GUIDE FOR THE CLINICAL EXAMINATION OF CHILDREN BY H. G. HARDT, M. D. CLARA HARRISON TOWN, Ph. D. THE LINCOLN STATE SCHOOL & COLONY H. G.Hardt, M. D., Superintendent LINCOLN, ILLINOIS. 1912 A GUIDE FOR THE CLINICAL EXAMINATION OF CHILDREN BY H. G. HARDX M. D. CLARA HARRISON TOWN. Ph. D. THE LINCOLN STATE SCHOOL & COLONY H. G. Hardt, M. D., Superintendent LINCOLN. ILLINOIS. 1912 ^ V Mm 17, ^9U ^ I Contents. * PACE Introduction I ^ History 15 Teachers' or Attendants Record 19 Physical Examination 23 Post Mortem Examination 32 Mental Diagnosis, Tests foi- 35 Mental Analysis, Tests for 69 A Guide for the Clinical Examination of Children INTRODUCTION This syllabus is designed to furnish a guide for the examina- tion and analytic study of atypical individuals, children primarily. It is divided into five parts, the first presenting an outline for the record of the subject's history, the second an outline for the re- cording of his characteristics and abilities as manifested during the first month or so of his institution life, the third an outline for the physical examination, the fourth an outline for the post-mortem examination, and the fifth explicit directions for the mental ex- amination. The mental examination is divided into two parts. The first an examination for the diagnosis, the second an intensive examina- tion for the purpose of mental analysis. The examination for diagnosis is made by means of the Binet- Simon Measuring Scale of the Intelligence. The Binet Scale is the most highly perfected system of tests for diagnostic purposes. It is the only series of tests of any description which has been so adapted to an established classification as to give absolute uni- formity of diagijosis in the grading of feeble minded children. The sub-groups of the feeble minded, the idiot, the imbecile, and the moron, are, without it, ill-defmed and depend largely on the per- sonal equation of the examiner, with it they depend absolutely upon three great planes of language development; the idiots are limited almost entirely to gesture, the imbeciles to spoken lan- guage, while the morons are capable of learning to read and write. The series is moreover the only series in which mental ability and age are correlated, and it thus gives us not only a fair standard for the examination of the partially developed child mind, but also a means of determining the actual mental retardation of any child whose exact age is known. The age correlation given by the scale, the hierarchy of tests there presented, has been submitted to ex- perimental trial by Binet and other investigators and the results confirm the norms given as true norms. 12 A GUIDE FOR THE CLINICAL The scale consists of a number of groups of tests, each group assigned to a certain age at which average children are capable of passing it successfully. The child's intelligence level or mental age is determined by the highest group all the tests in which he passes. To allow for unevenness of development, an extra year of mental age is added for every five tests passed in groups superior to that group of which all tests are passed. No child is considered as belonging to the feeble minded group unless his mental age is at least three years in arrear of his real age. If his retardatioA amounts to this he is graded an idiot, an imbecile, or a moron, ac- cording to his mental age; idiot if this mental age is one or two, imbecile if it is three, four, five, six, or seven, and moron if it is eight, nine, ten, eleven or twelve. Higher than twelve years the feeble minded child seems not to develop. The system of notation used in recording the results of the tests is : + for success — for failure, ! for absurd responses. Partial credit is occasionally re- corded by %. No one should attempt to make these tests without a thorough study of the directions for so doing published by Binet and Simon in L'Annee Psychologique 1908, and La Bulletin de la Societe libre pour I'Etude psychologique de I'Enfant, April 191 L The authors are most emphatic in their statements that the Scale, in spite of its simplicity, is not a mechanical one, and the results obtained when it is used by untrained individuals are of no value for scientific purposes. The second part of the mental examination consists of a series of tests designed to thoroughly explore the mental life of a devel- oped individual. Tests are all standard ones selected from the literature in the course of clinical work with abnormal subjects. Many of them will be found inapplicable to low grade mentality as of course the more difficult of the Binet tests also are. The series of tests is divided into four sections in accordance with the re- cognition of three fundamental mental processes; sensation, repro- ductive memory, and apperception, and their final expression volitional motor ability. Of course none of these processes can be absolutely isolated in experiment, sensation will always merge in- to perception, and perception into apperception. The tests used, the material required, and the directions for testing, are presented in parallel columns to facilitate their use. Models of Ear, Eye anu Brain. EXAMINATION OF CHILDREN 15 History. (Information to be obtained from parents others who know the family well.) General. family physician, and Child's full name and present address. Name and address of parents or guardian. Date of birth of child, or, if unknown, apparent age. Birthplace of child, of father, of mother. Occupation of father and mother. Heredity. Notes : — What other relatives of father or mother belong under 6, 8, or 1 1, giving details. Which of the above or other blood relatives had any of the following