6. Neurological History by Dr. Ray, August 5, 1932
NEUROLOGICAL HISTORY AND EXAMINATION
Aug. 5, 1932.
COMPLAINT Headache and failing vision.
- Personality and Systemic Note - This patient is a 43 yr. old married woman, sent in by an ophthalmologist with a question of intra-cranial tumor. She was seen first in the O.D.D. and transferred into the House. She is a Nova Scotian by birth, and has lived there up until about ten years ago, when she and her husband, and two children moved to this city. Her husband is a carpenter and cabinet maker. The patient herself has had a grade school education, and gives evidence of rather more than average intelligence. She is very pleasant and polite, and cooperates as best she can. It is evident from the start that she has some mental obtusion. She speaks slowly and occasionally with some hesitancy which suggests a little aphasia. Concentration seems difficult at times, but she tries hard, and if given enough time she will comply with any wish or answer any question. There seems to be no impairment of memory, orientation or judgment. The history is obtained entirely from her and is considered to be reliable in detail and chronology.
- She has been married for 22 years, and has 2 children l. & w. One dead and no miscarriages. She had tuberculosis, pulmonary, about 15 years ago, and had a 6 months sanitorium treatment. During the past couple of years she has had check x-rays at the M.G.H., and is reported to have completely recovered from her tb., and she has had no symptoms. Eight years ago she had a hysterectomy and salpingectomy for fibroids. She has had all her teeth out - the uppers removed 25 yrs. ago, and the lowers 3 yrs ago. Aside for this, she has been in good general physical health and has considered herself always fairly strong and healthy.
- Headaches - She does not remember that she has ever been particularly subject to headaches at any time during her life, but beginning sometime about two years ago, or perhaps a little before, she began to have occasional bitemporal headaches, which would at times extend up to the vertex and also to the occiput and down the back of her neck. These were, of course, unusual, and at the time of their onset it impressed her with the possibility of something definitely being wrong with her. However, these attacks occurred about once every two or three weeks only, and she found that she was able to stand them without too much discomfort and soon became accustomed to them. This went on at several weeks intervals until about 3-4 months ago with the attacks became definitely more increased, both in severity and frequency without a generalized headache. Some days it seems centered in the temporal and frontal region, other days she seems to have most discomfort in the back of her head, and again at other times she experiences sharp shooting pains running straight up to the top. Of late she has been experiencing a sense of dizziness with the more severe attacks and has had very frequent nausea. Vomiting never occurred, however, until the day she was admitted to the hospital, and then she vomited, projectile type, thruout the whole day.
- Failing vision - The patient has worn glasses for about 20 years. Beginning sometime about the middle of June, now about 7-8 weeks ago, she began to feel that her vision was becoming a little blurred and she felt that she needed a change in glasses. A week or so later she found that blurring was becoming so evident that she could put it off no longer, and she consulted an optometrist, who tested her eyes and fitted her with glasses. These seemed to benefit her in no way, and vision became progressively worse. She returned to the optometrist in about 10 days, and discovering that her vision had diminished so markedly in such a short period he sent her to a capable ophthalmologist, Dr. G.H. Ryder of Woillaston. This was about two weeks ago. He in turn found pathological fundi and referred her to our out-door-department. She has found that the progress has continued and that the left eye is definitely more diminished than the right.
- Diplopia - Transitory attacks several weeks.
- Visual hallucinations - For perhaps the past year the patient has noticed on many occasions that on looking at a white background, for example a newspaper, she sees large blotches of pink, and occasionally of brown. On a number of occasions which doing her ironing she has thought that a scorch mark existed on a white tablecloth or some other white cloth. There have been no flashes of light and no halos. During the past week or ten days she has been aware of form hallucinations, and describes them as black streaks occasionally, and at other times images that somebody or something is moving off to the side of her. These hallucinations always seem of to the side and more to the left than to the right.
- Weakness of the right side - For perhaps the past 5-6 months she has found on several occasions which doing something strenuous that the right arm did not seem as strong as it should be, and seemed to tire more easily - (in the wringing of clothes) - She found that the left arm and hand far out-did the right one, and this was not at all usual. Also, she began to notice about the same time, that she seemed a little unsteady on walking, and felt that she had a tendency to veer to the right side, and if walking with anyone to the right of her she would frequently bump them, and remembers with some embarrassment, on several occasions she bumped people to the right of her rather vigorously. She believes that there has been no particular increase in these symptoms of late.
- Right-sided paresthesia - On any number of occasions during the past several months she has found her right leg going to sleep, and also has experienced queer sensations in the right arm. Occasionally, it merely feels tired, and dead; at other times feels cold, and very rarely she has felt a tickling sensation in the right arm.
- Transitory soreness and numbness in the left side of the face - This occurred several weeks ago and lasted for a period of about half a day. She felt an indescribable sense of soreness in the left side of her face "as tho it has been scalded", and on touching the left side of her face it felt curiously numb. She at first was alarmed and when the condition wore off after 5-6 hours, she thought little more of it, and recalls it now only after direct questioning.
