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nation is out of the question for the time being and can be attempted only after subsidence of the hyperacute 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 coöperation is to be had.
In cases offering reasonable coöperation 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, without indeed letting him think that it is assumed that he is insane, but making him understand that such has been alleged to be the case and that it is the examiner's business as a physician to investigate his case in order either to establish or disprove the allegation.
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
Ꭰ 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?
It goes without saying that any hallucinations or delusions that may be elicited should be gone into thoroughly: Do you hear the voices all the time or only occasionally? Are they distinct? Are they voices of men or of women? Familiar or strange? Where do they come from? Transmitted by some apparatus? What do they say? What do you do when you hear them?
hear them? Do others hear them also or only you? Don't you think it is just imagination? Or, What makes you think you are being poisoned? Did you taste it in your food? Have you noticed any ill effects? Who is doing it? For what reason? For what object? What do you plan to do about it?
At this stage of the interview the examiner will probably already have gained some idea of the patient's orientation, memory, education, and mental capacity. But it is preferable to test these specially and by a uniform technique for all cases in order to obtain data for comparison. The following questions are recommended:
What is your
Where is London? Paris? Berlin? Vienna? Rome?
President? What war took place while Abraham Lincoln
Retention may be tested by giving the patient a number, or a name, or a phrase to remember (1473, physician's name, 238 Main Street), and asking him to recall it at the end of five minutes.
At some convenient time during the examination an attempt should be made to determine the degree of insight which the patient has in regard to the abnormal nature of his symptoms. It happens very seldom that a patient admits that he is insane, but this is hardly a proper criterion of insight; in fact where it does happen it is more apt to be dependent on a certain shallowness of personality and emotion than on a real preservation of auto-critical faculty. Thus one imbecile was asked, Why did they send you here? — “They said I was crazy,” he answered. Was that really so? he was asked again.
“I guess so,
, he said, grinning all the time. What is of importance in this connection is to gain a precise idea to what extent the patient realizes the unusualness of his morbid experiences and behavior and their dependence, not necessarily on insanity, but on being
nervous,” or “upset,” or on “overwork,” or “lack of sleep,” or “drinking too much,” etc.
Tests of reading and writing are also very useful.
The first consists in requesting the patient to read aloud some paragraph in a book or in a newspaper and then having him give an account of what he has read; his account is more or less accurate and complete. This test may demonstrate any existing disorders of (1) perception; (2) attention and association of ideas; (3) power of fixation; (4) speech (physical impediments).
A systematic study of the writings of the insane is of the highest interest. The symptoms which such writings reveal are sometimes so clear as to be sufficient in themselves to characterize an affection, and in all cases they constitute valuable elements of diagnosis. Joffroy has very properly classified them into calligraphic and psychographic disorders. The former pertain to the handwriting as such, which may be more or less irregular, tremulous, hesitating, etc. The latter pertain to the content of the writing and reveal psychic abnormalities: weakening of attention (omission of words, syllables, or letters, errors of spelling due to inattention), weakening of memory (errors of spelling due to effacement of word images or to forgetting the rules of grammar), mental automatism (flight of ideas, incoherence, stereotyped repetition of letters, words, or phrases), and various delusions.
The writings constitute trustworthy, permanent documents which may be indefinitely preserved as evidence of the state of psychic (sometimes also of motor) functions of a subject at a given time. One may also, with the aid of the data of graphic pathology and solely by means of examining the writings of a subject, follow in a certain measure the course of a mental disease the development of which is either progressive, as general paresis, or cyclic, as circular insanity.