Complete Text (Part 1)

Google This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project to make the world's books discoverable online. It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. Marks, notations and other maiginalia present in the original volume will appear in this file - a reminder of this book's long journey from the publisher to a library and finally to you. Usage guidelines Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing tliis resource, we liave taken steps to prevent abuse by commercial parties, including placing technical restrictions on automated querying. We also ask that you: + Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for personal, non-commercial purposes. + Refrain fivm automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the use of public domain materials for these purposes and may be able to help. + Maintain attributionTht GoogXt "watermark" you see on each file is essential for in forming people about this project and helping them find additional materials through Google Book Search. Please do not remove it. + Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner anywhere in the world. Copyright infringement liabili^ can be quite severe. About Google Book Search Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web at |http: //books .google .com/I THE DIAGNOSIS OP NERVOUS AND MENTAL DISEASES PERSHING THE DIAGNOSIS Nervous and Mental Diseases HOWELL T. PERSHING, M.Sc, M.D. ILLUSTRATED. PHILADELPHIA : P. BLAKISTON'S SON & CO. IOI3 WALNUT STREET. 1 90 1 Copyright, 1901, by P. Blakiston's Son & Co. ••Mb • 1p 4-6> '\0\ PREFACE. The object of this book is to facilitate the recognition of nervous and mental diseases by physicians who are not specialists in neurology. It makes no attempt to add to the facts of medicine but aims simply to set forth a practi- cal method of diagnosis in as convenient and compact a form as possible. Neurological diagnosis presents peculiar difficulties for those who have not been specially trained in it. A thorough examination must be followed by a complicated train of reasoning in which there are many possibilities of error. To avoid the difficulties by leaving them all to the neurologist is impracticable, for cases of nervous disease, often simulating other maladies, are sure to come to every one who practices medicine, even to the specialist who has least to do with neurology.. In trying to teach an available method of diagnosis, med- ical writers may well adopt a plan extensively used in other sciences. The student of botany does not have to carry in mind the characters of all the species he may possibly meet in order to find the name and classification of any speci- men in which he may be interested. He is provided with a table, or ** key," in which there is a condensed description of all the classes, orders, genera and species, so arranged that, having made a proper examination of the specimen, he can rapidly find the divisions and subdivisions to which it belongs. The same method is used with great advan- tage in zoology, chemistry and mineralogy. Of all the branches of medicine, neurology is the one to which it is most applicable. 540^^ 6 PREFACE. Some years ago, for the use of my classes, I began the construction of a series of diagnostic tables, under such general heads as Hemiplegia, Paralysis of Ocular Muscles, Optic Neuritis, Headache, etc., adopting the form of a botanical key. These tables have grown until they pretty fairly cover the field of neurological diagnosis and they are offered to the profession in the hope that they will be practically useful as an outline map of the field. They aim to show, explicitly but briefly, what symptoms are the most important in a given case of nervous disease, and how an analysis of the symptoms should lead to the recog- nition of the disease ; in other words they attempt to show on paper what a neurologist would have in mind in con- firming his diagnosis, step by step. As an intelligent use of the tables presupposes a knowledge of the essential features of the case under consideration and the ability to recognize certain general conditions, they are preceded by a description of the methods of examination and a brief discussion of the signs of organic disease, hysteria and neurasthenia. It is of course understood that such an outline of diag- nosis should be used as an adjunct to some complete trea- tise on nervous diseases and one of the hopes entertained by the writer is that it will make the fuller knowledge of the best text-books more readily accessible to the busy physician. CONTENTS. EXAMINATION OF THE PATIENT AND THE GENERAL SIG- NIFICANCE OF SYMPTOMS 17 Blank Forms for Recording Cases 17 Family History 17 Personal History 18 Previous Illnesses or Injuries 18 Mode of Onset and Course, of Present Illness 18 Present Sufferings 18 Nervous Spells 18 Syphilis and Other Sexual Disorders 19 Alcoholic Excess 20 Uric Acid Diathesis 20 Causes of Exhaustion 21 Importance of Studying Mental Peculiarities 21 Present Condition 22 General Appearance 22 Motor Disorders 23 Electrical Reactions and Trophic Condition of Muscles. . . 30 The Reflexes 40 Tests of Cutaneous Sensibility 48 Posture Sense 53 Taste and Smell 53 Examination of the Ear 53 Examination of the Eye 54 Examination as to Speech 64 Examination as to Mental Condition 65 THE RECOGNITION OF ORGANIC DISEASE THE PRINCIPLES OF LOCALIZATION . THE SIGNS OF HYSTERIA . THE DIAGNOSIS OF NEURASTHENIA . MIXED FORMS OF DISEASE 69 74 78 84 86 8 CONTENTS. THE RECOGNITION OF SPECIAL DISEASES . 