(4) WOODWORTH, R. S. and SHERRINGTON, C. S. A pseudaffective Reflex and its Spinal Path. Journ. Physiol. XXXI, 234-43, 1904. Cited in ref. (5), pp. 251-2, and in ref. (8), p. 26.

(5) SHERRINGTON, CHARLES, S. The Integrative Action of the Nervous System. 1911, p. 251.

(6) GOLTZ, F. Der Hund ohne Grosshirn. Siebente Abhandlung über die Verrichtungen des Grosshirns. Arch. f. d. ges. Physiol. LI, 570-614. Cited in ref. 5, p. 255 and in ref. 8, p. 26.

(7) STERNBERG, MAXIMILIAN, and LATZKO, WILHELM. Studien über einen Hemicephalus, mit Beiträgen zur Physiologie des Menschlichen Centralnervensystems. Deutsch. Zeitschr. f. Nervenh. XXIV, 209–73, 1903. Cited in ref. 5, p. 254, and in ref. 8, p. 26.

(8) CANNON, WALTER B. New Evidence for Sympathetic Control of Some Internal Secretions. Am. Journ. Psychiat. II, 1-30, July, 1922; see p. 26.

(9) SHERRINGTON (ref. 5), pp. 254–5.

(10) JAMES, WILLIAM. Principles of Psychology. 1890.

(11) LANGE. Om Sindbevägelser. 1885. Cited in ref. 5, pp. 258-9, in ref. 8, p. 26, and given in full, reference 1.

(12) SERGI, G. Dolore e Piacere, 1894, and Über den Sitz und die Physische Grundlage der Affekte. Zeitsch. f. Psychol. u. Physiol. XIV, 91–100, 1897. Cited in ref. 5, p. 259.

(13) SHERRINGTON (ref. 5), pp. 260-65.

(14) KEMPF, EDWARD JOHN. The Autonomic Functions and the Personality. 1918. (15) CANNON, W. B. (ref. 8), and his Bodily Changes in Pain, Hunger, Fear and Rage, 1915, and his references to co-workers and others in both places.

(16) NOVY, CAMMILE. The Biological and Social Significance of the Expression of the Emotions. Brit. Journ. Psychol. XIII, Part I, July, 1922, footnote to p. 80. (17) MARAÑON, G. Ann. de Méd. Ix, 1912, and Rev. de Med., Cu. y Especial, 1921, No. 87, Cited by Cannon in ref. 8, pp. 25-6. Also his contribution to Libro en honor de S. Ramon y Cajal, 2, 291-310, 1922, and abstracted by Nonidez in Archives of Neurology and Psychiatry, XII, 566-569, Nov. 1924.

(18) WILSON, S. A. KINNIER. Some Problems in Neurology. No. II. Pathological Laughing and Crying. Journ. Neurol, and Psychopathol. LV, 299–333, Feb. 1924, see p. 302.

(19) WILSON (ref. 18), p. 309.

(20) MOUTIER. La Pratique Neurol. 1911, p. 809. Cited in ref. 4, p. 209.

(21) CRILE, GEORGE W. Man-An Adaptive Mechanism. 1916. See in particular chapter v, pp. 118-156.

(22) SHERRINGTON (ref. 5), pp. 265–266.

(23) SHERRINGTON (ref. 5), p. 267.

(24) PAVLOV, IVAN PETROVICH. The Work of the Digestive Glands. Translated by W. H. Thompson. Second English edition. 1910.

(25) CANNON (ref. 8), p. 29.

AN AID IN THE DIAGNOSIS AND THE
PROGNOSIS OF MENTAL DISEASE

BY GEORGE VAN NESS DEARBORN.

(NEW YORK.)

EVERY constructive contribution toward accuracy and certainty in the diagnosis and the prognosis of nervous and mental diseases is worth the attention of psychiatrists. The present summary of a newly developed method is tentatively offered as such a progressive step along a long and hard road.

One of the most productive generalizations of psychology (that new science of things as they really are) is that mind is mind of whatever organism it may be the master or the slave-whether brute animal, infant, normal adult, or the mentally deranged. And could we examine ever into the mentality of a 'Martian,' or of a denizen of a world-speck ten million light-years away from us (such have recently been revealed), we have reason to believe that their mind would be qualitatively like

unto our own.

On this reasonable basis of identity between the sick mind and the normal, we have full right to measure the former with the same scales that have proved so useful and accurate for the latter, unless indeed it could be shown that some condition of the deranged mind invalidates the measurement. This 'invalidation' I am certain, after years of study of the problem, is contrary to the fact. With numerous but proper exceptions, a psychotic man, if not too far gone into dementia, can be as accurately estimated intellectually as an eager grammar schoolboy, a worried woman-teacher, or a fully cooperative moron. Those who assert the contrary (one here and there, unfamiliar for the most part with psychologic technique) apparently have based their notion on the false assumption that the mental state of the patient is one of emotional confusion or 'rattle.' But on the contrary, in the regular psychologic testing of the insane the surrounding conditions are very different, because wholly conducive to calmness and to deliberate thoughtful answers, provided the examiner be not wholly unfitted to his exacting work. What little mental stir may persist for a minute amounts only to an interest that suffices to stimulate attention and effort in the

patient's always pleasant task of telling what he knows or thinks he knows. One does not try to do psychometric tests on any patient when disturbed, evasive, or in a state of acute confusion; it is not that kind of a procedure at all!