conditions, specifying and giving details: Drug habit, vagrancy, special peculiarities of mind or body, hypochondria, 16 A GUIDE FOR THE CLINICAL sexperversion, defect of 'sight, hearing, or speech (stating whether congenital or acquired^ meningitis or brain fever (stating at what age) spasms or convulsions, chorea, hysteria, neurasthenia, par- allysis, other nervous diseases or conditions, apoplexy, heart disease, sudden death, diphtheria, typhoid, scarlet fever, small pox, goiter, other severe disease or defect, serious operations, confinement in hospitals or institutions (what and why?), miscarriages (;number and cause?), cancer, suicide. Parents : Father's parents : Mother's parents : Brothers : Sisters : Other near relatives : Growth and Retardation of Child. Order of birth. Weight at birth. Born at full term? Deficiency or peculiarity at birth. What? At what age and how were peculiarities first manifested? At what age did the child-recognize persons? Sit alone. Stand alone? Walk alone? Use spoon? Get first teeth? Use first words? First short sentences? Acquire tidy habits? Know most of his letters? Get second teeth? Start to school? What progress at school? Stopped at what age and grade? ' Why? Reads how? Writes how? Counts to? Adds. Multiplies. Divides. Weight. Height. Medical History. What was the condition of the mother's health or habits during gestation? Was she mentally troubled? How and why? Was labor long and difficult? Instruments used? Anesthetics? Did child show deficient animation or vitality at birth? Difficulty in breathing or nursing? Any indications of specific disease? What? Malnutrition in infancy? Rickets? What troubles, if any in teething? Has child had the following, stating age and severity: Meningitis or brain fever? Diphtheria? Typhoid EXAMINATION OF CHILDREN ' 17 fever? Scarlet fever? Whooping cough? Measles? Chorea or St. Vitus dance? Tuberculosis? Scrofula? Sleepwalking? Night terrors? Nervous attacks? Describe. Paralysis? Describe. What disease or trouble of eyes? Of ears? Of nose and throat? Of skin? Has child had epilepsy? Fainting spells or spasms?- State frequency of convulsions, if any, and date of last. What imperfections of speech? Of gait and movement? What troubles, mental or physical, at puberty? At the monthly periods? Has the child been pronounced insane or feeble-minded? When, and by whom? Name any other diseases or affections that child has had?. Has been in what hospitals or other institutions, and why? Has undergone what operations? What severe accidents? When was the child last vaccinated? With what results? Has the child recently been exposed to infection? ^ffifp (iisoRSP Give name and address of physician who attended at birth of child. Name and address of present family physician. Environment and Personal History. Has the family always been self-supporting? Cleanly? How was the child treated by. and what was the influence of the father? , .^^ Of the mother? Of step-parent or others charged with its care? Was the child indulged, maltreated, secluded? How many persons in the home? How many rooms? Was the liome tranquil or disturbed? Moral condition of the home? What was the influence of child's associates? • Of associates of the opposite sex? What have been the child's chief interests? In what ways has child been useful? How does the child spend its leisure time? Child's .deportment and the impression made, at school? At work? 18 ' A GUIDE FOR THE CLINICAL How long has child worked? At what work and wages? . How does he care for money or valuables given or earned? Capacities, Habits and Character. To what extent, if at all, has child used alcoholic drinks? Tobacco? Cocaine or other drugs? What harmful personal habits does he have? Does he run away from home? Ever hide or destroy things? What is his attitude to animals? To playmates? To parents? Is child's memory good? What evidence of it? What does he learn rapidly other than school work? Does he pay attention well? Obey well? Feed himself? Dress and undress? Tie a shoe lace? Have morbid fears? Queer ideas? Specify. Is child attentive to calls of nature? Does he sleep well? How many hours? Underscore words that describe child: Trustworthy, in- dustrious, untruthful, lazy, seclusive, moody, cheerful, sly, selfish, slovenly, neat, ill-tempered, violent, excitable, thieving, sissy or cry-baby, emotional, affectionate, unfeeling, fighter, fits of temper, obstinate, anxiouS;, fearful, complaining, gossipy, laugh or cry without cause, very changeable, proud (of what?), resentful. What cause has been assigned for deficiency, if any is present? Of what delinquencies has child been guilty? Give details? What other exceptional behavior has been noted? What punishments have been inflicted? What is child's attitude toward correction? What efforts have been made to help child, when, and by whom ? EXAMINATION OF CHILDREN. 19 Teachers' or Attendants' Record. The child should be under observation for at least a month before this blank is filled.) Observation data concerning the habits, capacities, and men- tality of Reported by Date Habits and Characteristics. Is the child very nervous? When, and how shown? Is he noisy? Mischievous? How? Does he run or stray. away? Often? Get lost? When? Can he see well? Hear well? Read outside of school work? What? Does he wet day clothing? Soil day clothing? What unfortunate habits, sexual or otherwise? Does he complain much? Of what? In what way is the child most troublesome or faulty? In what way does he most differ, if at all, from normal chil- dren ? Describe his habitual position in study or recitation. Underline the words that correctly describe the child: Cheerful. Morose. Quarrelsome. Active. Obsti- nate. Sensitive. Moody, Good-tempered. Excitable. Changeable in mood or character. Sly. ' Resentful. Lazy. Slovenly. Neat. Cleanly. Proud. Of what? Silent. Talkative. Obedient. Generally destructive. Heedless of danger. Destroys clothing. Destroys furniture. Cries with- out cause. Laughs without cause. Mouth usually open. Emotional. Lacking in feeling. Anxious. Impulsive. Lacks self-control. Easily managed. Superstitious. Ap- prehensive or fearful. Fears what? Cranky. Humorous. Very stupid. Selfish. Generous. Gossipy. Capacities and Incapacities. Does he help care for other children? 