Page:WHR Rivers - Studies in Neurology - Vol 1.djvu/27

Rh then allowed to empty his bladder, and from that time made no mistakes; his answers, which had shown much confusion, were now uniformly correct.

At first we were in the habit of blindfolding our patients; but in some cases, especially of cerebral disease, this is liable to lead to a state of defective general attention. During the observations on my arm, I sat with my eyes closed, as I found that this produced in me the condition most favourable for sensory testing; for I always answered more correctly to those tests which required no close introspection when I did not attempt to think of what was going on. This was also the case with many of our patients, especially those who tended to interpret their sensations, and were particularly anxious to do well in the examination. But, with those of a lower grade of intelligence, closing the eyes was liable to induce a condition akin to sleep, and they might even cease to give any answer, when tested over normal parts of the body.

The examination was therefore begun with the eyes closed; but, if the results showed an unexpected want of attention on the normal half of the body, it was continued with the eyes open with the parts to be tested carefully screened. This was particularly useful during examination of the lower extremities; but it is important that the patient should not be able to see any of the manipulations of the operation or the objects with which the tests are carried out. Some patients are more comfortable when this system is adopted than if they are forced to remain for long periods with closed eyes.

Certain well-recognised rules have guided our studies. The most important of these is to obtain the good-will and interest of the patient; for without this it cannot be hoped that the observations will be trustworthy. When attention begins to flag, or the patient to tire, it is necessary to interrupt the examination; for this reason we arrange that the tests demanding the greatest effort and concentration should be made early in the sitting, and the coarser and subjectively easier tests reserved till the later stages of the examination. In the second place, we have always avoided anything that might, on the one hand, suggest a response, or, on the other, confuse it. Each test was first explained to the patient, and he was allowed to watch it in action on the normal side. Then his eyes were closed or the part was screened, and the examination was begun seriously.

He was requested to reply "Yes" or to give some other simple answer appropriate to the mode of stimulation. For example, with the compass points he said "one," "two," or perhaps "I don't know"; with the test for the appreciation of passive movement his replies were "up," "down," or "bending" and "straightening." No questions were asked during the examination. It is most important to avoid all inquiries, such as, "Did you feel that?" "Did I prick you?" "Was that one or two points?" or "Did I move your finger?" etc. Once certain that the patient understands the nature of the test, the observer must remain absolutely silent till the examination is over. Then he may ask questions as to what the patient