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leptic or feeble-minded, or almshouse, or of imprisonment in a penal institution, should be recorded wherever ascertained with dates and other details.
In connection with cases of Huntington's chorea only similar heredity seems to be of significance; hence inquiry should be especially directed to other cases of chorea in the family.
In cases like juvenile paresis the question of congenital syphilis may arise, which the family history should, of course, help to clear up.
It is not enough to state in each case merely the alleged fact of the existence of one or more of the above-mentioned conditions; but wherever anything of the sort is found a description in terms of the conduct and life course of the individual should be given, sufficient to establish the fact as alleged.
Personal history. Here the main topics of inquiry are: (a) Were there any conditions during intra-uterine life (infections, eclampsia traumatisms of the mother; hydrocephalus or other diseases of the fœtus), at birth (premature labor, difficult or instrumental delivery with resulting head injury), or in infancy or childhood (meningitis, whooping cough with intracranial complications), likely to interfere with the mental development? (b) Were there at any time prior to the onset of the mental disorder any abnormalities in the patient's constitutional make-up? Convulsions in infancy, childhood, or later; fainting spells; delayed walking or talking; poor record at school, lack of success in work; anti-social traits (criminality, mendacity, prostitution, vagrancy); temperamental anomalies (undue irritability, spells
of "the blues," worrisome or hypochondriacal disposition, seclusiveness, excessive religious preoccupation, miserliness, or other eccentricities); and sexual anomalies (masturbation, perversions, inversions).1 (c) What were the patients habits in regard to the use of alcohol? What has led to its use? (Domestic infelicity, being out of work, business reverses, sociability.) Was its use regular (daily, week ends) or only occasional? What were the beverages used? (Beer, wine, whiskey.) In what quantities were they used? Did he go on sprees? Did he become intoxicated, if so, how often? Did the drinking affect the patient's appetite or health in any way? Did it cause him to lose time from his regular occupation? A particularly detailed account should be obtained for the time immediately preceding the onset of the psychosis. (d) Detailed information should be sought concerning venereal infections, particularly syphilis; date and source of infection, manifestations; was treatment prompt? of what did it consist? was it thorough? was it systematic, prolonged, and serologically controlled? did the serological tests ultimately become and remain negative? (e) Did the patient ever suffer a head injury? Did he become unconscious either immediately following the injury or after an interval? How long did the unconsciousness last? What symptoms were observed after recovery of consciousness? Was there a fracture of the skull? Was the patient oper
1 August Hoch and G. S. Amsden. A Guide to the Descriptive Study of the Personality. N. Y. State Hosp. Bulletin, N. S., Vol. VI., 1913, p. 344.
ated on? Did he eventually recover fully from the effects of the injury? (f) Obtain a description of the patient's bringing up, his sexual, domestic, marital, and business life with a view to determining whether there were any other pathogenic influences such as have already been mentioned in the chapter on Etiology under the heading of incidental or contributing causes.
History of psychosis. — Were there any previous attacks of mental trouble? What were the cause, date and mode of onset, principal manifestations, course, duration, and outcome of each? What was the immediate cause of the present attack? The date of its onset and the manner, i.e., whether sudden or gradual? Earliest observed manifestations? Principal features? What, if any, was the treatment of the attack prior to the patient's admission to the hospital? What led to the patient's commitment?
In cases of constitutional psychoses a neuropathic family history and evidence of abnormal make-up are now generally accepted as accounting, in a measure, merely for the fact that a psychosis has occurred, but not as explaining why it occurred at the particular time when it did, nor its special content and other manifestations. A case history
is imperfect which fails to connect specific environmental happenings with the development of symptoms, both chronologically and by content. It will be granted, of course, that in many cases, owing to a symbolic nature of the trends or reactions, the etiological mechanism is veiled; but this should not prevent an attempt, at least, to seek out the con
nections which, it must be assumed, exist in every
§ 2. METHODS OF EXAMINATION.
Physical examination. — Height, weight pared with usual weight), malformations (especially of skull), general state of nutrition, pallor (hæmoglobin estimation and cell count, if indicated), temperature, pulse, respiration, appetite, condition of the bowels, sleep, menstrual function; subjective complaints (vertigo, headache, pains, weakness); cyanosis, dropsy, jaundice, eruptions; scars or other evidences of old or recent injury. Heart, lungs, abdominal organs, urine; vaginal examination; blood pressure. Nervous system: smell, hearing, taste, cutaneous sensibility; vision, errors of refraction, hemianopsia, ophthalmoscopy if indicated; nystagmus, strabismus; pupils, equal or unequal, regular or irregular in outline, reaction to light normal or sluggish or slight in excursion, reaction to distance; innervation of facial muscles,
asymmetrical; grips in the two hands,
unequal (dynamometer test); strength of legs (for test of weakness of one lower extremity have both lower extremities raised and held; the weaker limb will sink before the other); coordination, — writing, buttoning coat, gait, Romberg sign, balancing power on either foot; reflexes, - knee jerks, with and without Jendrassic reinforcement (normal, unequal, exaggerated, diminished, lost), ankle clonus, plantar reflex (Babinski sign), sphincter control; tremors, — eyelids, lips, tongue, hands, fine, coarse, intention
(handwriting); choreiform or athetoid movements; speech, stuttering, slurring, scanning (test phrases: third riding artillery brigade, particular popularity, Methodist Episcopal); aphasia (systematic examination if indicated); convulsions, - frequency, loss or preservation of consciousness, localized or general, with or without aura, biting of tongue, voiding of urine, followed by stupor or prompt recovery.
Mental examination.1 Much of value can be learned on a patient's being brought to an institution from his general appearance, manner, and spontaneous utterances: his appearance may be disheveled, neglected, untidy; he may seem dejected, or irritable, or happy, or apathetic; he may coöperate in the hospital routine showing a more or less intelligent adaptation; or merely submit in a passive way to being undressed, bathed, etc., by the attendants; or he may be resistive and violent; he may be taciturn or even mute, failing to respond to any question, or he may be talkative, protesting, or complaining, or wailing, or merely commenting on things about him, perhaps showing disturbances in the flow of thought like distractibility, flight of ideas, incoherence, verbigeration.
The manner of the clinical examination proper will depend to a considerable extent on the nature of the case and the amount of coöperation. In an irresponsive, seemingly stuporous case, or in one presenting great excitement a complete mental exami
1 Sommer. Diagnostik der Geisteskrankheiten. Berlin and Vienna, 1901. Fuhrmann. Diagnostik und Prognostik der Geisteskrankheiten. Leipsic, 1903.