Neurological and mental diagnosis; a manual of methods

Front matter

Class re q 3 ^ a

Book .. C &

Copyright N°

Preface

This volume is designed to aid the student and general practitioner to make thorough and systematic examinations in nervous and mental diseases. A definite method of procedure is laid down in both lines of examination in order that proper analysis may be easily and readily made in routine case study either in hospital or private practice. The necessity and desirability of forming correct habits in case examination are in line with the advanced teachings of modern medicine. The chapter on neurological methods is by Dr. Clark and that on mental examination is by Dr. Diefendorf.

THE AUTHOES.

February 1, 1908.

Contents

PAGE

Methods of Examination in Neurological Diagnosis 1

Methods of Examination in Mental Diagnosis . 61

Part I CHAPTER I

In the clinical study of nervous diseases it is essential for accuracy and rapidity in diagnosis to employ a systematic method of examining patients.

Inasmuch as the forms of nervous diseases vary so much in character, no one method of examination can always be adhered to rigidly, but this does not destroy the feasibility of using a more or less definite system of study of the cases. In the following pages a general method of procedure is indicated which may be modified or curtailed to suit individual diseases. When a patient is first seen by the physician it is often eminently desirable to make a preliminary rapid survey of the case. Such examination sometimes enables the physician to make a provisional diagnosis for immediate treatment and gain intelligent guidance for subsequent more elaborate and special examination. A preliminary examination should cover the essential points of an extended scheme; a detailed record of the latter is shown in a composite case which is reproduced here to illustrate the points in the examination. In recording the clinical findings of the examination intelligible abbreviations should be used wherever possible, but the use of symbols is to be discouraged for obvious reasons.

The diagnosis must rest largely, at least in most cases, upon the careful objective or direct examination of the patient for the detection of the signs and symptoms of disease. The history of the patient and of the development of his disease as gathered from the patient or his friends is of course of great importance, but the diagnostic indications that are obtained in this way are to be used in subordination to the objective signs of disease about to be detailed. Where the indications derived from the two sources conflict, preference is always to be given to conclusions that are obtained from an examination of the patient. In short, an effort should constantly be made to make the diagnosis of organic nervous diseases as purely objective as possible, the history being used chiefly in subordination to the physical signs for the confirmation and correction of the diagnosis based upon them.

Complaints. — A brief statement of what the patient complains and the duration of the disorder should begin the history.

Family History. — The cause of death of the immediate relatives should be learned as far as possible. Particular inquiry is to be made regarding alcohol, syphilis, tuberculosis, insanity, epilepsy, or other nervous diseases in the family.

Personal History. — Noteworthy facts of intrauterine life, birth (its accidents and incidents), diseases of infancy, habits, etc., are to be recorded in chronological order. Special inquiry is to be made concerning evidences of rickets, as this often seriously influences the vulnerability of an individual to nervous stresses in later life, particularly epilepsy and allied conditions. A very important question is that of infectious diseases. Both the acute and the chronic infectious diseases may lay the basis for nerve troubles that follow directly or after an interval of weeks, months, or years. Typhoid, smallpox, diphtheria, scarlet fever, measles, and influenza are specially to be noted. Tuberculosis and nerve diseases are often related. The greatest care must be given to the question of past venereal diseases, particularly syphilis. The misuse of alcohol, morphine, cocaine, chloral, and other poisons is to be noted. Inquiry should also be made concerning long-continued occupation with lead, arsenic, mercury, copper, brass, etc. Anomalies of sexual life, such as masturbation and perverse instincts, are to be asked after. Injuries, overexertion, and mental excitement play very important roles in the etiology. The age of puberty, and in women, periods, — frequency, pain, etc. Number of children and miscarriages, etc., should be carefully inquired into.

Present Illness. — A chronologically arranged account of both the physical and mental symptoms should be followed by a summary of the present condition. The inquiry should be specific concerning alienation, exaltation, perversion, depression, defect, stupor, delirium, coma, memory, vertigo, convulsions, headache, epileptic or apoplectic attacks, vomiting, etc.