20 A GUIDE FOR THE CLINICAL Need careful and close supervision? Can he talk? Much? Distinctly? Can he do er- rands? Does he know some letters? How many objects can he count? Can he add? Multiply? Divide? Reads how, in Reader? Understands '^hat he reads? Writes fairly. Spells fairly. Copies dictation how? badly. badly, well. well. Draws fairly. Plays fairly, on what musical instrument? badly. badly, well. well. Sing fairly. What kind of songs or music? badly, well. What and how well can child do in manual or industrial work? In kindergarten? In gymnastics? In athletics gen- erally? In entertainment work? Details. What other studies or work is he engaged in, and what pro- gress in each? In what does he do his best work? His poorest? What is he "good at" in any direction? Are there times when he does much better or worse than usual? How account for these variations? What prevents his doing better? What noticeable defects has he? Intelligence and Perception. Can he tie an ordinary knot? Understand and obey com- mands? Tell time? Take care of apparatus and furniture? How complicated are machines or tools which he can use? How well adapt himself to changed schedule or other new conditions? Does he think of what to do in emergencies, or in play? Examples. What other evidences of intelligence or stupidity? Ever imagine that he sees things? That he hears voices or other sounds? EXAMINATION OF GHILEREN 21 Movements and Play. Can he throw and catch a ball? Dance? How well? How does he walk? Is he very awkward? Very ac- tive? Left-handed? Use both hands equally well? Quick or slow? What automatic movemejits or mannerisms has he, and when? How does he go up and down stairs? Play much, or at all? How? How long at one thing? What, for example? Does he build blocks? Collect things? Excel or lead others in play? Play over past exper- iences? "Make believe" much in play? Play alone or with others, usually? Learning, Interests, Imitation and Memory. Name the main interests noticed in this child, underlining the strongest. Does he learn new work easily? Remember it well? Learn "pieces" easily? Remember them well? Talk or seem to think much of old-time experiences? Of recent experiences? Is he very forgetful? What does he imitate? How much and how well? Mechanically or with understanding? How much progress or decline have you seen in him, in how long? Does he stick to tasks well? Willing and tries? Is he easily confused? When and how? Do you think he will improve, stand still, or go back? Morals. Is he cruel? Profane? Obscene? Deceitful? Thieving? Untruthful? Lacking in shame or modesty? Ever -violent to others? Show sense of duty? Of right and wrong, or remorse? What evidences of interest in religion? Is he trust- worthy? Of what immoral acts is the child frequently or sometimes guilty? 22 A GUIDE FOR THE CLINICAL ' Other Social Relations. Is the child easily led or persuaded? By whom? Over-dependent on others? Like to have and show authority? Is he confiding? . Chummy? Timid? Bashful? Affectionate? Sociable? Sympathetic? What is his attitude toward hig parents? Toward his brothers or sisters? Toward strangers? Toward animals or pets? Does he get on well with other children? Why not? Is he a sissy or cry-baby? EXAMINATION OF CHILDREN 23 Physical Examination. I. General Anthropological Data. 1. Height. 2. Stretch of arms. 3. Weight. 4. Skull measurements (circumference at level of occipital protuberance and glabella, greatest lateral width). Rieger tracing if necessary. 5. Malformations. .^Underscore those found, in list below, and add any others.) Head: — ^Microcephalic, macrocephalic, hydrocephalic, asym- metrical. Face: — Prognathous, immobile, inferior maxillary small, large, superior maxillary small, nasal bones sunken, forehead retreating, narrow; face asymmetrical as to forehead, nose, eyes, ears, mouth. Nose: — Much deHocted, septum abnormal, base of nose broad, nostrils open forward. Lips: — Hare-lip, lips very thick, very thin, fissured above, below, very long, very short. Teeth: — Hutchinson's, persisting milk teeth, serrated, pointed or notched, chalky, impacted, irregular in shape or arrangement, decayed, rachitic. Soft Palate: — Twisted R. L. Response of azygos muscle. Hard Palate: — Cleft, V-shaped, semi-V-shaped, saddle-shape, high, narrow. Eyes: — Pupil irregular or eccentric, congenial ptosis, epican- thus, oblique Mongolian, palperbral fissure small, asymmetry, in size, in color strabismus. Ears: — Very large, very small. Darwinian tubercle, abnormal development, asymmetrical position or formation. Tongue: — Very large, very small, thick. Hat, pointed, fissured, enlarged papillae. Thyroid: — Enlarged, atrophied, absent. Thorax: — Breasts absent, atrophied, small, large, supernu- merary; development of breasts in male; pigeon breast, funnel breast. 