particularly in the line of profound exhaustive states, early senile changes, and more requisite watchful care in the after-dressing and treatment, yet the results obtained fully demonstrate that surgery, in carefully selected cases, is one of the valuable means at our command for the alleviation of physical suffering, and, in many instances, if judiciously employed, will also be attended by an amelioration of the mental state.

Clinical Psychiatry.

THE MAKING OF PSYCHIATRIC RECORDS.

BY CLARENCE B. FARRAR, M. D.,

Assistant Physician and Director of Laboratory, Sheppard and Enoch Pratt Hospital; Assistant in Psychiatry, Johns Hopkins University.

I.

It would seem almost thankless task to discuss the subject of history-taking, of the examination of patients, and of the keeping of psychiatric records, and yet there are several reasons why such a discussion may not be without value, especially in view of establishing a department of Clinical Psychiatry in this JOURNAL. It is not the aim of this paper to suggest a programme or to present anything particularly new, but merely to recall as emphatically as possible a few familiar and self-evident facts which are often enough neglected in practice,—perhaps because of their very familiarity and obviousness. Every year a large amount of valuable clinical material is lost, particularly, it would seem, in America and England, because of the relatively small number of men in psychiatry, who give themselves the trouble to make observations which are on a level with those of their colleagues in other departments of medicine, and of the still smaller number who make records of their observations which are worthy to be preserved.

Naturally a great part of the work connected with the making of histories falls upon the younger men of the service. In their medical school or general hospital careers, the importance of detailed anamnesis and examination was duly emphasised and they were armed with rational methods of observation of physical disease. How sadly incomparable and inadequate are oftentimes the instruction and methods which are furnished to those who later come for their special work to hospitals for mental diseases! Insanity in any form is to be reckoned with the severest diseases to which man is subject, it is apparently increasing in most civilised countries, in medicine there is no subject which demands more careful study, and yet it has always been and still remains the subject about which least is known. The very facts of the difficulty of the task and of the relatively little which is actually

known should only stimulate to a more conscientious, deeply painstaking interest, and not to a satisfied apathy or laissez-faire.

It is with the hope that in reviewing a more or less familiar topic some points may nevertheless appear which will prove suggestive to some brother who is putting together his first psychiatric records, that these pages are written.

A casual perusal of the clinical history of a mental case selected at random, gives one as a rule one of three impressions.

(1) One feels that the writer has set down one after another a lot of isolated facts and symptoms without synthesis or analysis; he has given a superficial recital of events without drawing conclusions and has left a weak and anæmic record from which it is impossible for any one else to form an idea as to the nature of the case.

(2) In a second history one is at once conscious that the author has approached the case with a strong idée préconçue, and has more or less moulded the elements of history and examination to fit the disease-picture which he has unconsciously started out by assuming, rightly or wrongly, that the case presents. In this instance one has no trouble in following the deductions of the history writer, but one is troubled by the question,-Would possibly a second observer with a different idée préconçue have constructed from the case with equal facility quite a different clinical picture?

(3) Finally one reads a history in which it is apparent that the author has attempted to approach the case with a virgin mind, and has tried to construct a synthetic history of a group of morbid phenomena, their relations and significance. He has endeavored to show in what manner and degree the diseased psyche departs from the individual norm, and has drawn up his premises, so that the conclusion, if a conclusion be possible, will rather deduce itself, as a result of the comparative and adequate valuation of the clinical signs as they present.

The histories which give rise to the third impression just described, are unfortunately in the minority.

II.

A fixed idea with which many men begin their history writing is that the prime aim and object of the history is to establish a

diagnosis, to give a name to the disease, which is supposed to contribute something to the knowledge of the condition. This is an idea which must, on general principles, be combated. The fight from the beginning in psychiatry has been over names and classifications. Let us notice for a moment some of the results to which this conflict has led.

For 6000 years the tripartite symptomatologic classificationMelancholia-Mania-Dementia, based upon the most superficial of observed facts-has served as the groundwork for the study of mental diseases. Each of these terms by common acceptance represents at present a more or less definite external diseasepicture, each one differing conspicuously from the others; and yet if one follows these names through the classifications from early to late, one finds that not only to each one have the most divergent meanings been attached by different men or at different times, but that cases described by one observer as mania have been classified by another as melancholia and vice-versa. If one could collect together all the cases that were ever described under mania or melancholia, and such an assemblage would embrace practically the entire psychiatric gamut,—and should then attempt to separate them into two distinct groups under their respective labels, the attempt would be found to be utterly futile, as the two groups would encroach upon each other at every step.

This confusion of meanings and names is conceivable when it is remembered that all the ancient names and terms used to designate forms of alienation, meant at bottom, one and the same thing, namely "madness," thus:

Mavía madness.

Melaryolia (etymologically, atrabilious insanity) = madness. Dementia (literally) madness.

=

Παράνοια = madness.

It might indeed well be possible to find one and the same condition described by different observers or at different times under all of the above heads.

TO HIPPOCRATES is generally attributed the distinction between Mania, the insanity of fury and violence, and Melancholia, the insanity of sadness and fear.

ARETAEUS took quite a different view-point and introduced the distinction between general insanity (mania) and partial insanity