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were partially flexed, and similarly the
elbows, the latter being pressed firmly against the trunk. There was
generalized muscular rigidity, due to hypertenus of an
extra-pyramidal tract lesion.
On the physicians' entering the room, the patient fixed his gaze
on them, and replied to their greeting with "Guten Tag,"
and gave his hand when they offered theirs to him. He shook hands
normally, but he could not relax his hold or remove his hand, and
continued to squeeze the physician's hand; this was due to the
presence of a forced grasp-reflex, which was more marked in the left
than in the right hand. When asked how he felt, he replied
"Gut," but to all further questions he gave no reply at
all. He was silent and showed no reaction to, or comprehension of,
other questions, and simple commands, such as "Open your
mouth," "Put out your tongue," "Look this
way." Only painful and disagreeable stimuli produced any
reaction, and then it was merely a facial expression of discontent,
sometimes accompanied by grunts of disapproval.
The disturbance of verbal response was not due to dysarthria,
because the patient was able to pronounce such words as he did use,
quite distinctly. Neither was it due to motor aphasia, because the
few words he used were used correctly, and he never exhibited the
jargon responses of the true aphasic when attempting to answer
questions.
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 fund), 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 planter 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
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