24 A GUIDE FOR THE CLINICAL Upper Limbs : — Very long, very short, asymmetrical; mal- formation of right, left hand; Angers united, supernumerary, two- jointed, very long, very short. Little, Angers imperfect. Left handed, ambidextrous. Lower Limbs : — Club foot ; toes united, supernumerary ; knock- knee, bow-legs, legs or feet very long, very short, asymmetrical. Genitals: — Incomplete descent of one or both testicles. Organs over-developed, undeveloped; atrophied. Hermaphrodism, true or false. Phimosis. Stenosis or reduplication of vaginal and uterine canals. Undeveloped uterus, ovaries, vagina. Clitoris enlarged or hooded. Skin:— Pallid, sallow, leathery, prematurely wrinkled, birth- marks. Hair :^Coarse, scanty on face, eye brows, chest, pubes. Hairy moles or tufts on body. Gray hair in patches. Bald spots. Eye brows meet. Abnormal distribution of hair. Nails: — Thin and friable, pigmented, arched and thickened, long, short, furrowed lengthwise, crosswise. Bodily characteristics : — Gigantism, dwarAsm. General balance relaxed. Asymmetrical posture or head balance. Scoliosis, Lordosis. Feminine aspect. Mincing or shuffling gait. 11. General Appearance as Regards Past and Present Health. General state of nutrition. Color of mucous membranes. Presence of jaundice, oedema, etc. Presence of skin eruptions (describe in detail and chart). Evidences of syphilis recent or remote, (gummata, scars on genitalia, tibial crests, and tongue). Evidences of old rickets. Signs of gout or rheumatism. Enlarge- ment of thyroid. Scars and bruises. Bodily temperature. Appar- ent age. III. Spontaneous Complaints. Feeling sick, weakness, nervousness, vertigo, headache, pain, etc. These should all be carefully investigated and recorded in the patient's ov^^n words, or if he does not speak, with his description. EXAMINATION OF CHILDREN 25. IV. Respiratory System. A. Upper Respiratory Tract. Character of naso-pharyngeal mucous membrane, presence of obstructions such as polypi, adenoid growths, or enlarged tonsils. Abnormalities of pharynx or larynx. B. Lower Respiratory Tract. Rapidity and character of breathing (easy or difficult, nasal or oral, abdominal or thoracic). Dyspnoea. Any pain on breathing, cough or expectorations (character and amount). Shape and degree of expansion of chest. Inspection, palpation, percussion, and auscultation (make both anterior and posterior examination of chest including apical region). V. Circulatory System. Sensation of palpitation, arhythmia, pain or anxiety, with full details. Position and character of cardiac impulse. Occurrence of abnormal pulsation in chest wall. Area of cardiacdullness. Char- acter of sounds at apex and base. Pulse: Rate, quality, variations in both as the result of change posture (lying, sitting, standing), emotion and exertion. Sphygmogram. Sphygmomanometricread- ing. Condition of the walls of the arteries (radial, brachial, tempor- al, femoral, dorsalis pedis, and in ocular fundus on both sides) Abnormalities of veins — -variecosities, pulsations, etc. Examina- tion of blood. VI. Digestive System and Abdomen. Appetite, thirst, nausea, vomiting, eructation, pain, etc. Con- dition of mouth, teeth and tongue. Size and position of stomach. Analysis of stomach contents where indicated. Outline of liver, spleen, palpation of kidneys, (movable or not movable^ Charac- ter and frequency of stools with microscopic examination if indi- cated. Areas of tenderness over abdomen (McBurney's point, etc.) 26 A GUIDE FOR THE CLINICAL VII. Urinary Apparatus. Pains or subjective symptoms referred to kidneys or bladder. Frequency of micturition. Amount of urine in 24 hours. Chemi- cal and microscopicexaminationof urine. Inflammationof mucosa, bladder and urethra. VIII. Genital Organs. The menstrual functions, their regularity as to frequency and amount; any accompanying symptons (pains, irritability, nervous- ness, etc.) Examination of the pelvis per vaginam orper rectum as indicated. Quantity and character of any discharge. Frequency and character of functional activity. Examination of prostrate if indicated. Presence of scars or discharge. XI. Nervous System. A. Centripetal Apparatus. I. Special Senses. Smell. Examination of nerves. Test each nostril separately with peppermint, oil of cloves, and asafoetida. Note the actual answers. Vision. Examine cornea (for opacities and signs of intersti- tial keratitis), lens, humors, and ocular fundus (describe and chart any abnormalities). Acuity of vision (any areas of refraction to be corrected). Fields of vision (examine with fmger roughly and if necessary with perimeter for scotomata, hemianopia, etc. Taste. Condition of tongue should be noticed. Test separately the interior two-thirds and posterior third on both sides with salt, s.ugar, quinine and vinegar. (Do not a-llow the patient to roll the tongue in the mouth and let him answer by pointing to card on which is written salt, sweet, bitter, sour). EXAMINATION OF CHILDREN 27 Hearing. Examine the meatus, canal, and membrane. Note the presence of any cerumen or discharge. Test each ear with the watch and tuning fork both for air and bone conduction. Galton's whistle. 2. Cutaneous Sensibility. Both touch and pain sense should be examined roughly in every case and a more exhaustive examination with charts made wherevnr any changes are noted. Always test the ulnar borders of the fore-arm, the outer sides of the thighs just abovetheknees, and the dorsum and soles of the feet. Remember sensibility to pain and temperature may be diminished or lost when the tactual sense is unaffected in tabes, general paralysis, etc., as well as insyringomelia. 1. Subject symptoms. — Pain, (character and distribution), numbness, formication, pins and needles, coldness, and heat. 2. Tactile sensibility. — Examine with tip of finger or by draw- ing thread over the skin. Note the acuteness of sensibility and the accuracy of localization for space andtime. In recording on a chart, tactile anaesthesia is marked by horizontal lines and its degree in- dicated by the length of the lines. 