The data for diagnosis, prognosis, and treatment are obtained in psychiatry, as in other branches of medicine, from the case history and from the direct examination of the patient.
Information must be sought from all available sources and the various data checked against each other to insure accuracy as far as possible.
The patient himself, if able and willing to cooperate, can often furnish information that is of the most intimate kind and not to be had from other informants; this is especially true in regard to the sexual life and venereal infections. Besides, it is always useful to have a free expression of the patient's viewpoint, even if the statements made by him are incorrect.
Further information is to be sought from the patient's relatives and friends and, in a case presenting a history of previous admissions, from the records of the institutions in which he was treated.
Efforts to secure a case history should not stop here, as they do too commonly. It is now widely recognized that a satisfactory knowledge of the family history and of the nature of the environment, in the midst of which the patient has lived and developed his psychosis, is hardly to be had without field investigation, affording opportunities of interviewing relatives, friends, neighbors, family physicians, employers, and others who do not visit the hospital; consulting public records of births, marriages, divorces, and deaths; and studying at first hand the home conditions.
A full family history in a given case may be of value not only for a study of its etiology, but also for the assistance that is at times to be derived from it in the interpretation of clinical manifestations.
The questioning should be systematic, taking up members of the family individually, and covering wherever possible at least the patient's children, brothers and sisters, nephews and nieces, parents, and grandparents, uncles, aunts, and cousins on both the paternal and maternal sides.
For each member of the family it is desirable to place on record the name, sex, birthplace, age (or age at time of death), cause of death, education, occupation, and marital condition.
As special subjects of inquiry may be mentioned the following: psychoses, a description to be secured in each case of time and manner of onset, principal manifestations, course, termination, and recurrences; epilepsy and other disorders which seem to be related to it, namely, convulsions in childhood, fainting spells, migraine, and periodic dipsomania; arrests of development, as shown by delayed walking and talking not due to physical causes, poor record at school, lack of success in work; suicide, method and immediate cause to be given if known; the milder psychoses, "nervous prostration," and psychoneuroses, hysteria, neurasthenia, psychasthenia; addictions to alcohol or drugs, details to be given of amounts and frequency of indulgence, periods of abstinence, etc.; anti-social traits, criminality, mendacity, prostitution, vagrancy, pauperism not dependent on physical causes; temperamental anomalies, such as undue irritability, spells of "the blues," worrisome or hypochondriacal disposition, excessive religious preoccupation, miserliness, and other eccentricities; sexual anomalies, especially perversions and inversions; and finally conditions like asthma, sick headaches, and recurrent vomiting, the relation of which, if there be any, to the neuropathic states, is not clearly established.
1C. B. Davenport, in collaboration with others. The Family History Book. Bulletin No. 7. Eugenics Record Office, Cold Spring Harbor, N. Y., 1912.
The fact of a sojourn for treatment or?ustody in a hospital, sanatorium, asylum, colony for the epileptic or feeble-minded, or almshouse, or of imprisonment in a penal institution, should be recorded wherever ascertained with dates and other details.
In cases like juvenile general paralysis, the question of eongenital syphilis may arise, which the family history should, of course, help to clear up.
It hi 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.
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 foetus), 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? (6) 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, seclu-siveness, excessive religious preoccupation, miserliness, or other eccentricities); and sexual anomalies (masturbation, perversions, inversions).1 (c) What were the patient's 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 operated on? Did he eventually recover fully from the effects of the injury? (/) 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.
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.
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 etiologic mechanism is veiled; but this should not prevent an attempt, at least, to seek out the connections which, it must be assumed, exist in every case.