The patient was indifferent, apathetic, and was not in good rapport with the external world, lacked initiative, exhibited paucity of emotion. He uttered no spontaneous speech, and his reaction to painful stimuli was primitive.
Neurological examination showed the following additional abnormal findings: There was a right facial weakness of a supranuclear origin. The pupils reacted promptly to light, and appeared normal, save that the left was slightly larger than the right. Ophthalmoscopic examination of the fundi, limited by lack of cooperation from the patient, showed clear media and normal retina and retinal vessels. The right disc, the only one visualized, appeared normal. Extra-ocular movements could not be tested; there was no obvious strabismus. All deep reflexes in the arms and legs were present and very brisk. Clonus was not elicited. The plantar reflexes were flexor. Abdominal reflexes were absent, except for the right upper. There was incontinence of urine and feces, of the type associated with senile dementia. There was an associated minimal degree of intertrigo. Owing to lack of cooperation of the patient a full sensory examination could not be made, but the patient responded to pin-prick, deep pressure and muscular movement throughout the body.
4. Cardio-vascular Examination:
Pulse: Rate 100, rhythm irregular. The irregularity was due to extra-systoles. The radial arteries were just palpable, without evidence of pathological thickening or tortuosity. Blood pressure: systolic 130 mm. of mercury, diastolic 80 mm. of mercury.
Heart: The heart was clinically not enlarged. The cardiac sounds were feeble, there was no accentuation of the second sound in the aortic area, nor were any cardiac murmurs audible. There were no vascular changes observable in the vessels of the fundi. There was no evidence of cedema or of congestive heart failure.
5. Respiratory Examination: Chest movement satisfactory. There was no impairment of percussion noted. Auscultation revealed no impairment of air entry, no alteration in the breath sounds, and the absence of any adventitious sounds.
6. Alimentary-renal Examination: There was slight distention of the abdomen, due to increase in the gaseous content of the intestines. There was no evidence of ascites. The spleen was not palpable, nor was there any evidence of glandular enlargement. The liver was just palpable, one finger’s breadth below the right costal margin, but there was no evidence of enlargement upwards. Urinalysis: no sugar or albumen present.
7. Skeletal Examination: The patient’s rigidity limited the examination of joints. There was limitation of movement of the neck due to muscular hypertonus. The hypertonus was so marked in the lower dorsal and lumbar region as to produce rigidity of the spine. Attempts to move the joints passively stimulated involuntary contractures of the muscles. There was evidence of crepitus in both knee-joints.
DISCUSSION:
The clinical record presented by this patient is that of an organic cerebral disorder, with predominant involvement of the frontal lobes and basal ganglia. The mental disintegration of the patient renders him incapable of comprehending his environment, and of reacting normally to it. He remains uniformly apathetic and disinterested, intellectually retarded to a very marked degree, and shows no evidence of spontaneous activity.