Complete Text (Part 9)

paralysis is congenital or occurs in early infancy, associated with globular enlargement of the cranium. Convulsions and other paralyses common. Hydrocep k alus. . The paralysis occurs at birth or afterward, a. The combination of other symptoms, especially hemiplegia, headache, dizziness, vomiting or mental impairment, with the ocular paralysis in- dicates the existence of coarse organic disease within the cranium. NERVOUS AND MENTAL DISEASES. i. The onset of symptoms is sudden and 5 Occurs at birth. Hemiplegia, diplegia or monoplegia accompanies the ocular par- alysis. Epilepsy and mental defect com- mon in survivors. Cerebral Birth Palsy^ generally due to meningeal Hemorrhage. %% Immediately follows a blow on the head. Damage to nerve trunks or nuclei by Concussion, Hemorrhage or Frac- %%% Is not related to jnjurj- of the head. Hemorrhage or Thrombosis in the re- gion of the nuclei or, very rarely, hemorrhage into nerve sheath. . Onset of cerebral svmptoms acute in a few hours to a week. PARALYSIS OF OCULAR MUSCLES. § A sour e of intracranial infection or ir- ritadoii is present, e g., purulent otitis media, tube rculosis, pneumonia epi- demic nflu nee or insolation. Onset marked by headache and fever, often accompanied by vomiting. General hy- peresthesia exists at first, but is soon fol- lowed by delirium vrliich merges into stupor and coma, headache persisting as long as the patient can answer questions. Rigidity of the neck with retraction of the head, localized twitching and general convulsions are common. Other paraly- ses may occur. Optic neuritis, rarely intense, is common when the disease is at the base, rare when it is over the con- vexity. Meningitis, possibly cercbritis or abscess. %% The eye-lids and temple on the affected side are edematous and distended by venous blood and the eye-ball is prom- inent. The patient is depressed by an exhausting disease or there is a source of infection. Temperature normal or only slightly raised, unless meningitis also exists. Thrombosis of Cavernous Sinus. §§S Ocular paralysis preceded or followed by atrophic paralysis of limbs or of lips, tongue and throat. No sensory loss. Onset like that of an eruptive fever. Polio-encephalitis, acute infiamma- tion of nuclei analogous to polio- myeliiis. §§SS Onset of cerebral symptoms rapid in a person who gives a history or the 114 NERVOUS AND MENTAL DISEASES. signs of chronic alcoholism. Paralysis of the limbs accompanied by tenderness of muscles and nerves and sensory loss (alcoholic neuritis), often by character- istic delirium, usually, but not always precedes the ocular paralysis. Alcoholic Polto-encephalitis. iii. Onset acute, subacute or chronic. A source of purulent infection present, e, g, , suppura- tive otitis media, infected wound of the head, empyema or abscess, in any part of the body. Temperature irregular, usually elevated, but sometimes depressed. Rigors followed by fever and sweating common. Optic neuritis frequent, but rarely intense. Duration may be short or very long with a period of latency. Intracranial Abscess, iv. Onset chronic. § No source of purulent infection. Personal or family predisposition to new growths may be apparent. Temperature normal or only slightly disturbed. Headache gen- erally intense, often accompanied by giddi- ness and vomiting. Optic neuritis in four- fifths of all cases, usually intense. Pulse often slow. Course long and mostly pro- gressive. Toward the end mental failure tending toward stupor and coma. Intracranial Tumor^ including aneu* rism and hydatid cyst, §§ Patient alcoholic or syphilitic. Optic neu- ritis absent or slight. No fever or slowness of pulse. There may be spasm or paral- ysis in the domain of other cranial nerves, rarely in the limbs. Chronic Meningitis, b. Proof of the existence of coarse organic intra- cranial disease is lacking, but there is evidence of an intoxication or infection. PARALYSIS OF OCULAR MUSCLES. Ilj i. The paralysis is limited to the muscles con- certied in light reaction and accommodation. The patient, intentionally or by accident, is under the influence of atropia or a drug of simitar action, ii. Syphilis is active, as shown by the historj- or the presence of cliaract eristic symptoms. Syphilitic Iiiflammation of nerves or nu- clei or pressure upon them by a gumma. iii. The ocular paralysis follows diphtheria or, rarely, comes on during its course. Commonly limited to loss of accommodation together with paralysis of the soft palate but any or all of the external ocular mnscles may be affected and the mtiscles of the limbs may show a wasting paralysis with loss of tendon reflexes. In severe cases there is a corresponding sen- sory loss. Diphiherilic J^euritis. iv. The ocular purjilysis occurs as a synjptom of influenza, pneumonia, scarlatina, measles or typhoid fever or of poisoning by metals, pto- maines or gases, without other signs of men- ingitis. Probably /nJJammation of Nuclei., possibly Neuritis. 