'nh ltll1\·l'fgl'nll' Llnd dl\l'r.~l'nll' nl'Uftln .... In I1lldl'f<lIn I .\(:/"' I,f/lI'I"; 51: III'II-IIIIS;. I'I,,~ /12 lillY!. \\. f dnd D.lftJtt, 1\. B ~lIF'f,lnlll']l',H dl ....llrdt'r.... III Ultd,lf ll)ntfU] .... \· .... !t'n1 .... In 111.1n In IIII' ((lilt/(li (ll Llll' ,\Ll~'t'. IIIt'l/I,. P. Bad'-I'-R,I,l, C ('IlJIm" and I liI·,it'. Ed.... A,a' dl'l11ll' Prt'S', "'t'" YIlrk. Iq;,1. p. 223 hJ Inllll'nl-Il), ~ r ,1nd B.llll'lt'f" R I ul't'r(tJ!t l .... \ .... ,oL,r,lntill)nl,1 III Ihl' I11ldl'ralll ,au"n>; ",lll-t'lt'd 1,11,1 tc'r,l I Jlltc'rnuclt'ar llphthcllnll)plt'glcl (\\·l'bll1t l ) I L-/P/ \t'lilr\ l )t '/zt l lL11nit1i 5: ~I_~;. 14~; b~. J\kCl'ttrJ'~. [' ,1I1d Eu,I",t' P TIlt''' t' I' In,' "ndWIllt'. \t'III,'-l)I,llliJ,Ji/lI,,1 5: llN-Il;. lq~; I ell1l ;\h,ltw-opJltllIl/mol, \'0/, b, .""0, 1. 19St> |