Physical Examination. — For the present purpose the special examination can be made under the following headings: —

A. Cranial Nerves

I. Olfactory. — Injury to this nerve shows itself by loss of smell. When the sense of smell has been lost, the person often complains simply of loss of taste, as this is the more serious deprivation. Since disease of the mucous membrane of the upper part of the nose may show itself in the same way, this must be excluded in case loss of smell is found. To test the sense of smell a bottle stopper or a piece of cotton touched to some odorous substance (asafoetida, musk, peppermint, cloves) is held for a short time to one nostril while the other is closed; the patient is to name the substance, or at least to say that the smell is familiar. These substances are chosen because they act on the sense of smell only; moreover, they are easily identified and named. Many persons, even though such common substances are employed, can only recognize an odor, but cannot name it; this is, however, practically sufficient, as all that is desired is to know that the nerve impulses are transmitted.

Only a small amount of the substance should be used in the test. It is used on the bottle stopper or on a piece of cotton. This is applied to the nostril for only a brief time, because excessive stimulation may deaden or paralyze the weakened or imperfect sense organs before the entire examination is finished. The test is applied to the nostrils alternately.

II. Optic. — The only data required are those concerning acuteness of vision, the limits of the field of vision, and the state of the optic disk. The acuteness of vision is tested by the familiar test types of Snellen. The types are placed at a distance of 6 meters (20 feet), and the patient is required to read the letters on the chart; the number under the line of smallest letters he can see is placed under the number 20. With normal vision he should read to the line having the number 20; his vision would then be 20/20. If his vision is less than this, he moves toward the chart until he can see the largest letter; if this is at 8 feet, his vision is 8/20. If the top letter cannot be read, the distance at which the fingers can be correctly counted is recorded, thus V fingers at one foot, or at seven inches. If this cannot be done, the hand is moved before the eyes and perception of hand movement is recorded. Where no vision of form is found, the perception of light (P. L.) is tested by shading and exposing the eye or flashing a light into it in a dark room.

Each eye is tested separately. For testing near vision, Jaeger's test type is often used.

To find the limits of the visual field the hand or candle test may be employed. The patient is placed with his back to the light about two feet in front of the examiner. One eye is covered; with the other eye the patient must look at the examiner's eye constantly. The examiner's hand is moved in various directions from outside the field of vision inward until the patient sees it. Both examiner and patient should see the hand simultaneously if the field has the normal extent. A lighted candle may be similarly used. When defective, the field may have temporal, nasal, upper or lower contraction. Scotomata are detected by passing the hand through all parts of the field. The blind spot is an anatomical affair.

The examination of the fundus is made with the ophthalmoscope by the direct and the indirect method. These examinations should be made whenever organic lesion of the central nervous system (especially in cerebral cases) is suspected.

Ill, IV, VI. Motor Oculi, Patheticus, and Abducens. — These are examined together, as they control all the movements of the eye. The patient is required to follow the finger from right to left, left to right, up and down, and approaching in the median plane to the nose. The head must be held steady (candle test with red glass in front of one eye).

The first point to be tested is (a) limitation of movement. This occurs always in the direction in which the paralyzed muscles act; limitation of movement of the right eye toward the right side indicates paralysis of the right external rectus, which is controlled by the sixth nerve, and so on.

The next test concerns (b) correspondence of the visual axes. Normally the visual axes remain parallel for fixation at infinity in all associated movements of the eyes. Any non-correspondence shows itself as internal or external strabismus in one or both eyes.

The third test concerns (c) secondary deviation of the sound eye. This is the most delicate test of a slight paralysis in any single eye muscle. It never appears in any form of ordinary squint. To carry out the test the sound eye is prevented from seeing by screening the object by the hand or a piece of cardboard; the patient fixes the object with the affected eye. The object is moved in the direction of one of the muscles. If any paralysis is present, the sound eye will move farther than the affected one. The increase over the primary deviation of the axes is called the " secondary deviation." The result is tested by covering the paralyzed eye and requiring the

B A C *

Fig. 1. Diagram to illustrate Production of Diplopia by the Erroneous Projection. In Consequence of Weakness of the Right External Rectus, the Image of A formed at the Macula, M, of the Left Eye, Falls within the Macula of the Right Eye at a. But the Effect corresponds to that Necessary to bring the Macula to m (in the Broken Arc).