5 History of exposure to lead. Dark line at junction of gums and teeth. Lead often present in the urine. Characteristic colic and other paralyses, especially of the exten- sors of wrists and fingers, almost always precede ocular paralysis. Plumbic Neuritis or degeneration of V. Sugar in the urine, thirst, excessive appetite and general weakness indicate the presence of diabetes. Diabetic Neuritis. c. There are signs of degenerative disease of the ^ Il6 NERVOUS AND MENTAL DISEASES. central nervous system. Individual muscles sup- plied by the third nerve often paralyzed alone, indicating disease of the nuclei. The ocular palsy is often transient but may be permanent and some- times progresses to complete paralysis of all the external muscles of both eyes, accommodation and contraction of the pupil usually being preserved. Optic atrophy and the Argyll-Robertson pupil are common. The ocular paralysis may precede all other symptoms, i. The knee-jerks are absent. A history of lightning pains in the legs is common, also of loss of virility and slight difficulty in voiding or retaining the urine. The patient sways on standing with eyes closed and in the later stages the gait is ataxic. Argyll-Robertson pupil in most cases. Tabes. ii. Failure of judgment and memory, often com- bined with monstrous and unsystematized de- lusions of grandeur, accompanies signs of organic disease, among which inequality of pupils and stumbling speech are common. Paretic Dementia. iii. Intention tremor with nystagmus or scanning speech is associated with various signs of scat- tered lesions, such as isolated paralyses, con- traction of the visual fields with impairment of color sense, loss of smell, nervous deafness, etc. Disseminated Sclerosis. iv. Ocular paralysis associated with spastic para- plegia of gradual onset accompanied by ataxia. No sensory loss. Poster o-lateral Sclerosis. V. Ocular paralysis associated with wasting pa- ralysis and fine fibrillary twitching in other muscles. § Wasting paralysis begins in muscles of hand, shoulder or upper arm. PARALYSIS OP OCULAR MUSCLBS. iiy ! Spastic ■weakness of legs. Tendon re- flexes of paralyzed muscles exaggerated. Awnyotropkic Lateral Sclerosis. ! ! No weakness of legs until latest stages. Tendon reflexes of paralyzed muscles abolished. Spinal Muscular Atrophy. %% Wasting par.ifysis begins in muscles of lips, tongue, pharynx and larynx, interfer- ing with speech and swallowing. Bulbar Paralysis. vi. Ocular paralysis associated with loss of pain and temperature sense in areas where touch is retained, togetlier with paralysis and trophic disturbances of -variable and irregfular distribu- tion. Syringomyelia. d. There is no evidence of coarse organic disease, infection or organic degenerative disease of the central nervous system. The ocular paralysis oc- curs periodically, usually associated with migraine or severe neuralgia, at first completely disappear- ing after each attack but tending to become per- manent. Periodic Ocular Paralysis. (^Migraine Oph- thalmoplegique. ) e. The ocular paralysis is a complication of a gen- eral nervous condition in which rapid heart action, enlargement of the thyroid gland and exophthalmos are prominent symptoms. Exophthalmic Goitre, i. The ocular paralysis exists alone or together with facial paralysis. i. Muscles of one eve affected after exposure of that side of the head to a draft, '■^ Rheumalic" Ocular Paralysis, due to neuritis and analogous to the ordinary form of facial palsy. Il8 NERVOUS AND MENTAL DISEASES. ii. No cause can be found. Diagnosis necessarily uncertain but in most cases a symptom, of Syphilis or the first symptom of a degeneration such as Tabes or Paretic Dementia, II. The movement lost is one of the associated movements of both eyes normally under control of the vv^ill, viz., conver- gence, divergence or motion to either side or upward or downward. When either eye is tested alone all the muscles may act. To be distinguished from spasm of the muscles opposing those appearing to be paralyzed, although an error in this respect might not affect the pathological diagnosis. A. The combination of other symptoms vv^ith the ocular paralysis, especially of hemiplegia, headache, dizziness, vomiting or mental impairment, indicates the existence of coarse organic disease within the cranium. Ocular paralysis generally transitory. Diagnosis to be made as in Hemiplegia or as in /, B of this table^ q, v. B. Proof of the existence of coarse organic intracranial