- Slowed mentality - For the past several months she has felt that her power of concentration and thought seemed to be slowing. She has come to speak much more slowly than formerly, and finds that very frequently her mind seems to be fuddled, and it is with great effort that she is able to concentrate on what is being said to her or what she attempts to say in return. On a number of occasions she has had to grope around for words, and believes that she has used wrong words several times, but does not remember that this has been particularly in the nature of an anomia, and on talking to her now there is no obvious aphasia, tho speech is quite deliberate.
- General lassitude - This has been coming on her for at least 6 months, and she has found it necessary to literally drive herself to do her housework since this began. She seems to have lost interest in a number of things, and did not seem quite able to have the ambition to keep up former activities. She has not, however, had any symptoms of hypersomnolence. In fact, has had some tendency to insomnia of late.
- Tinnitus - This has been a very recent feature, present only for a few weeks. There is a low buzzing sensation in both ears of fluctuating intensity. Perhaps, a little more marked in the left ear. During her periods of very severe headaches this usually assumes the nature of a pulsating buzz. Probably, synchronous with her pulse.
- Miscellaneous - Aside from the above mentioned features no other relative symptoms can be elicited, either by direct or indirect questioning. There have been no periods of loss of consciousness. No Jacksonian seizures. No marked loss of muscle power. No hyper-somnolence. No polydipsia or polyuria. No increased desire for sweets. No particular change in weight. No epistaxis or rhinorrhoea, etc.
- General appearance: A f.w.d. and n. woman of 43 yrs. who is prematurely gray, and although fairly well preserved appears to be at least 5 years older than her given age. She has a somewhat pallid complexion, and although not appearing acutely ill, gives evidence of considerable mental and physical slowing up. She lies rather listlessly in bed, and there is no particular abnormality about position or body, head or extremities.
- Skin - Of after texture, smooth and moist, without abnormal areas of pigmentation, naevi or moles. She has several scars - evidence of recent furuncles about the buttocks, and there is at present a subsiding furnuncle of the left buttocks.
- Hair - Normal in amount, texture and distribution.
- Perspiration - Unremarkable.
- Head - Normal in size and shape. No dilated veins, exostoses, scars or depressions. No tenderness to palpitation or percussion. No cracked pot sound, and no bruit.
- Neck - There is a definite suboccipital tenderness on both sides, a little more marked on the right. Patient seems to experience some discomfort on extreme flexion of the head and on extreme lateral deviation, but there is no actual limitation of motion, and the head is moved readily in all directions.
- Subjective - No hallucinations or impaired function.
- Objective - Responds very well to test odors on the two sides.
- Subjective - History of definite failing vision of about 2 months duration.
- Objective - For visual acuity and perimetry see accompanying chart. There is an acuity of 20/70 O.S. and 20/50 O.D., and definite bitemporal defects with rapidly encroaching central scotoma.
Fundi - Media clear. Disc margins are discernable, but definitely blurred; on the right side there appears perhaps to be very slight pallor of the disc. The margin particularly on the nasal side is almost obliterated. The physiological cupping is practically gone. The veins are full and tortuous, and there is a measurable choking of about 1-D. On the left side this condition is more marked, and the elevation measures of 2-D., or perhaps a little more. There are several fresh retinal hemorrhages.
- Subjective - There is a history of diplopia, transitory
- in type for several weeks.
- Objective - There is an anisocoria of the left, definitely greater than the right, and both are moderately dilated. They react directly and consensually to l. & a. The left one with considerably less excursion and promptness than the right. There is no nystagmus, and no demonstrable extraocular muscle palsy. There is a slight prominence of both eyes, suggesting exophthalmos. This is about equal on the two sides. There is a slight ptosis of the right upper lid.
- Subjective - There is a history of transitory attack of burning and numbness in the left side of the face several weeks ago.
- Objective At the present time there is no demonstrable sensory change, and sensation is about equal on the two sides. Corneal reflexes are brisk bilaterally, and the motor divisions are intact.
- Subjective - No history of hyperacousis nor taste disturbance
- Objective - There is a slight but definite right lower facial palsy.
- Taste on anterior 2/3rds of the tongue not tested.
- Lacrimal and salivary secretions unremarkable.
- Cochlear -
- Subjective - There is history of recent tinnitus, bilaterally, the left slightly more marked than the right. Apparently no diminution of hearing.
- Objective - Hearing to gross test as tested with the tuning fork 512 vibrations shows approximately normal hearing on the two sides, and equal.
- Subjective - History of slight dizziness associated with severe headaches of late, but no actual staggering gait or vertigo.
- Objective - Romberg slightly positive with swaying to the right. There is no nystagmus. Caloric test not done.
- Glossopharyngeal and vagus
- Subjective - No history of dysarthria or dysphagia.