4 • . 87 Explanation of Tables 87 Diseases Which Maj Cause Hemiplegia 89 Localization Diagnosis in Hemiplegia 94 Partial Hemiplegia and Monoplegia 96 Localization Diagnosis in Partial Hemiplegia and Monoplegia . 99 Paraplegia and Double Hemiplegia 100 Localization Diagnosis in Paraplegia and Double Hemiplegia . 107 Paralysis of Ocular Muscles 1 1 1 Localization Diagnosis in Paralysis of Ocular Muscles . . .120 Facial Paralysis 123 Bulbar and Pseudo-bulbar Paralysis 125 Laryngeal Paralysis 128 Paralysis of Partial or Irregular Extent 130 Ataxia 136 Tremor 139 General Spasms 142 Localized Spasms 149 Optic Neuritis 159 Optic Atrophy 165 Trophic and Vaso-motor Symptoms 169 The Pains of Nervous Disease 174 Vertigo 193 Coma 197 Disorders of Speech 199 Insanity 205 THE DIAGNOSIS OF Nervous and Mental Diseases. EXAMINATION OF THE PATIENT AND THE GENERAL SIGNIFICANCE OF SYMPTOMS. In order to be thorough the neurological examination must follow an orderly routine. In any case involving difficulties of diagnosis or treatment it is true economy of time and labor to get all the available data and accurately record them at the beginning, making such additional notes from time to time as new facts may require. For this purpose loose sheets of paper with printed headings, properly arranged, are most convenient, although an ordi- nary record book may be used. FAMILY HISTORY. After getting a general idea of the patient's complaint and making the usual notes of the name, age, race, domes- tic condition and occupation, inquiry is to be made as to the family history. The state of health, if living, or the age at death and cause of death, should be noted of each of the parents, grandparents, brothers and sisters. Care should be taken not to overlook the existence, in any of the near relatives, of nervous or mental disease, tuber- 2 17 l8 NERVOUS AND MENTAL DISEASES. culosis, rheumatism or gout, and a general denial on the part of the patient should be supplemented by specific in- quiries, extending often to the history of the uncles and aunts. PERSONAL HISTORY. The salient points in the personal history prior to the present illness are first to be noted in chronological order, after which the history of the present illness is to be ob- tained with special reference to the first symptoms and their mode of onset, whether sudden, rapid or slow, the order in which the subsequent symptoms have appeared and the patient's complaints at the time of examination. Skilful questioning will be necessary to bring out the full history and it should be definite in regard to the following subjects : 1. Injury at birth. 2. Damage to the nervous system by previous diseases, such as scarlatina, influenza, meningitis, etc., or by injury. 3. Convulsions or nervous spells of any kind. 4. Syphilitic infection. 5. Other diseases of the sexual organs, real or imagi- nary, and sexual excesses. 6. Habits as to alcohol, tobacco and other possible poisons. 7. The uric acid diathesis. 8. Exhausting influences and signs of exhaustion. 9. Abnormal suggestibility, morbid fears, hypochon- driacal worry and other signs of mental instability. Possible injury at birth is of especial importance when paralysis, spasm or arrest of development dates from infancy. If convulsions or nervous spells of any kind have oc- curred care is to be taken to ascertain when they began, how often they have recurred and under what circum- EXAMINATION OF THE PATIKNT. I9 stances, as well as to get an accurate description of them. It must be remembered that some symptoms, such as at- tacks cii_pettl fttal, are not likely to be mentioned unless the examiner asks specifically about them and, on the other hand, that leading questions will often elicit totally incor- rect answers. Syphilis is so common a cause of headache, neuralgia, and many grave organic affections and so much depends on early specific treatment that it is difficult to exaggerate the importance of its prompt recognition. There need be no hesitation about asking any male patient whether ven- ereal infection has occurred and cross-examining him i£ the answer is negative. When the direct question cannot be asked, as in the case of most women, or when the an- swers are inconclusive, the examiner must be alive to the significance of the symptoms of syphilis, such as the erup- tions, mucous patches, nasal ulcers, alopecia, keratitis, iritis, choroiditis, nodes on bones or cartilages, enlarged glands, nocturnal headache, etc. When hereditary syph- ilis is suspected inquiry is to be made as to snuffles, emaci- ation, eruption and parchment- like character of the palms and soles in early infancy. The historj' as to sexual disorders other than syphilis is important because they occasionally cause reflex pains and 'ery often are a source of exhaustion or worry. Worry- ing about an imaginary disease may be far more harmful than the physical effects of the real disease, so patients should be induced to express themselves freely. Many a man carries a mental burden for months or even years be- cause he has an occasional seminal emission or has dis- covered a little mucus at the meatus, which he fancies to be an exhausting seminal discharge, or because he has dis- covered the normal epididymis or the veins