Physical Examination

Height, weight (compared with usual weight), malformations (especially of skull), general state of nutrition, pallor (haemoglobin 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; pulse rate at rest and after exercise; 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 - equal or asymmetrical; grips in the two hands - equal or 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

Much of value can be learned on a patient's coming before the examining physician 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 cooperate in the hospital routine, showing a more or less intelligent adaptation; or merely submit in a passive way to being undressed, bathed, etc.; 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.

1 Sommer. Diagnostik der Geisteskrankheiten. Berlin and Vienna, 1901. - Fuhrmann. Diagnostik und Prognostik der Geisteskrankheiten. Leipsic, 1903.

The manner of the clinical examination proper will depend to a considerable extent on the nature of the case and the amount of cooperation. In an irresponsive, seemingly stuporous case, or in one presenting great excitement a complete mental examination is out of the question for the time being and can be attempted only after subsidence of the hyper-acute phenomena. It should be borne in mind, however, that a condition of seeming stupor may prove to be either one of marked depression or of catatonic negativism with well-preserved lucidity. A detailed record should be made of the condition found, especially of any unexplained peculiarities in attitude or conduct, to be discussed with the patient when better cooperation is to be had.

In cases offering reasonable cooperation it is of great advantage to proceed systematically. Some patients volunteer to tell their story as soon as they are brought into the examining room, which they should be, of course, encouraged to do; others will speak only when questioned, and then but briefly. In any case it is desirable, before actual testing is begun or any specific questioning concerning hallucinations or delusions, to get the patient's account of his trouble or at least of the situation which led to his commitment. Should he show, in the course of his account, a tendency to ramble from his subject, or any disconnectedness, or other disturbance of the flow of thought, then it is very useful to make an exact stenographic record of a sample of his utterances to the extent, say, of half a page or a page; that being done, he may be assisted by the examiner by being interrupted whenever necessary and reminded of the points on which he was asked to give information.

It is very important to have the patient at his ease as far as possible, not to arouse his antagonism or suspicion or apprehension. The only correct way of approaching him is with perfect candor, letting him understand that the examiner is Dr. ---------, a physician, a specialist in nervous and mental diseases, and that the object of the examination is to find out if he has not some such trouble.

Thus one may begin with such questions as, Tell me about your case; have you been sick? Did you have any trouble at home? Why have they brought you here? Have you been ill-treated?

As the next step the patient may be questioned about the statements in the commitment paper made to show insanity and necessity of commitment, and from that it is easy to pass to direct questions concerning hallucinations or delusions, following the leads made available by his account: Have you heard voices? Has anyone hypnotized you? Do people talk about you? Do they read your mind? Have you been poisoned? Are you followed by detectives? Is it true that you are very wealthy?