3. Pain.— Test with a pin point, which should be guarded by the tip of the examiner's finger to prevent discrimination as point by the smallness of the area touched. Ask whether the stimulus is actually painful, and note accuracy of localization in lime and space. Be sure that patient is attending. Mark on chart with ver- tical lines. 4. Temperature. — Test with warm and cool water in test-tubes. For charting use diagonal lines. 5. Stereognostic sensibility. — Tliis is not strictly a pure cuta- neous sensibility, but may for convenience be considered here. It consists in the power to recognize objects by palpation with the eyes closed. 3. Deep Sensibility. 1. Tendernessof nerve trunks to pressure. (Ulnar at elbow and musculo-cutaneous of leg below head of fibula, i 2. Tenderness of muscles on pressure. 3. Sense of position. Test by asking patient to describe the position of a limb after it has been passively moved or by asking him to imitate the position with the limb on the other side. 4. Sense of passive movement. 5. Sense of tension as estimated by judging weights. 28 A GUIDE FOR THE CLINICAL 6. Coordination of muscles. Finger-nose test, Rhomberg test, walking along line, putting heel on opposite knee, etc. 7. Pallaesthesia. — Sensibility to vibration of tuning fork. B. Centrifugal Apparatus. Cranial. i. -Ocular Group Pupils: — Size, shape, position, (central or eccentric) . Note any evidence of old iritis. Rapidity and degree of contraction to light (notice whether they dilate again at once and oscillate) , dilatation to shade. Contraction in accommodation, con- vergence, and after tightly closing the lids. Dilation from painful stimulus, e. g., over cheek bone. Where there is any suggestion of affection of the sympathetic test dilatation with cocaine. Extrinsic muscles : -—Are the optic axes parallel? Examine movements of the eyes in all directions and note whether the move- ment is full and steady (jerky, nystagmoid, nystagmus. In this last describe the direction of the movement and the position of eyes in which it occurs.,; If there is any complaint of diplopiaexamine with flame and colored glass. Upper lids: — Width and equality of palpebral Assures the di- rection of the wrinkles on the forehead (may be altered as result of weakness of the levator palpebrae.) Ptosis, subptosis. Lagophthal- mos, von Graefe's and Stellwag's signs. 2. Masticatory Group: — Any deviation of the jaw in opening the mouth, power to hold jaw open, power in closing (compare the degree of hardening of the masseters and temporals in clenching the teeth). 3. Facial Group. Upper Part — Scowling, frowning, and rais- ing the eyebrows, closing the eyes tightly. Lower Part — Showing the teeth and tongue, whistling. Com- pare the two naso-labial folds. Observe the facial movements also in emotional and associated movements (clenching flsts,etc.) 4. Phonation-Articulation-Deglutition. Character of voice smooth or harsh, nasal. (For this last good test words are amber, under, kick, cook^ . If there is any change examine the larynx. Movements of the palate in phonation (compare the arch on each side of the uvula.) Hardening of the muscles of the floor of the mouth when the tongue is pushed against the closed teeth. Position of the tongue as it lies in the mouth when this is slowlyopened. Protrusion of tongue (use line between median EXAMINATION OT CHINICAL 29 incisor teeth as guide for midline), freedom of movement when out, power of thrust into either cheeli. I^ook for signs of early atrophj' of the tongue along the lateral margins. De- scribe any defects in articulation, using as test words elec- tricity, truly rural, royal Irish constabulary, Methodist Epis- copal, particular popularity. If there is any difficulty in swallowing, note whether due to defect in palate (nasal voice and regurgitation of fluids), in passing the bolus back to the pharynx, or below the pharynx. If indicated use oesophageal sounds. (Exclude thoracic aneurism first.) Spinal. 1. General muscular development in relation to occupa- tion, tonus of muscles, power in comparison with development. Always compare on the two sides the grip (use dynamometer), flexion and extensioa at the wrist, elbow, knee, and ankle. Describe the general character of the movements as to ease or clumsiness, extent (if restricted examine the joints^, and take special note of gait (when not conscious of direct examination; , taking off and putting on clothes, and writing. Samples of the last should be inserted in every case — name, date, and test phrase. Where any weakness or atrophy is observed, it is necessary to examine in detail the muscles moving each point, and often to examine the excitability of the muscles to mechan- ical stimulation and to the electric current — ^Faradic and Gal- vanic. 2. Abnormal Contractions. a. — Fibrillary twitching, ils distribution and persistence, and conditions modifying its oc- curence, b. — Tremors. Location, character, rapidity, am- plitude, and direction. How modified by rest, exercise, sleep, and effort of will. c. Irregular movements, such as chorea" d. ■ Spasm, such as facial spasm, hysterical spasm, e. Psycho- genic — tic, catalepsy, negativism, etc. 3. Examination of cerebral spinal fiuid. 