Hence B, whose Image is at m, seems to occupy the Position of A, and the Image formed at a to the Left of m is projected to the Other Side of A, and seems to occupy the Position C, as if it were formed at c to the Left of m.

Fig. 2. Paralysis of the External Rectus; Colored Glass over Right Eye : Primary Deviation on Looking toward an Object (0) on the Left : Position of Amble Images ; Secondary Deviation of the Right Eye when the Screen, S, obstructing the Fixation of + by this Eye, compels Fixation by the "Weak Muscle. When the Screens are moved, the Right Eye, in Fixing, moves Back to the Position of the Dotted Outline of the Cornea. (In the Diagram of Diplopia the Highest White (False) Image should have been represented a Little Lower than the True Image) .

patient to fix the object with the sound eye, which will then move to its original position.

In ordinary squint, or " strabismus," the deviation is present in all movements; it is the same no matter which eye is used for fixation. In paralysis of one of the eye muscles — " paralytic strabismus" — the normal eye produces the primary deviation, the affected eye the secondary one. The primary deviation indicates defective movement, whereas the secondary shows itself as an excess of movement. They are similar in direction, but opposite in character.

The fourth test concerns (d) erroneous projection of the retinal pictures. The positions of objects seen depend upon the feeling of muscular effort required to turn the eye to look directly at them. When an eye muscle is weakened, a greater effort must be made to force it to act; the distance which the eye has to turn thus involves more work. Consequently the distance between objects appears greater than otherwise. The paralyzed eye therefore does not correctly locate objects. The error is a mental one of judgment. The test is made by closing the patient's sound eye and requiring him to grasp quickly with thumb and finger an object in front. He misses toward the side of the paralyzed muscle. The degree of the errors increases with the amount of the paralysis and with the extent of the eye-movement required. The amount of the error is to be recorded.

In carrying out the fifth test — for (e) double vision — a lighted candle is moved around in the field of vision, preferably over a diagram, divided into nine squares by two horizontal and two vertical lines, placed ten feet away. A red glass is placed over one eye so that the patient can tell which of the two images he sees belongs to that eye. The points recorded for each of the nine spaces are (1) single or double vision, (2) whether the image on the right side belongs to the right eye (uncrossed images) or to the left eye (crossed images), (3) the relative distance between the images, (4) any difference in the level of the images, (5) whether they are erect or tipped. All these symptoms are in the direction of the normal action of the paralyzed muscle. In a paralysis of several muscles, solution of the results of the test requires great patience. Before drawing diagnostic conclusions from the presence of diplopia we must show that it is not monocular (due to dislocation of the lens), and that it ceases in using only one eye. Crossed diplopia means that the prolonged ocular axes are not crossed.

As a sixth fact (/) the characteristic position of the head is to be noted. The patient turns the head toward the side of the paralyzed muscle and in the direction in which the muscle would move the eye if not paralyzed. The head muscles are thus used to diminish or correct the double vision.

The character and degree of nystagmus are noted, if present, during these tests.

V. Trifacial. — Disease of the nerve first shows itself in injury to the sense of touch. The presence of the sense of contact and the ability to localize objects on the skin are the only points tested. Two pieces of cotton-wool are applied simultaneously to corresponding parts of both sides of the patient's face in the three areas of distribution (forehead, cheek-bone, and chin). The patient's eyes are, of course, closed. He is required to tell how many times he is touched, whether the two were on one or both sides of the face, and to name the portion touched. In the case of correct answers, he is to put his finger on the spots touched. When this test shows diminished or lost sensibility, the sensitiveness of the conjunctiva and the tongue is tested by a camePs-hair brush. The irritability of the mucous membrane of the nose is tested by snuff or ammonia. A complete sensory examination (for details see " Sensory Examination ") is to be made in case any alteration of touch is found.