dis- ease is lacking but there is evidence of an intoxication (alcohol, opium, chloral, lead, diabetes, ptomaines) or an infection (syphilis, diphtheria, influenza, pneumonia, scarlatina, typhoid fever) . Infiammation or functional impairment of cortical centers^ subcortical tracts or nuclei, C. There are signs of degenerative disease of the central system. Optic atrophy and the Argyll- Robertson pupil are common. Diagnosis to be made as in Optic Atrophy or as in /, i5, J, c of this table, D. Signs of organic disease, intoxication or infection absent. I . There is weakness and lack of balance of the ocular muscles but no actual paralysis. Errors of refraction are commonly associated. The patient's nervous energy has been exhausted. Disagreeable sensations in the head and along the spine which shift their PARALYSIS OF OCULAR MUSCLES. II9 location within a very short time, irritability and morbid fears are common. Neurasthenia. 2. Ocular paralysis occurs and may vary or disappear under the influence of emotion or direct or indirect suggestion. History and other symptoms indicate the presence of hysteria, while no other cause can be found. Rare. Hysteria, 3. The ocular paralysis is a complication of a general nervous disorder in which rapid heart action, en- largement of the thyroid gland and exophthalmos are prominent symptoms. Exophthalmic Goitre, ^ . The ocular paralysis exists alon6 and no cause can be found. Diagnosis necessarily uncertain but in most cases a symptom of Syphilis or the first symptom of a degeneration^ such as Tabes or Paretic De- mentia* I20 NERVOUS AND MENTAL DISEASES. LOCALIZATION DIAGNOSIS IN PARALYSIS OF OCULAR MUSCLES. The nature of the lesion causing ocular paralysis affords some indication of its situation. Meningitis and syphilis are especially likely to damage the surface of the brain and the nerve trunks at the base ; they rarely attack the nuclei. Degenerative diseases, such as tabes, spinal mus- cular atrophy, bulbar paralysis, and the acute inflamma- tion of alcoholism or poliomyelitis attack the nuclei, usually on both sides. Paretic dementia may cause paralysis of conjugate movement (inability of both eyes to look in a certain direction) by damage to the cortex, or paralysis of definite muscles by damage to the nuclei. More precise indications are given by the distribution of the paralysis, as shown in the following table : I. The paralysis is limited to the muscles of one eye. Swell- ing and venous congestion of the lids and protrusion of the eye-ball appear along with the paralysis or soon after it. Optic neuritis or atrophy may occur. No signs of disease within the cranium. Lesion within the Orbit, II. All the muscles supplied by the third nerve are paralyzed or weakened at the same time. Other cranial nerves may be involved. The pathological condition is hemorrhage, men- ingitis, syphilis or tumor. Lesion at the Base of the Brain^ damaging the nerve trunk. A. The paralysis of the third nerve is accompanied by hemiplegia on the opposite side, with or without corre- sponding hemianopia. Lesion of the Crus, LOCALIZATION DIAGNOSIS. 121 III. The paralysis is bilateral and may be limited to only a part of the muscles supplied by the third and fourth nerves, the others retaining their function or becoming paralyzed at a considerably later time. The pathological condition is usually a vascular lesion, an intoxication, acute inflammation or a degeneration. Lesion of the Nuclei • IV. The external rectus of one eye is paralyzed, the motions of the other eye being normal. The pathological concjition is hemdrrhage, meningitis, syphilis or tumor. Lesion at the Base of the Brain^ damaging the nerve trunk, V. The external rectus of one eye is paralyzed and the other eye cannot voluntarily be turned inward. Facial paralysis may occur at the same time, or paralysis of the muscles of mas- tication, or facial anesthesia. Nystagmus is common. Swal- lowing and articulation are likely to be impaired. Lesion of Nucleus of Sixth Nerve. VI. There is inability to look in a certain direction, both eyes being affected alike. Usually occurs in acute cerebral lesiohs along with hemiplegia, the eyes and head being turned away from the paralyzed side. May be preceded by spasm in which the eyes and head are turned toward the convulsed (afterward paralyzed) limbs. Lesion of JFrontal Cortex or subcortical tract. 122 NERVOUS AND MENTAL DISEASES. FACIAL PARALYSIS. 1 23 FACIAL PARALYSIS. Muscles supplied by all branches of the seventh nerve paralyzed with wasting and loss of f aradic irritability in all but the mildest cases. ^ I. Paralysis follows external injury. A. Injury occurs at birth, forceps having pressed upon nerve near its exit from the skull. Pressure Neuritis. B. Paralysis follows wounds or operations about the ramus of the jaw. 1. Occurs immediately. Section or Crushing" of Nerve. 