30 A GUIDE FOR THE CLINICAL C. Reflexes. I. Superficial. Corneal. Blow on cornea. Palatal, Sneezing. Scapular, Gluteal. Epigastric, Abdominal. Cremasteric. Plantar. Stimulate with the finger or handle of percus- sion hammer, drawing it from heel toward the toes. Be care- ful to have the knee bent and the ankle loose, and do not press hard on the sole. Describe the movements which occur, espec- ially in the big toe, and where no response is obtained in the toes, notice for any contraction in the Tensor Fasciae Femoris. Note whether response is more readily obtained from the inner or outer side of the sole of the foot. 2. Deep. Masseteric. Tap on the chin with the mouth slightly open. Scapulo-humeral. Tap on the edge of the scapula just above the ridge while the arm hangs loosely by the side. Biceps. Percuss the thumb placed on the tendon. Supinator longus. Tap the lower end of the radius. Triceps. Tap the tendon. Knee jerk. Examine with feet resting on the floor, but pushed forward as far as possible. Compare the two sides and note the ease with which obtained, whether elicited with every tap, the effects of reinforcement. Depressed patellar jerk when lying down. Note the occurrence of patellar clonus, and spread to other muscles. Adductor jerk by tapping the inner side of the knee. Ankle jerk. Examine where possible with the patientkneeling with feet hanging over the edge of the support and tap the tendon, varying the tension of the muscles by bending the ankle more or less. (This reflex is often lost earlier than the knee jerk.) In ex- amining for ankle clonus, have the patient lying down, and test with the knee flexed at various angles. Gordons paradoxical reflex. Pressure on the calf ^flexor) muscles gives rise to extension of the big toe. This is probably present in slighter degrees in pyramidal tract affection than the Babinski phenomenon. EXAMINATION OF CHILDREN 31 3. Organic. Bladder. Delay; retention; incontinence witli full or empty bladder; dribbling after micturition; residual urine. Consciousness of passage of urine. Peculiar sensations. Reef urn. Spasm or relaxation of sphincter (insert finger), in- voluntary evacuations, consciously or not. Sexual. Any abnormalities. Examination of Convulsions. Is there any aura? Describe carefully -in patient's own words. Is it always present? Does it sometimes occur without a convul- sion? Is consciousness lost? How soon? And for how long? Is there a cry? fall? Where does the convulsion begin? Always in the same place? What is the direction of its march? Is it confined to a single part?- to one side of the body? general? Is a paralyzed part involved or omitted? Is there a clonic as well as a tonic stage? Attitude of the body at the height of the convulsion? What is the average duration? Frequency and hour of occurence? Is the tongue bitten? Involuntary micturition or defaecation? Where possible, study carefully the condition of respiration and circula- tion, the pupils andreflexes during and after the convulsions. Is it followed by deep sleep? headache? transient or permanent weak- ness or paralysis of any part of the body? any automatic move- ments? Investigate for any history of petit mal (momentary sen- sations, flashes of light, vertigo, loss of self, involuntarymicturi- tion, etc.) for any evidence of automatism, sudden inexplicable outbursts of anger, etc. Any conditions which seem to have any bearing in the excitation of the convulsions. 32 A GUIDE FOR THE CLINICAL Record to be Made at Post-Mortem Examination. Name Case No Date Age Sex Color Address Married — Single ....Admitted Died Autopsy Hrs. after death, weather cold, mild, hot. History alcohol syphilis Tbc Injury Clinical diag Autopsy ordered by Performed by Cause of death 1. External Appearances Nutrition Weight Lbs., l^ength Appearance of skin , Eruptions Scars Wounds — Bruises — Deformities P. M. Lividity : . . 2. Read Scalp Hair Eyes, Sunken Protruding Pupils Skull depressions Size Thickness Injuries Fluid in Cranium Character Dura Mater, thickness Color Adherent to — Sinuses, quality of blood Thrombi Pia Mater, thickness Vascularity Fluid Vessels at base - Cortex Convolutions Brain, weight. . Consistency Color Ventricles lateral size Contents Choroid Plexus Softening Blood Clots Tumors . . 3. Spine, Deformities Cord EXAMINATION OF CHILDREN 33 Thorax and Neck. Glands Neck Axillae Mammae Tongue Salivary glands Tonsils Trachea Larynx Mediastinal gland Lungs left upper Lobe : Lungs left lower Lobe Lungs right upper Lobe Lungs right middle Lobe Lungs right lower Lobe Bronchi Diaphragm right side Left side Pleurae left adhesions : Effusion Right adhesions Effusion Heart Size Position Pericardium adhesions...- Effusion Quan Char, Thickness Surface Heart opened in situ blood Clotted Clots right Chicken fat Red White Clots left Chicken fat Red White Weight Ounces Hypertrophy R.V R.A. L.V L.A Dilatation R.V R.A L.V. L.A Cardiac Muscle Firm Friable Fatty Color . . . Valves Mitral Aprtic Tricuspid Pul Coronary Arteries Sclerosed Thrombosis Pulmonary Arterj^ Aorta Arch Thoracic Abdominal Others Genito Urinary Tract. Kidney Lft. wt. Oz. Color Shape Size.. Capsule Venae Stellae — Infarcts Cortex Relation to Medulla Cysts Pelvis Distended Fluid Pus Stone ' Large White Kidney Passive Congest. Kidney Amount of perinephritic Fat — Movable Ide. . .2de. . .3de. . . Chronic contracted Kidney Right wt Oz., Color Shape Size Capsule Venae Stellae Infarcts Cortex Relation to Medulla Cysts Pelvis Distended Fluid Pus — Stone Lesion Pas. Cong LargeW Ch. Cont Amount of perinephritic fat. . .Movability ide. .2de. ..3de. . . Supra Renal Bodies Lft Rt 34 A GUIDE FOR THE CLINICAL Bladder contents Oz Thickness M. M. Ureters Lft Rt Prostate Size Cent. Lobe Rt Lt... Urethra M.M Stricture Malfor Testicles Lft Rt Seminal Vesicles Lft Rt Uterus Size Tumor M.M Tubes Lft..... Rt. Ovaries Lft Rt 6. Abdomen. Position of organs • . Peritoneum Adhesions Fluid in cavity Amt Character liiver Weight Color Size Surface... Edges Cut Surface Consistence Gall Bladder Stones Gall Ducts Bile Lesion Pancreas Spleen Wt. Capsule Cut Surface — Peritoneal Lymph Glands Stomach size Contents Mucous M. Thickness Ulcers Scars Pylorus thickness Esophagus Congestion Lesion •. Small Intes. Appendix contents Ulceration Contents Obstruction Intuss Volvulus. Parasites Hernia Large Intest dysentery Contents Construction Location • Hemorrhoids » Other organs Spec. Preserved in Museum No EXAMINATION OF CHILDREN 35 Mental Examination. I. Examination for Mental Diagnosis. BINET=SIMON MEASURING SCALE OF THE IN = TELLIQENCE. 