If a man be somewhat evasive and exhibit it at first in his performance of these tests, it means merely that more care, patience, and time must be used in administering the scale to him. Evasiveness unless excessive in no way invalidates the psychometry-it only makes it harder of application in that particular instance to see that sooner or later he does it the best he can. And, as Professor A. Gesell of Yale says in his Mental Growth of the Pre-school Child, "We ought not, however, to give too much recognition to resistance as a clinical obstacle. Rather, we should regard resistance as a symptom of our failure to devise the right technique and to find the right clinical approach. Resistance is not a specific personality-trait. Is it not a mildly rationalizing designation of a failure of clinical rapprochement?" The writer corroborates this fully as concerns both adults and children from his own experience, and feels fully confident that actual trial with the psychotic and even with the psychoneurotic (harder to deal with) will convince any competent (i.e. in part, patient!) psychologist or even the amateur physician-psychologist, that fully nine-tenths of all cases can be accurately analyzed and some of the other tenth at some other hour or on some later day. This matter, like that noted in the next paragraph, has never before, apparently, been adequately tried out as a deliberate matter of research.

The experienced examiner, with this elaborate and explicitly determined series of mental situations for solution, soon finds that there is a kind of total impression to be gained from each of the types concerned, such as native mental defect, precox-regression, paretic deterioration, arterio-sclerotic deterioration, cerebral traumatic deterioration. Just as the expert abdominal surgeon gets general diagnostic impressions from palpation of the abdomen, so the experienced psychologist learns that the 'feels' of these regressions and deteriorations, when measured and studied in this fixed and complicated way, are different and respectively characteristic.

The old instrument employed in this new constructive psychiatric method is the Binet-Terman scale, the Stanford Revision of the BinetSimon test now familiar more or less wherever English is spoken. But in this case we use this scale in so intensive a manner that we may be wholly certain that its findings are true-or else we do not employ it

on that patient and at that time at all. A patient may be, of course, too demented for its use at any time.

Somewhat as an efficient physician may conduct either of two grades of medical examination, so intellectual psychometry may be carried on in the manner usual with defective or normal persons, or intensively, with minutely consistent strictness, in a psychotic individual not too demented or non-cooperative.

In the former kind of physical examination, often adequate, the physician considers the height-weight ratio, looks at the tonsils and teeth, auscultates the heart and the lungs, palpates the abdomen, quickly examines the urine—and has a good-enough opinion of the situation.

In the other kind of medical scrutiny, regularly made by the medical philosopher seeking for truth, these same tests are carried out, but in addition technical trials like these: Family and personal histories, blood and spinal Kahns or Wassermanns; gastro-intestinal fluoroscopic series; ocular fundi; complete neurologicals; blood-cell count and differentials; blood-nitrogen and -sugar and -alkalinity; urinary chemistry and microscopy; X-rays of chest, head, and abdomen; basal metabolism; microscopic and chemical of feces; stomach-contents, and acidity; electrocardiograms; blood-pressure series; cystoscopic; proctoscopic; serial thermometric; tuberculin; Widal; etc., etc.-in short an intensive search for essential physical pathology.

Qualitatively, but not quantitatively, in a manner somewhat like this latter we examine the psychotic's intelligence. We give him the regular Binet-Terman test, but we push it so intensively and strictly, and with such minute and continuous insistence on his attention, his comprehension, and on the 'doing-his-best' that the test is essentially a new one; and the adequate examiner absolutely can be at least as confident of his findings as in case of a person non-psychotic. In an hour or more of concentrated 'third-degree' inquiry, pushed to the limit of detailed insistence, one is very apt to get the truth! and to form a definite opinion, based in part on having heard exactly the same performance possibly thousands of times before. His cortex has acquired a delicate standard of comparison !

This intensiveness of examination in the precisely established series of tests is the essence of this new method. It is perfectly valid as anyone at all deft in psychometry can prove for himself in two hours, as a means of gaining knowledge perhaps not otherwise attainable.

In the short (starred) form of this scale (the omitted tests seem to have nothing of especial importance, for this purpose, at least), there

Med. Psych. VII

21

are thirty-five tests from the eighteenth year downward including the seventh year, which experience shows, is the lower measurable limit for psychotic regression. Most of these thirty-five tests have different contributions to the total result, but lack of space prevents the presentation of their interesting psychological analysis in this Journal. (See the American Journal of Psychiatry for April, 1927, where the entire paper as read before the meeting of the American Psychiatric Association in New York City on June 10th, 1926, was published.)

One of the really funny things sometimes seen and heard in a neuropsychiatric veterans hospital is the materialistic physician (now happily going out of style) who thinks that he can guess at a person's abstract intelligence more accurately than a psychologist can measure it with an instrument of relative precision. These grandiose men but reveal their lack of accurate observation and their ignorance of what modern applied psychology now means and is. To continue sceptical is as if a physician disputed the significance of casts persisting in a man's urine from visual observation of a beaker of it; or as if he denied the validity of a Kahn test because the patient's fundi oculorum or kneejerks failed to agree with the test's implications.

The 'method' here set forth of intensive, minutely controlled observation and analysis of the patient's more basal intellectual processes (we cannot, as yet, unfortunately, measure so accurately his feelings and emotions or his behaviour) for an hour or more under exactly formulated conditions must inevitably give the thoughtful examiner a definite and accurate insight into his patient's relative mental condition. It always means at least an hour's accurate and detailed comparison of the various phases of the intellectual processes with their respective standards in normal persons in general and with previous performances in the same patient one year or more before.

This method of prognostic and diagnostic change-determination takes advantage of the certainty of evidence that inevitably must come from the application of a thoroughly uniform and standardized analysis of a fixed set of intellectual processes-it constitutes a mental instrument of precision entirely comparable to those used in the physical sciences for the measurement of space, energy, and time.

It is generally recognized that the benefit and cure of the patients in our Veterans Bureau is the primary desideratum and aim of its physicians. This psychiatric method, aside from its value in diagnosis (and it has been in hundreds of doubtful and mixed cases the deciding evidence) has much use in immediate and remote prognosis.