It is well to examine the sense of taste at this point, because any abnormality is considered as a disease of the fifth nerve. Sugar, citric acid, salt, and quinine are representative substances that produce the four tastes — sweet, sour, salty, and bitter — without arousing the sense of flavor (that is of smell). Bitter and sweet are tested at the back of the tongue; sour and salt at the tip and edges. The tests are not to be confined to minute areas, as there are spots that perceive one taste and not another. Taste is more acute in the young than in the old; individuals differ greatly. The test substances are employed in the form of solids, as their action can be more readily limited. The powder is employed with light friction and a short time allowed for it to dissolve. The tongue is kept protruded. The patient gives a signal as soon as he perceives a taste.

A constant electric current furnishes the most accurate test for the nerve of taste, because it acts directly on the nerve endings. Two insulated wires with their points a few millimeters apart are connected to one or two galvanic cells; such a current (of two or three volts) is sufficient to arouse the sense of taste in normal conditions;

a stronger current would cause pain and obscure the result. This method should be employed specially to test the three regions : front and back of the tongue and the palate, when fracture of the base of the skull involving the chorda tympani is suspected.

By placing the fingers on the masseter and temporal muscles of both sides and requesting the patient to bite forcibly, it is possible to recognize feebleness or absence of contraction resulting from affection of the motor branch of the fifth nerve. When the injury is slight, the affected muscle may contract a little slower and later.

Inability to move the jaw toward the unaffected side, and deviation toward the paralyzed side when the jaw is depressed, indicate paralysis of the external pterygoids. Inability to thrust the lower jaw forward indicates paralysis of the internal pterygoids. When the loss of power is only slight, it may be disclosed by opposing any of these movements. The downward movement of the jaw may be somewhat limited in cases of atrophy and secondary shortening of the paralyzed muscles of mastication.

Any trophy or spasmodic disorders should be noted. Painful points and areas of pain-radiation are found in neuralgic states of either functional or organic basis. When there is loss of masticatory power, unilateral furring and accumulation of food in the cheek may occur on the weakened or anaesthetic side.

VII. Facial. — Since this is the motor nerve of the face and is involved in all voluntary acts and emotional expressions, the patient is required to perform such actions as elevating the eyebrows, frowning, closing the eyes firmly, showing the teeth, whistling, puffing the cheeks, and smiling. Voluntary and emotional acts may show differences. Unilateral loss of muscular tone shows itself in comparison of the two sides during rest. In cases of facial paralysis there may be secondary overaction after partial voluntary power returns; this defect may be seen during rest; it is intensified by slight movements and becomes marked during more forcible ones. When the patient closes the eye in strong contraction, the zygomatici on the paralyzed side will overact. This associated overaction may also be excited by reflex action through the fifth nerve (Chvostek's reflex). Any spasm present should be studied in regard to character and degree, during rest, voluntary and emotional movements. The difference in the voluntary movements of the lower part of the face, as in hemiplegics, for example, is tested by having the patient raise the upper lip and move the mouth from side to side, when the unilateral defect will be obvious. Defect in emotional movements is seen in a smile, while the presence of an associated movement in the defective side is obtained by causing the patient to grasp strongly with the sound hand. One may detect whether the wide open eye in the early stage of hemiplegia is peripheral or central palsy by noting, under test, whether the emotional as well as voluntary movement of hemiplegic defect is lost.

VIII. Acoustic. — In order to exclude the frequent troubles due to disease of the ear, an ear examination has to be made. All impacted wax should be removed from the external meatus. To test the hearing the patient, with closed eyes, is required to say when he first hears the ticking of a watch that is gradually brought nearer his ear, or first loses the sound as the watch is moved away. A tuning fork may also be used. If there is no hearing in the ordinary way, the watch may be heard on touching it to the ear. If there is no hearing through the external ear, the watch or fork may be placed over the zygoma, mastoid process, or at the base of the nose. Slight defect in the meatus or middle ear is indicated when the sound is heard longer by bone conduction than by air transmission; this is tested as follows: when the sound is no longer heard from the fork held close to and opposite the ear, it is at once placed against the mastoid process; normally, the sound will be still heard, although the vibrations of the fork are steadily decreasing.