1911 REVISION. Idiots. Mental Age i and 2 Years. 1. Move lighted match slowly before child's eyes. Full credit given if eyes folloio light for briefest period. 2. Place a wooden block in child's hand. Credit given if block is grasped. 3. Show the wooden block without touching child with it and say, "This is for you, don't you want it to play with?" Credit given if child takes it. 4. Offer child a piece of wood and a piece of chocolate of the same size. Credit given if he eats the chocolate and does not at- tempt to eat the ivood. 5. Show child a piece of chocolate, then wrap it in paper and present it to him, telling him to eat it. Credit given if he removes the paper before eating. 6. Make simple movements, clapping the hands, sitting down, standing up, etc., and tell child to do the same. Credit given if one imitation is accomplished. Imbeciles. Mental Age 3 Years. 7. Show me your nose. Show me your eyes. Show me your mouth, 8. Listen well and repeat what I say. 4; 3 — 7; 6 — 4; 5 — 8; Pronounce numbers slowly and distinctly with one-half second in- terval between, one pair at a time. Full credit given for one exact repetition. 9. Place Picture 1 before child and ask, "What is that?" or "What do you see there?" Follow this by Pictures 2 and 3. (Fig- ures 1, 2, 3.) Full credit given if some objects are enumerated. 36 A GUIDE FOR THE CLINICAL 10. "What is your name?" If first name only is given — '"and your other name?" Surname required. 11. "Listen well and repeat what I say. I am cold and hun- gry." No errors of any kind alloived. Mental Age 4 Years. 12. "Are you a little boy or a little girl?" If necessary— "Are you a little girl?" "Are you a little boy?" 13. Show child a pen knife saying; "What is that? What is it called?" Then show' penny and finally key, asking same ques- tions. Name of three objects required. 14. "Listen well and repeat what I say. 4 — 9 — 2; 3 — 7 — 4; 5 — 8 — 1." Full credit given for one exact repetition. 15. "You see these two lines. Tell me which is the longer." (Figure A.) Mental Age 5 Years. 16. Place two boxes weighing 3 and 12 grams respectively on the table before the child leaving a space of 5 or 8 centimeters be- tween them and say, "You see these two boxes? Tell me which is the heavier." Repeat, using boxes weighing 6 and 15 grams and repeat again using first pair. //' there is still doubt about the child's ability to compare weifihts, repeat process. 17. Draw a square 3 to 4 centimeters in diameter with ink and ask the child to copy it, giving him pen and ink to do so. 18. "Listen well and repeat what I say. My name is Charley. 0! the naughty dog." 19. Place four pennies in a row before the child and say, "Do you see these pennies? Count them and tell me how many there are." ■ Child is required to point to each with finger, no error allowed. 20. Place an oblong card on the table before the child and place also, nearer to the child 2 triangular cards formed by cutting another card like the first one in two, along a diagonal. Place these two triangular cards in such position that their hypotheni form a right angle one with the other, then say to the child, "Put these two pieces together so that they will form one card like this," (indicating the oblong card.) If the child turns over one triangu- lar piece without noticing it it is permissible to begin again. FlfiURE 3. Figure A. Figure 4. EXAMINATION OF CHILDREN 47 Mental Age 6 Years. 21. "Is it morning now?" "Is it afternoon now?" 22. "What is a fork?" "What is a table?" "What is a chair?" "What is a horse?" "What is a mama?" //' some use of three of the objects is mentioned the reponse is considered correct. 23. Draw a diamond figure with ink and ask the child to copy it, giving him pen and ink for the purpose. 2i. Place 13 pennies in a row on the table before the child and say, "Count these pennies for me, pointing to each one as you count it." 25. Show pictures of faces (.Figure 4). Expose first the up- per two alone, next the two middle ones, and last the two lower ones, saying each time, "Which is the prettier of these two faces? ' No error allowed. Mental Age 7 Years. 26. "Show me your right hand." "Show me your left ear." No error alloived. 27. Show picture as in Test 9, requiring descriptions. 28. "Take this key and put it on that chair, bring me that book lying on the table, and open the door." Repeat these direc- tions distinctly ttvice. 29. Place three two cent and three one cent stamps on the table before the child. Make sure that he knows the 2's from the I's and ask him to count how much they would all cost. 30. Have four pieces of colored paper, red, blue, yellow, and green. Point to "each asking "What is this color?" No error allowed. Mental Age 8 Years. 31. (a) "Do you know what paper is?" "Do you know what cardboard is?" "Are they alike?" "In what way are they not alike?" (b) "Have you ever seen a lly?" "Have you ever seen a but- terfly?" "Are they alike?" "In what way are they not alike?" (c) "Do you know wood when you see it?" "Do you know glass when you see it?" "Are they alike?" "In what way are they not alike?" Two satisfactory answers required. 