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From the standpoint of symptomatology four kinds of writings may be distinguished: spontaneous writings, writings from copy, writings from dictation, and painstaking penmanship. Each has its special interest, as each enables us to study particular types of pathological phenomena. Spontaneous writings reveal chiefly the delusions of the subjects and are often of great value in cases of dissimulation. Writing from copy reveals chiefly disorders of attention, and writing from dictation reveals disorders of memory. Finally, painstaking penmanship, which results from the subject's effort to produce the best possible handwriting, brings out motor disorders (tremor and ataxia).
Unfortunately the study of graphic pathology in order to be fruitful must go into certain details which could not be entered upon here for want of space. We must therefore limit ourselves to this brief discussion and refer the reader to works in which this question is specially treated.1
Having completed the examination it will be found very advantageous to prepare a summary of the findings which are of significance for diagnosis, prognosis, and treatment.
Many attempts have been made to simplify and standardize for institutions the work of clinical ex
1 Séglas. Les troubles du langage chez les aliénés. Bibliothèque Charcot-Debove. Köster. Die Schrift bei Geisteskrankheiten. Leipzig, 1902. —- Joffroy. Les troubles de la lecture, de la parole, et de l'écriture chez les paralytiques généraux. Nouv. Iconogr. de la Salpêt., Nov.-Dec., 1903.-J. Rogues de Fursac. Les écrits et les dessins dans les maladies nerveuses et mentales. 1905.
aminations by the use of printed blank forms. Experience has shown that to rely entirely on records thus prepared is not consistent with good clinical work. For a part of the records, however, it will be found helpful to have a statistical data sheet or card such as is used in the New York state hospital service, somewhat like the following:
Marital condition (single, married, widowed, divorced, separated). Occupation (or that of husband, father, or other person on whom patient is dependent)...
Nativity (state or country).
. How long in U. S..
Nativity of father.....
Education (none, reads only, reads and writes, common school, high
school, collegiate, professional). Religion (denomination).. Previous hospital residences (dates and duration of each).
Constitutional make-up (intellectually and temperamentally).
Other etiological factors.
Date and manner of onset of psychosis..
...Legal status (committed, voluntary)
Permission for autopsy in event of death....
Names and addresses of relatives, friends, or legal guardians.
TESTS.—BINET-SIMON TESTS. —EXAMINATION FOR ASSOCIATION TESTS. — OTHER TESTS.
It is not to be supposed that the case history and the clinical examination, obtained by the methods outlined in the preceding chapter, will complete the investigation of every case. Very often these methods afford but leads for further investigation by special methods according to the indications presenting themselves in the case under consideration. A suspicion of syphilis, for instance, can by no means be definitely dismissed by a denial made either by the patient or other informants; the differentiation between certain alcoholic psychoses, neurasthenia, arteriosclerotic dementia, and other condition, on the one hand, and general paresis, on the other, cannot always be made with certainty without the aid of special diagnostic procedures; the intellectual make-up of a patient cannot be determined with any degree of accuracy without resort to measurement by means of the Binet-Simon or other appropriate psychological tests.
§ 1. LUMBAR PUNCTURE.
Lumbar puncture is a simple and harmless procedure. The only danger, that of infection, can be entirely avoided by the exercise of ordinary precautions of asepsis.
It is, however, contraindicted in cases of great general weakness and in those in which there is evidence of abnormally high intracranial pressure (brain tumor). In such cases lumbar puncture should not be performed, as there is possibility of fatal issue.1
The technique of obtaining and examining a specimen of cerebro-spinal fluid is as follows:
The patient is placed on a convenient table, lying on the side, with the back arched as much as possible and with the knees drawn up so that they almost touch the chin; in this position the spaces between the laminæ of the lower lumbar vertebræ are as wide as they can be made. If the patient is so resistive that he cannot be made to assume and retain this position the attempt might best be postponed until he is more tractable.
The back is then scrubbed with soap and water and washed with alcohol, ether, and 1–2000 bichloride, as for any operation. The operator's hands are, of course, also properly sterilized. No anæsthetic, general or local, is required, as the pain caused by the puncture is scarcely greater than that which would be caused by a cocaine injection.
1 See Minet and Lavoit. La mort suite de ponction lombaire. L'Écho Medical du Nord, Apr. 25, 1909.
A sterilized hollow needle, about four and a half inches long, is then introduced straight, that is to say, without any vertical or lateral inclination, into the space between the laminæ of the fourth and fifth lumbar vertebræ; if more convenient, the space above or the one below may be selected. The usual guide for the intervertebral space is the level of the iliac crests. The point at which the needle should be introduced is a trifle below and a quarter of an inch to one side of the tip of the vertebral spine. Extending from the level of the upper border of the second lumbar vertebra to that of the sacrum is a large meningeal reservoir which is easily reached in the manner described above. In this reservoir are contained the fibers of the cauda equina, which are in no danger of being injured by the point of the needle.
If the needle strikes bone no attempt should be made to alter its direction by partly withdrawing it and inclining it one way or another, as it soon becomes filled with blood and the cerebro-spinal fluid, if thus obtained, will be contaminated. The needle must be withdrawn, cleansed of all blood, and reintroduced at another point. It is best, perhaps, to have two or three needles at hand whenever lumbar puncture is undertaken.
As soon as the point of the needle has entered the meningeal reservoir cerebro-spinal fluid begins to escape from its outer opening either in drops or in a stream, depending upon the degree of intracranial and intra-spinal pressure.
Sometimes, as the needle passes through the skin