Complete Text (Part 4)

there will be inability to retain urine or feces and digital examination will find the sphincter ani loose and flabby instead of contracting on the finger; these re- flexes, although not lost, are disturbed by disease of the cord above the centers and by bilateral brain disease, in which case there is both retention and incontinence of urine and feces, that is inability to secure voluntary evac- uations and inability to place restraint upon involuntary ones, but the sphincter ani is firm and contracts on the ex- amining finger. I Taking the reflexes as a whole, it will be seen that they furnish a means of testing an extensive series of reflex arcs whose centers form an almost unbroken line reaching from the lower sacral segments through the entire cord into the medulla and pons. As it is highly improbable, in any organic disease of the nerves, cord or brain, that all the reflexes should remain normal, their presence in a normal degree is often a strong reassurance when organic disease has been feared, and in medico-legal cases it may ' disprove the claim of an hysterical, neurasthenic or maling- I ering plaintiff that he is suffering from an irreparable '| ^injury. 48 NERVOUS AND MENTAL DISEASES. TESTS OF CUTANEOUS SENSIBILITY. The sensibility of the skin to touch, pain and temperature may demand careful investigation in certain cases. In making the tests the patient is blindfolded or required to keep the eyes closed. Sensibility to touch is tested by lightly touching various points with a camel's hair pencil, a bit of absorbent cotton or the end of the finger and noting whether the patient feels the touch and can locate it accurately. To test pain the quill end of the pencil may be sharpened or the point of a pin used to prick the skin ; when the pain sense is defective pricking the skin gives an impression of touch instead of a sharp sting. The temperature sense is tested by applying bottles or test- tubes, one filled with warm and the other with cool water, the temperatures being such as to cause a distinct feeling of warmth or coolness to the normal skin. These tests are quite decisive and easily made when th^ cutaneous sensibility is normal or is greatly impaired, but when the defect is slight the investigation is tedious and perplexing. In such a case it is important to compare the surface whose sensibility seems to be diminished with a part known to be normal, especially with the correspond- ing part on the opposite side of the body, and for a delicate test the two parts should be touched or pricked at the same time. In all cases in which sensory loss is an important factor in diagnosis the limits of the insensitive area should be carefully marked on the body and then transferred to a diagram so as to determine as accurately as possible whether it corresponds to the area of one or more nerves or spinal segments or merely to the external configuration of some part of the body or to a geometric area. (Figs. 8 to II, 28 and 29.) EXAMINATrON OF THE PATIENT. (deKCDdlng branch ■pir^ brauch). ■F Cutaneous Nerve- (Fram Ormerad. a/lit Floj Anterior Surlkce. NERVOUS AND MENTAL DISEASES. ioT Surface. (Fmm Ontiitod ) EXAMINATION OF THE PATIENT. 52 NERVOUS AND MENTAL DISEASES. Lumbar and sacraJ. oraDlerlorcruraL Poilcrlor tibial. I L EXAMINATION OF THE PATIENT. 53 THE POSTURE SENSE. The recognition of the posture of different parts of the body, without the aid of sight or touch, depends mainly on muscular sense, but is aided by the sensibility of the various parts of a joint and of the skin over it. It is tested by having the patient's eyes closed and then firmly grasp- ing the parts on one or both sides of a joint and putting it in different postures, telling the patient to imitate each posture with the opposite limb or to tell what is being done, TASTE AND SMELL. For testing taste one should have on hand solutions of sugar, common salt, citric acid and quinine, to be used in the order named. The tongue is protruded and held by the examiner while some of the solution on a brush or wisp of cotton is gently rubbed in on either side. The patient should nod assent or dissent to the examiner's questions without having the tongue released. Some- times, however, the taste is not perceived until the tongue is replaced, when it immediately becomes quite distinct. This as a rule has no clinical significance. Smell can easily be tested by dropping some perfume of any kind on a little cotton and holding it to either nostril. EXAMINATION OF THE EAR, Inspection of the external ear maj' reveal anomalies of form indicating degeneration and predisposition to neurotic affections. Hearing is most easily tested by holding the watch op- posite either ear and noting the maximum distance at which it can be heard. This distance is to be put down as the numerator of a fraction of which the normal distance is the denominator ; thus if the watch is heard at 20 inches 54 NERVOUS AND MENTAL DISEASES. and no farther, and the normal ear hears it at 30 inches, hearing is recorded as 20/30. If the watch shows deafness on one side the next ques- tion is whether it is due to disease of the external or middle ear or to disease of the internal ear, auditory nerve or brain. This question can be answered, aside from in- spection of the external auditory canal and tympanic mem- brane, by placing the handle of a vibrating tuning fork on the top of the head or on the upper teeth and noting in which ear the sound seems louder. If it is louder in the deaf ear then bone conduction is not impaired and the dis- ease is in the external or middle ear and has no significance from the strictly neurological point