When the external meatus is closed during the test by bone conduction, the sound from the fork is intensified normally; when this does not occur, lowered conductivity of the labyrinth is indicated. The patient often fails in this test through inability to observe. Galton's whistle may be used to test nerve deafness, as its sound is shrill and short. Deafness to all its sounds is pathological. The watch may also be used. The test is carried out as follows: the antitragus is pressed over the external meatus. The watch is held near the mastoid or zygoma, but not against it. After a moment it is pressed firmly against a bone. If the watch is heard better in contact than when not in contact, the labyrinth is intact. If it is not heard better, the experiment is repeated with the tuning fork. If it is heard more faintly, this may be due to anchylosis of the stapes. No disease of the middle ear will entirely abolish bone conduction. Failure to hear the watch by bone conduction often occurs after fifty years of age, yet there may be no other evidence of impaired nerve function; labyrinthine changes due to age are the cause. Bone deafness is normally rare in the first half of life. Bilateral deafness to Galton's whistle by air-transmission even in advanced life is pathological. In bone conduction the vibrations pass directly through the bone to the labyrinth; the test is therefore one that excludes the conducting medium, the meatus and the middle ear, and serves to indicate the functional state of the internal ear. The perversions and elaborations of simple sounds into definite words are usually symptoms of insanity or epilepsy.

Electrical tests of hearing produce vertigo and should not be employed. Their results are variable; they do not always aid in differentiating diseases of middle ear and nerve.

There are no tests that can be applied to labyrinth and nerve separately; the associated symptoms can be used for differentiation.

If the low notes of the Galton whistle are heard with undue loudness (hyperacusis), the stapedius muscle may be assumed to be paralyzed by disease.

If pulsating sounds are heard, their frequency should be noted. When they are synchronous with the pulse and can be modified or suppressed by compression of the carotids, they are vascular.

IX. Glosso-pharyngeal. — The patient is made to swallow liquids. Regurgitation through the nose shows imperfect action of the upper muscles of the pharynx, and consequently paralysis or weakening of this nerve. Loss of the pharyngeal reflex to tickling indicates loss of sensibility of the superior pharynx. Unilateral impairment of this nerve is of little importance; there are no tests for detecting it.

X. Vagus and Accessory. — For practical purposes the tests are confined to the muscles of the pharynx, larynx, thorax, heart, and gastrointestinal tract.

Inability to swallow indicates paralysis of the pharyngeal muscles. Slight disability indicates a unilateral affection of the nerves or some physical obstruction.

Paralysis of the larynx shows itself in changes or even loss of the voice. Coughing may arise from hindrance to inspiration or defective closure of the glottis. Laryngoscopic examination may reveal defective movements. Absence of vocal sounds with stridor or deep inspiration indicates complete paralysis.

When the ordinary explosive cough is changed to a sudden rush of air through the glottis, complete bilateral paralysis is indicated. When the voice is low-pitched and hoarse, one cord is usually unaffected. With slight bilateral paralysis the cords can be used in phonation and cough, while deep inspiration produces stridor; there is no expiratory stridor, although expiration is shorter than inspiration. Tracheal stenosis does not produce so much movement of the larynx as does laryngeal paralysis. The presence of these symptoms makes a positive diagnosis of laryngeal paralysis possible. They may be slight or absent in unilateral affection of the cords; laryngoscopy examination is then necessary.

Hysterical adduction palsy is always bilateral. Speech is not affected; expiration is noiseless; inspiratory stridor may occur. A differential diagnosis from spasm of the glottis is thus rendered possible. Hysterical aphonia shows itself as paralysis of the adductors; the patient can cough but cannot speak; he can usually sing but he cannot whisper. Organic palsy shows itself in a less explosive form of cough; serious bilateral palsy is suggested in entire loss of cough and voice; loss of phonation without loss of speech indicates adduction palsy of minor import. Paralysis of one cord is indicated by loss of cough without loss of voice. The routine of examination in a case of suspected laryngeal paralysis may well proceed according to the following scheme : —

Symptoms Lesion

No voice ; no cough ; stridor only on deep inspiration = Total bilateral palsy.