2. Occurs after a few days. Neuritis. C. Follows fracture of the skull, nervous deafness usually occurring at the same time. 1. Occurs immediately. Section or Crushing of Nerve. 2. Occurs after a few days. Neuritis. II. No external injury. A. Onset sudden, in a few moments. 1. Limbs on opposite side paralyzed (crossed hemi- plegia) or sixth nerve on same side. Hemorrhage or Thrombosis of Pons. 2. Nervous deafness and vertigo occur at the same time. Hemorrhage pressing on Seventh and Eighth Nerves. 3. Taste lost in anterior two-thirds of tongue on same side. Hemorrhage into Facial Canal above origin of Chorda Tymfani. 4. Face alone affected. Hemorrhage into Canal below origin of Chorda. 'Paralysis of the lower part of the face without wasting or loss of faradic irritability is included under the head of Monoplegia. 124 NERVOUS AND MENTAL DISEASES. B. Onset gradual but acute, in a few hours to a few days. 1. A source of intracranial infection or irritation is present. Onset of disease marked by headache and fever, often accompanied by vomiting. General hyperesthesia exists at first and is soon followed by delirium which in severe cases merges into stupor and coma, headache persisting as long as the patient can answer questions. Retraction of the head, local- ized twitching and general convulsions are common. Other paralyses may occur, especially in the ocular muscles. Optic neuritis, rarely intense, is common in the more protracted cases. Meningitis. 2. Suppurative otitis media present; no other cause. No other paralysis or spasm ; mind clear. Inflammation of Nerve Trunk, 3 . Face has been exposed to cold especially in a wind or draught ; no other cause. Eye muscles on the same side very rarely paralyzed. The most common form ; often called rheumatic. Inflammation of Nerve Trunk, C. Onset of disease chronic. I . Accompanied by headache and often by vomiting. a. Optic neuritis present, generally intense. Other cranial nerves affected, especially the eighth and sixth. Convulsions may occur. Pulse often slow. Intracranial Tumor ^ Aneurism or Cyst. b. Patient alcoholic or syphilitic. Optic neuritis ab- sent or slight. No fever or slowness of pulse. There may be paralysis or spasm in the domain of other cranial nerves, rarely in the limbs. Nerv- ous deafness and vertigo generally present. Chronic Meningitis. c. Intention tremor is present together with nystag- mus, scanning speech or other evidence of scat- tered lesions. Disseminated Sclerosis. d. Absence of knee-jerk and other symptoms indi- cates tabes. Rare. Tabes, BULBAR AND PSEUDO-BULBAR PARALYSIS. 12$ BULBAR AND PSEUDO-BULBAR PARALYSIS. Two or more of the following organs are paralyzed: lips, tongue, palate, pharynx and larynx. I. Onset sudden in a single attack. Paralysis commonly bilateral, rarely unilateral. Palatal, pharyngeal and laryn- geal reflexes usually impaired. Atrophy and reaction of degeneration may occur in affected muscles. Apoplectiform Bulbar Paralysis. A. Not immediately fatal. Thrombosis of Medulla Oblongata or^ very rarely^ Hem- orrhage or Embolism, B. Immediately fatal. Hemorrhage or Thrombosis of Medulla^ very rarely Embolism. II. Onset sudden but in two attacks, paralysis of the muscles supplied from the medulla not occurring until the second attack and the larynx usually escaping. Double hemiplegia or other symptoms show that each hemisphere is involved. Nutrition and electrical reactions of the paralyzed muscles not affected. Throat reflexes preserved. Very rare. Pseudo'bulbar Paralysis due to vascular lesion in each hemisphere. III. Onset acute, in a few hours to a few days. The affected muscles waste and lose faradic irritability. The throat re- flexes are lost. There is usually also atrophic paralysis of the eye muscles, face or limbs. A. The paralysis follows or possibly accompanies diphtheria, beginning in the ciliary muscle and palate. Diphtheritic Bulbar Paralysis. B. Paralysis secondary to influenza, typhoid fever or other infectious or toxic disease. Very rare. Neuritis or^ possibly^ Inflammation of Bulbar Nuclei. 126 NERVOUS AND MENTAL DISEASES. C. Paralysis is part of the primary disease whose onset is attended by headache, fever and perhaps vomiting or convulsions. Very rare. Inflammation of Bulbar Nuclei^ analogous to folio- myelitis. IV. Onset generally chronic, sometimes acute or subacute. A. There is disease in the upper part of the neck capable of affecting the ninth, tenth, eleventh and twelfth nerves at their exit from the skull, e» g.^ tumors, cellulitis, ver- tebral caries, wounds, etc. No signs of intracranial disease. Neuritis. B. No