Objective - Pharyngeal reflexes brisk bilaterally and the palate deviates well in the midline.
- Spinal Accessory
- No paresis or paralysis of the sternocleidomastoid and trapezius.
- No paresis or paralysis of tongue. No tremor.
- Memory and orientation are quite normal. Cerebration and concentration, however, are definitely obtruded. There is no anosmia.
- There is a questionable story of aphasia. At the present time speech is slow and deliberate, but no actual aphasia can be demonstrated. There are bitemporal field defects. No history of uncinate seizures nor of hallucinations of taste or smell.
- There is a history of right sided paresthesia intermittent for several months. Objectively there is definitely a right hemi-hypesthesia.
- There is no astereognosis or apraxia. There is some diminution in sense of position on the right side, which seems to be related to the general right hypesthesia.
- No hallucinations of light. No homonymous hemianopsia.
- No athetosis, tremors, loss of associated movements, loss of plastic tone, retropulsion, deviation of the head, perseveration or emotional disturbances.
- Romberg is positive with slight tendency to fall to the right. Gait is that of a right-hemiparesis with slight dragging of the right foot and immobility of the right arm.
- There are no cerebellar signs such as hypotonicity, dysmetria, nor adiadococinesia.
- There is a bilateral choked disc of low degree.
- Corneals brisk and equal. Abdominals all brisk and equal. Plantars equivocal. This seems to be normal for the most part on the left.
- Deep reflexes in the upper extremities are readily elicited, and seem about equal on the two sides. In the lower extremities deep reflexes are difficult to elicit. The left k.j. seems increased over the right. Achilles jerks are very sluggish. There is no clonus.
- - As mentioned above, there is a right hemi-hypesthesia. There is a decided weakness in the right arm and leg tho very slight and almost unnoticeable on cursory examination. The right arm falls away on past-pointing test, and soon tires on prolonged motion, as compared to the left arm. In walking the patient is rather unsteady from having lain in bed for some period, but the right leg moves in a spastic manner, and drags slightly when walking. There are no deformities, nor atrophies. The patient is right handed.
- History of headaches.
- There is diplopia of uncertain origin.
- No sellar changes except for slight atrophy of the posterior clinoids.
- No epistaxis or rhinorrhoea.
- No anosmia.
- No uncinate seizures.
- Fundi show very questionable slight atrophy but with definite low grade of choking.
- There is a bitemporal hemianopsia.
- Temperature an pulse quite normal - See chart.
- Cerebration and concentration is slow.
- Height and weight unremarkable, -- See record for estimate.
- No prominence of the jaw or offsetting of the teeth.
- Hands and feet of average size and shape.
- Hair of normal amount and distribution.
- Basal metabolism
- Genitalia of normal development. Patient has undergone an artificial menopause 8 yrs. ago.
- No polydipsia or polyuria.
- No increased desire for sweets.
- Thyroid - No tachycardia, palpitation, tremor, diarrhoea, or other thyroid symptoms.
- Adrenal - There is a sense of general lassitude and weakness but no other adrenal signs, such as abnormal pigmentation or abnormal blood pressure.
- Pancreas - No bulimia. No glycosuria. Blood sugar is normal.
SUMMARY OF POSITIVE FINDINGS: -
- Generalized headaches for 2½ years, of increasing severity and frequency. Recently associated with dizziness, nausea and vomiting.
- Failing vision. Rapid progress for two months.
- Visual hallucinations - 1 year.
- Diplopia - several weeks.
- Slight weakness of right arm and leg - 6 months.
- Transitory paresthesia of right side of the body - several months.
- Slowing up of speech and mental processes, - 2 months.
- General lassitude - 6 months.
- Transitory attack of soreness and numbness in left side of the face - several weeks ago.
- Bilateral tinnitus - several weeks.
- A normal appearing middle aged woman, partly gray hair, unremarkable features; negative general physical findings; blood pressure 120/90.
- Slight suboccipital tenderness.
- Acuity 20/70 O.S. and 20/50 O.D.
- Bitemporal hemianoptic defects with encroaching scotoma.
- Anisocoria, left greater than right.
- Slight exophthalmos, equal.
- Slight right ptosis, of upper lid.
- Slight right lower facial weakness.
- Slight right hemi-paresis.
- Right hemi-hypesthesia and hypalgesia.
- Negative x-ray findings except for slightly atrophic posterior clinoids.
IMPRESSION Chiasmal syndrome, probably suprasellar meningioma.
ADDENDUM Dr. Ray.
- This, of course is not a true "chiasmal syndrome" with choked disc rather than atrophy. The most positive localizing sign, however, is the clear cut bitemporal field defect which I do not believe could be caused by any lesion other than one directly at the chiasm. A lesion here that is also large enough to cause choked disc must extend into the 3rd ventricle and curiously enough there are no 3rd ventricle symptoms. The above diagnosis of meningioma is probably erroneous - an "interpenduncular tumor" would more nearly fit the signs and symptoms.