of the sper- matic cord or that the left testicle hangs lower than the 20 NERVOUS AND MENTAL DISEASES. right. That a nervous woman's mind is often fixed upon her pelvic organs to her great detriment is well known to every physician. A morbid idea of this kind often con- stitutes a mental traumatism which is the most important fact in the case, and the removal of the idea may be the most difficult as well as the most essential part of the treatment. A true estimate of the effects of sexual excesses and of masturbation requires careful discrimination. In many cases these vices are an important physical cause of ex- haustion, but in many other cases the fear and remorse oc- casioned by past errors are of serious import while the physical effects are insignificant. The intemperate use of alcohol is generally freely con- fessed by men but often denied by women, who are more apt to drink secretly if at all. When excessive drinking is not confessed, alcoholism may be revealed by a history of gastric catarrh witl^ morning vomiting, delirium tremens or multiple neuritis with the mental state characteristic of the alcoholic form. The possibility of poisoning by lead, arsenic, mercury, carbon disulphid or other toxic agents may have to be con- sidered, especially in connection with the patient's occupa- tion. The uric acid diathesis is a very important factor in the etiology of headache, neuralgia, sciatica, neurasthenia and mental depression, as well as of ordinary gout and rheu- matism. No uncertainty as to its essential cause should prevent its full recognition in diagnosis and treatment. A history of muscular or articular pains without organic cause, or of repeated attacks of tonsillitis, pharyngitis or eczema, or of so-called bilious attacks, or even a history of head- ache or despondency habitually worse in the early morning, ought always to suggest the possibility of this condition being the cause. If further inquiry shows that the urine is often dark and sometimes deposits urates the possibility be- comes a probability. The caiisKS of nervous exhaustion, such as the infectious diseases, repeated pregnancies, lactation, overwork, anxiety and grief, are generally clearly indicated in the patient's account. The signs of exhaustion, such as early fatigue, irritability, lack of zest for work and a loss of the former ambitions and interests, are also likely to receive prominent mention. More often overlooked is the fact that moral delinquencies, such as neglect of plain duties, cowardice, addiction to stimulants and narcotics and offenses growing out of irrational antipathies or unrestrained impulses, may have their origin in exhaustion, especially in patients of neurotic inheritance. In functional nervous disorders it is of the greatest im- portance for diagnosis and treatment that the facts in the personal history which reveal the patieiit's mental peculiari- ties should be fully noted. If the patient tells of most e.- traordinary effects of medicines, of queer sensations felt on the approach of a thunder storm or while riding in an elec- tric car, or of severe pains or profound emotional disturb- ance caused by some trivial occurrence, the physician, in- stead of controverting the statements at this time, should be an interested and sympathetic listener, and so lead the conversation as to get a full understanding of the degree of emotional instability and susceptibility to suggestion. For the same reason, if the patient is afraid to go into the street alone, or is absurdly convinced that his heart is seriously diseased, he is not to be laiighed at, but encouraged to tell the whole of his troubles. Failure to elicit this part of the history often causes fail- ure in the management of the case when better methods would insure success. Even if the diagnosis be correct, a 22 NERVOUS AND MENTAL DISEASES. plan of treatment which is perfect on the physical side may be rendered useless by a mistaken idea on the part of the patient that he cannot stand some of the remedies or that his first temporary backset, after a period of improvement, shows the futility of continuing on the same plan. On the other hand, the mental peculiarities which are a source of danger may be made the means of securing confidence, obedience and unfaltering constancy by a physician who understands them. The psychologic management of neu- rotic patients is a difficult art which can hardly be taught on paper, but it is so important a means of success that every young practitioner should make a conscious effort to acquire it. The three questions to be kept in mind when taking a history of such a patient are : " What light do the mental characteristics of the patient throw upon the diag- nosis of his case? " " What is there in his mental constitu- tion which may endanger the success of treatment?" and " How can his peculiarities be made to contribute to a suc- cessful result? " It is hardly necessary to remind even the beginner in neurology that he should not express an opinion based on the history alone, but should always proceed to a thorough physical examination. THE PRESENT CONDITION. The objective examination should be begun by observing the general appearance as to vigor, color, state of nutrition and expression of the face. Any abnormality in the size or conformation of the head or any of its parts will be ob- served at the same time. The actual bodily weight