48 A GUIDE FOR THE CLINICAL 32. "I want you to count backward from 20 to 0. Like this — 20 — 19 — 18/' This must be accomplished in 20 seconds. One error allowed. 33. The four pictures in figure 5 are shown one at a time and the question asked with each, "What is missing in this picture?" Three correct replies required. 34. "What day is today? What date is it?" 35. "Listen well and repeat what I say : 3-8-5-7-1; 9-2-7- 3-6; and 5-1-8-3-9." One group given at a time. One exact response required. Mental Age 9 Years. 36. In a pile before the child place the following coins; — ten pennies, two nickels, two dimes, one quarter, one half dollar. Then propose a game of storekeeping, the child to keep the store and use the pile of money to make change, the experimenter to be the customer. Add some articles for sale., Then buy something for four cents. Give the child a quarter and require the change. 37. Test No. 22. Definitions superior to use are required. 38. Show the child successively a penny, a dime, a dollar, a quarter, a nickel, a half dollar, a two dollar bill, a ten dollar bill, a five dollar bill. Ask, "What is this?" with each. 39. Name the months of the year in order. One error allowed, time 15 seconds. 40. (a) "If you were going away and missed your train, what would you do?" (b) "If one of the boys should hit you without meaning to, what would you do about it?" (c) "If you broke something belonging to some, one) else, what would you do about it?" Txvo good responses required. FlCURE 5. EXAMINATION OF CHILDREN 51 Mental Age lo Years. 41. Place on the table before the child five boxes weighing 3, 6, 9, 12 and 15 grams respectively. Say to him "Theselittle boxes all weigh different amounts. Some are heavier and some lighter. I want you to place the heaviest here and by its side the one which is a little less heavy, and then the one a little less heavy and the one still a little less heavy, and Anally here the lightest." Three trials made, the boxes mixed after each. Two successes in three are required. -tm- Figure 6. 42. "I am going to show you two drawings and after you have looked at them I shall take them away and ask you to draw them from memory. You must look at them closely because you will only have them for ten seconds and this is a very short time.' (Draw- ings shown in figure 6.) Full credit is given if the whole of one drawing and half of the other is reproduced exactly. 43. "I am going to read you some sentences; in each one of them there is something foolish or absurd. You listen carefully and tell me each time what it is that is foolish." (a) "An unlucky bicycle rider fell on his head and was in- stantly killed; they took him to the hospital and fear that he can- not get well." — After a pause — "What is foolish in that?" (b) "I have three brothers, Paul Ernest, and myself" — "What is foolish in that?" (ci "The body of a young girl cut into 18 pieces was found yesterday. People think that she killed herself". — "What is fool- ish in that?" (d) "There was a railroad accident yesterday, butnot a serious one, only 48 persons were killed" — "What is foolish in that?" 52 A GUIDE I^OR THE CLINICAL (e) "A man said; — "If I should ever grow desperate and kill myself I should not use Friday for the purpose because Friday is an unlucky day and might bring me unhappiness" — "What is foolish in that?" Correct solution of three of the five statements required. 44. (a) "If you were delayed on your way to school, what would you do about it?" (b) "Before taking part in something very important, what would you do?" (C) "Why do we more easily pardon a bad act done in anger than a bad act done without anger?" (d) "If some one should ask your opinion of one whom you did not know very well, what would you say?" (e) "Why should we judge a person by his acts rather than by his words?" Two errors allowed.. 45. Write the words, Paris, fortunes, stream. Show them to the child reading then! to him several times. Then give him pen and ink and tell him to write a sentence containing all three of these words. Full credit is given for two sentences containing the three words. Mental Age 12 Years 46. "Which is the longer of these two lines?" Fig. 7. "Which is the longer of these two lines?" Fig. 8. "Which is the longer of these two lines?" Fig. 9. "And of these?" Fig. 10. "And of these?" Fig. H. "And of these?" Fig 12. Full credit given if suggestion of longer line to the right does not hold in last three pair. One -half credit if it only partially holds. 47. TQ°,i^^. Credit given for one sentence containing the 3 words. 48. "I want you to say just as many words as you can in three minutes. Some boys say as many as two hundred. Now you must try and see how many you can think of." Sixty words the minimum accepted. 49. "What does charity mean?" "What does justice mean?" What does kindness mean?" Two correct answers required. 50. "Find the sentences which these words make. Fix the words in their proper order." c s EXAMINATION OF CHILDREN 65 (a; At-counti'y-we-for-started-hoiir-an-the-early. (b) Teacher-I-to-my-exercise-asked-my-correct. (c) Defends- a-his-dog-master-good-bravely. Mental Age 15 Years. 51. "I am going to say seven numbers. Listen well and repeat them exactly. 4-9-2-6-5-3-7; 9-3-5-1-8-2-6: 2-7-4-9-3-8-5." One success in three re-■ Xi i> o 'r -M -d _^ ^ t: •H o -g u .S « « "2 ^ ^ > S . ■— > „ C c i; e e 'z; c 2 o o u G c " r >> 2 Q 4) J= ■« 5^ — .t; o S ^ 2 rt O I. u 5 u o .2 XI ^ t; H "5 - o *: ^ H = 2 • " ^ u. '■ « g O a _, Z (8 " ™ o C .11 „ u ^ _> Zi a £ o "3 j3 3 c u ;, u o o « u