Finding Common Ground in the MSE Debate

In regard to the letters of Dr. Tesar and Dr. Hofman in Practical Neurology (vol. 8, no. 3) I find myself feeling that both physicians are passing each other in the night. I learned to do a mental status exam under Norman Geschwind at the Boston VA, Boston City Hospital and the Jamaica Plain VA. He used it, in my experience, to pinpoint the site of the lesion at a time (1967) when only cerebral angiograms and pneumoencephalograms were available. They were not done casually.

The tests mentioned in Dr. Hoffman's reply refer primarily to initial localization of the lesion when, e.g. there was neglect (clockface) or short term memory problems (serial 7s). I don't think they were "ugly" or ritualistic, but they may be archaic in the sense that nowdays a CT possibly followed by appropriate MRI testing can give localization quickly and the nature of the lesion at the same time.

The probing of a patient's inner life—I assume Dr. Hoffman means testing higher cortical functions—may indeed require gentle, polite and non-threatening probing followed by detailed neuropsychologic testing (along with the appropriate search for metabolic or other causes of non-neurologic etiologies). My impression 40 years ago was that most patients were not intimidated or threatened by Dr. Geschwind and took it in the "bear with me" way he presented it. My own experience seemed to confirm this and made it possible to minimize imaging and other expensive, time-consuming studies. My neurosurgeon son assures me that before he sees the patient the imaging and most every other test has already been done, so the point is moot.

— Joseph W. Markey MD
Castle Rock, CO