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? 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 name? Where were you born?

In what year were you born?

What year is this?

How old does that make you?

What is your occupation?

Where do you live?

What is the name of this town or city?

How far is it from New York (or other notable city)?

What kind of an institution is this?

What date is to-day? What month? What day of the week?

Is this morning or afternoon?

Where did you come from? When?

How did you come (train, boat, trolley, carriage, walk)?

Did you come alone or with somebody?

What did you have for breakfast this morning?

Where were you yesterday?

Where were you a week ago?

Where were you last Christmas?

Where did you go to school? Can you name some of your teachers?

When did you leave school?

When did you begin work?

Who was your first employer?

Count backwards from 20 to 1.

5+4? 9+7? 26+39? 4X8? 5X12? 9X17?

Give the months of the year.

Name five large cities in the United States.

Where is London? Paris? Berlin? Vienna? Rome?

Who is the President of the United States? Who was the first President? What war took place while Abraham Lincoln was President?

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 aoked, 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 psychotic patients 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 psycho-graphic 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 patient 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 paralysis, or cyclic, as some manic-depressive psychoses.

From the standpoint of symptomatology four kinds of writings may be distinguished: spontaneous writings, writings from copy, writings from dictation, and penmanship. Each has its special interest, as each enables us to study particular types of pathological phenomena. Spontaneous writings reveal chiefly the delusions of patients and are often of great value in cases of dissimulation. Writing from copy reveals disorders of attention, and writing from dictation reveals disorders of memory. Finally penmanship, which results from the patient's effort to produce the best possible handwriting, brings out motor disorders (tremor and ataxia).

Unfortunately the study of graphic pathology in order to be fruitful must go into certain details which could not be entered upon here for want of space. We must therefore limit ourselves to this brief discussion and refer the student to .works in which this subject is specially treated.1

Having completed the examination it will be found very advantageous to prepare a summary of the findings which are of significance for diagnosis, prognosis, and treatment.

Many attempts have been made to simplify and standardize the work of clinical examinations by the use of printed blank forms. Experience has shown that to rely entirely on records thus prepared is not consistent with good clinical work. For a part of the records, however, it will be found

1 Seglas. Les troubles du langage chez les alienes. Bibliotheque Charcot-Debove. - Koster. Die Schrift bei Geisteskrankheiten. Leipzig, 1902. - Joffroy. Les troubles de la lecture, de la parole, et de Vecriture chez les paralytiques genraux. Nouv. Iconogr. de la Salpet. Nov.-Dec. 1903. - J. Rogues de Fursac. Les Scrits et les dessins dans les maladies nerveuses et menlales. Paris, Masson, 1905helpful to have a statistical data sheet or card such as is used in the New York state hospital service, somewhat like the following:

Patient's name in full........................Admission No.......

Date of admission............191 Race..............Sex.......

Residence......................Date of birth....................

Marital condition (single, married, widowed, divorced, separated). Occupation (or that of husband, father, or other person on whom patient is dependent)......................Citizenship (American, foreign).

Nativity (state or country)............How long in U. S...........

Nativity of father..................of mother....................

Education (none, reads only, reads and writes, common school, high school, collegiate, professional). Religion (denomination)............

Previous hospital residences (dates and duration of each)............

........................................................................................................................

Heredity.......................................................

Constitutional make-up (intellectually and temperamentally).........

Alcoholic habits................................................

Venereal history................................................

Other etiological factors.........................................

Date and manner of onset of psychosis............................

Diagnosis......................Legal status (committed, voluntary)

Permission for autopsy in event of death..........................

Names and addresses of relatives, friends, or legal guardians..........

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