Voice low-pitched and hoarse; no cough; stridor absent or slight on deep breathing = Total unilateral palsy.

Voice little changed ; cough normal, inspiration difficult and long with loud stridor = Total abductor palsy.

Symptoms inconclusive ; little affection of voice or cough = Unilateral abductor palsy.

No voice; perfect cough; no stridor or dyspnoea = Abductor palsy.

The examination for pulmonary, cardiac, and gastric symptoms of lesions of the tenth nerve should be preceded by search for diseases of the organs themselves. It is only when such organic lesions are absent that the symptoms can be used for conclusions concerning the nerve itself. Disease of the nerve shows itself more or less positively in retarded respiration, accelerated or retarded action of the heart, and vomiting. The way in which the symptoms are distributed and the disturbances associated with them will point out which portion of the vagus is diseased ; the roots and branches are most frequently affected.

XI. Spinal Accessory (Spinal Portion), — Lesions of this nerve show themselves most markedly in paralysis of the sterno-mastoid, the trapezius, and the elevation of the palate. When the sterno-mastoid is affected it loses its regular prominence in the contour of the neck when the head is moved from side to side. The degree of weakening can be estimated by opposing this side movement. If only one nerve is affected (unilateral paralysis), the defect in rotation is to the opposite side. In a condition of rest there is no deviation of the head in cases of unilateral paralysis unless the opposite muscle produces it by secondary contraction.

To examine the trapezius, the examiner tells the patient to straighten the shoulders while he strives to hinder him from doing so. Complete paralysis and wasting show themselves at once to the eye. With unilateral paralysis the curves at the side of the neck will differ, producing an effect of asymmetry when the examiner stands directly in front or behind. The asymmetry appears most markedly during deep respiration. When both sterno-mastoid and both trapezii are affected, the patient cannot maintain the head in upright position. If only both sterno-mastoids are involved, the head tends to fall back; if both trapezii, then it readily falls on the chest. Unilateral paralysis of both these muscles lets the head fall to one side or the other. Unilateral paralysis of the elevators of the velum is seen most clearly when the patient sings a long "ah" while the examiner looks into his mouth.

XII. Hypoglossal. — The tongue should be examined both while at rest and during protrusion. Unilateral paralysis shows itself by increased height on the affected side in the position of rest; this is due to the posterior fibres of the hypoglossus. When the tongue is pressed into the cheek it can be overcome by the finger more easily on the paralyzed side. On protrusion the action of the unopposed genio-glossus deflects the tongue toward the paralyzed side. An imaginary line is drawn vertically between the two central incisors (the nose is often deflected from the median line) ; the amount of deflection of the tongue is estimated from this line.

In complete bilateral paralysis the tongue lies motionless and cannot be protruded.

It may happen that slight deflection of the tongue is noticed; this is not to be considered as indicating paralysis unless some other symptoms are found.

Articulation, mastication, and deglutition are modified by bilateral palsy. Since the tongue is used to keep the food between the teeth, failure to do this is a convenient indication. The tongue also initiates the act of swallowing; the meaning of defective action here is also clear.

Irregular longitudinal folds in the mucous membrane of the tongue — not " geographical tongue," a functional disease — indicate atrophy of the muscles.

Defects of articulation are to be noted. The patient is required to pronounce certain letters. The occlusion sounds p and b are pronounced with lips tightly closed; paralysis of the lips makes it impossible to close them tightly, and these sounds become fricatives that resemble / and v. The occlusive sounds t and d are formed by pressing the tip of the tongue against the palate; in a case of paralysis the closure will be loosened and the two sounds will become th, as in "thin" and " thine." Other tongue sounds like I are also affected. When the soft palate is paralyzed, it cannot close off the nasal cavity from the mouth.