of view. But if it is louder in the sound ear bone conduction is impaired in the deaf one so the disease must be in the inner ear, auditory nerve or brain and the defect is called nervous deafness. The result of this test may be confirmed by comparing the patient's bone conduction with the examiner's in the following way : The tuning fork while vibrating strongly enough for the patient to distinctly hear it by bone conduc- tion is pressed on the temporal bone just above and behind the ear. The sound gradually becomes fainter and the patient makes a signal as soon as he no longer hears it. The examiner then immediately transfers the fork to the same position on his own head and if he still hears it the patient's bone conduction is impaired and the deafness is nervous. This method is especially valuable when hear- ing is impaired on both sides. In certain cases of nervous deafness it may be important to determine the limits of the auditor}' field for high notes by means of Galton's whistle. EXAMINATION OF THE EYE. A mere inspection of the eyes will often reveal impor- L EXAMINATION OF THK PATIENT. 55 tant s3-mptomR, such as drooping of the upper hd, protru- sion of the ball, difference in the pupils, strabismus and nystagmus. Proceeding to a more minute examination, the pupils should be compared with each other when exposed to light and again when shaded. Then each pupil should be tested for light reaction while the other eye is closed, the patient looking at some distant object so as to eliminate the effect of accommodation. In health each pupil contracts when a near object is looked at. This is called the reac- tion to accommodation, or convergence, and is tested by observing the pupils while the patient looks first at a dis- tant object and then at the point of a pencil close at hand, the line of vision remaining the same so as to exclude variations in the light. Inequality of pupils without loss of light reaction may be due to so many conditions of the eye, of the nervous system and even of other organs, that it has no definite significance when considered alone. But when it appears in addition to cerebral symptoms, such as headache, vomit- ing and disturbance of consciousness, and cannot be ac- counted for by disease of the eye or of the chest or neck, it is strongly indicative of organic cerebral disease. Ab- sence of light reaction, if not caused by a drug or by disease within the orbit, is proof of cerebral or cerebro- spinal disease, which is almost invariably organic. Ab- sence of light reaction together with preservation of reaction to accommodation constitutes the Argyll-Robertson pupil, a sure sign of degenerative disease of the central nervous system, often seen in tabes and sometimes in paretic de- mentia, A general idea of the condition of the motor apparatus of the eyes may be obtained by observing them while the patient looks to the right and left, upward, downward and 56 NERVOUS AND MENTAL DISEASES. obliquely. Nystagmus, a tremulous or jerky oscillation of the eyeball, may be apparent in the extreme positions although entirely absent when the eyes look straight ahead. Paralysis of the ocular muscles is of the greatest sig- nificance and must be looked for whenever organic disease within the cranium is suspected. Paralysis of the levator palpebrse is easily recognized as it causes ptosis, or droop- ing of the upper lid, which can be due to no other cause except spasm of the orbicularis. This spasm is rare and can readily be distinguished as an active resistance to the separation of the lids which causes fine, concentric wrinkles in the skin over them. Paralysis of any of the external muscles of the eyeball is indicated by four symptoms : (i) Displacement of the eye at rest in a direction opposite to that in which the paralyzed muscle should move it; e. g.^ in paralysis of the external rectus the eye is turned inward. (2) Limita- tion of movement in the direction in which the affected muscle acts; e. g..^ in complete paralysis of the external rectus the eye cannot be moved outward beyond the mid- position. (3) Diplopia, the image of the affected eye, called the false image, being displaced in the direction in which the paralyzed muscle should turn the eye ; when the posi- tion of the object requires an effort to look in this direction the two images are farthest apart, but when the object is carried to the opposite side, so that no effort is required of the paralyzed muscle, the two images come together ; e.g.^ in paralysis of the right external rectus the image seen by the right eye (false image) is displaced to the right of the true one when the object is directly in front of the patient ; when it is carried to the patient's right the images separate still farther but when it is carried to his left they come together again. In paralysis of the right internal rectus the false image is displaced to the left of the true one, the two images coming together when the object is taken to the patient's right. It will be noticed that the di- plopia is crossed (image of right eye to left and vice versa) when the axes of vision diverge and that it is homonymous (image of right eye to right and left to left) when the axes of vision are crossed, 4. Secondary deviation of the sound eye : When an at- tempt is made to look at an object in the direction in which the paralyzed muscle should move the eye, the sound eye, if covered, will move too far in this direction, but will immediately move back to its proper position when un- covered. The displacement of the eye at rest and the limitation of movement are readily observed by the examiner except when the paralysis is slight or affects one of the oblique muscles alone. It must be remembered, however, that in coma and even in deep sleep the eyes may diverge and be turned upward and yet be perfectly normal when con- sciousness returns. To study the diplopia let the patient look at a candle or a vertical strip of white paper and, in order to distinguish the two images, place a colored glass before one eye, pre- ferably the sound one. If both images are not readily seen or if no colored glass is at hand, have the patient close first one eye and then the other, carefully noting the apparent change in the position of the object. To test for secondary deviation hold a card between the sound eye and the point of a pencil held in such a position that to fix it with the affected eye the muscle in question must act. Then if the sound eye moves too far it can be obser-ed and on quickly removing the card it will be seen to move back to its proper position. The following table gives a condensed description of the signs of paralysis of each of the individual muscles : I J 58 NERVOUS AND MENTAL DISEASES. TABLE OF SIGNS OF PARALYSIS. OF EXTERNAL OCULAR MUSCLES. • Muscle. i Displacement I«iniitation of visual axis, i of movement. Position of false image. Secondary deviation of sound eye. External Rectus. Inward. Outward. To the side of affected eye. To the side oppo- site that of affected eye. Inward. Internal Rectus. Outward. Inward. Outward. Superior Rectus. Downward. Upward. Above and to side opposite that of affected eve. Upward. Inferior Rectus. Upward. Downward. Below and to side opposite that of affected eye. Downward. Superior Oblique. Difficult to detect. Difficult to detect. Below and to side of affected eye. Image tilted, top inward. Downward and inward. Inferior Oblique. Difficult to detect. Difficult to detect. Above and to side of affected eye. Image tilted, top outward. Upward and inward. The two internal muscles of the eye, the sphincter of the iris and the muscle of accommodation are also liable to paralysis, which is indicated by dilatation of the pupil and loss of light reaction and reaction to accommodation in the case of the sphincter and by inability to focus the eye on near objects when the muscle of accommodation is paralyzed. Individual ocular muscles may be paralyzed alone or in combination with others, according to the seat and extent of the disease. Such a paralysis is one of the strongest proofs of organic disease of the nervous system ; it may in rare cases be due to toxic influences without organic change or to a functional neurosis like migraine or epi- lepsy but it is practically unknown in hysteria. EXAMINATION OF THE PATIENT. 59 The external rectus is frequently paralyzed alone, being the only muscle supplied by the sixth ner'e, which from its long course is especially exposed to danger in disease at the base of the brain. Isolated paralysis of the superior oblique is also not rare because it is the only muscle sup- plied b}' the fourth ner'e. Either of these muscles may also be parah'zed by disease of the corresponding nucleus. All the other ocular muscles, external and internal, are supplied by the third ner'e and, in a lesion of the ner'e trunk, generally suffer together, so that the eye is turned outward, motion is limited inward, upward and downward, the lid droops, the pupil is dilated, accommodation is lost and there is crossed diplopia. When only a part of the muscles supplied b>' the third ner'e are paralyzed the dis- ease is more commonly in the nuclei beneath the aqueduct of Sylvius, but it may possibly be limited to the corre- sponding branches of the ner'e. So far paralysis of individual muscles or muscle groups has been spoken of. But there is another form in which the muscles, tested separately, give no characteristic sign of paralysis or even act normally, while there is distinct loss of power to perform one or more of the associated movements of both eyes: viz., convergence, divergence, looking to either side or upward or downward. As these associated movements are normallv under voluntarv con- trol, it will readily be understood that they may be lost, as a result of suggestion in hj'steria. They may also be lost in organic central disease, particularly of the cortex. Spasm of ocular muscles, especially of the internal recti, may occur and may be mistaken for paralysis of the op- ponents. In spasm the limitation of movement, especially if the eyes be separately tested, is less marked and less constant, the double images do not separate on looking 6o NERVOUS AND MENTAL DISEASES. one direction to come together again on looking the oppo- site way and there is no secondary deviation. Lack of proper balance of the muscles moving the eyes, not sutHcient ordinarily to cause diplopia, may be of con- siderable importance in hysteria and neurasthenia, al- though the reports of remarkable cures from the correction of such a defect alone are to be received with much allow- ance for the patient's susceptibility to suggestion. The balance of the internal and external recti when the eyes are at rest can be tested by placing a prism of eight or ten degrees, with its base downward and accurately horizontal, in the trial frame before one eye, and then having the patient look at a candle or a vertical strip of paper or a horizontal scale at the other side of the room. The prism causes vertical diplopia and if the muscle balance is nor- mal the upper image will be exactly above the lower or (on account of the slight convergence necessary in looking at an object only a few yards distant) very slightly dis- placed to the side opposite the prism. If the upper image is displaced a few inches or