for the coming situation shown by purposive behaviour1." The reflex "is not prepared for by previous activity." "The reaction occurs when the stimulus is applied as a loaded pistol goes off when the trigger is pulled. Until the appropriate stimulus is applied the animal remains passive. On the other hand the bird gathering materials for its nest... takes the initiative...and goes out to meet coming impressions2."

This criterion seems to withstand criticism better. Some stimuli of reflexes, indeed, are within the organism: which brings them nearer to instinctive action proper, from this particular point of view. Admittedly, however, when there is prevision of a result and desire for it-even if it is a desire for the sensation of a reflex as in snuff-taking there is intelligence and something more than a mere reflex. It may be noted here that the distinction between reflex and intelligent action or deliberate choice is much easier to make than is that between the reflex and the conception of instinct which holds that intelligence is not an essential element in instinctive action. One sentence at least of Stout's suggests that he could build up his conception of instinct simply by means of reflexes plus intelligence. "The difference between reflex action and instinctive conduct" he says, is that "instinctive conduct does and reflex-action does not presuppose the cooperation of intelligent consciousness, including under this head interest, attention, variation of behaviour and the power of learning by experience3."

Even the stimulus of the reflex is said to be outside of, or independent of consciousness. "When the sensation is present," writes Stout, "there is no reason for regarding it as a factor generating or influencing the reflex process itself." It may be said that this does not seem to hold as to such reflexes as the eye-blink in response to objects seen approaching, or to a pretended hand clap, but these are, I have suggested, of the nature of 'conditioned reflexes,' that is, in part, 'habits.’ In any case they are relatively simple responses to isolated sensations. It remains true, as Stout goes on to say, that instinctive activity, as contrasted with the more purely reflex, is "guided by and adjusted to complex and variable combination of different sense impressions5."

If some reflexes, however, are guided through sensations and even by our apprehension of varying sensations, and if also some are dependent

1 McDougall, op. cit. p. 54.

2 Stout, Manual, p. 343.

3 Ibid. See also his article on "Instinct and Intelligence," British Journ. of Psychology III, p. 244.

upon general conditions of the organism, it seems that the distinction between many actions generally regarded as reflexes and those termed instincts, is one of complexity rather than of absolute difference; and that it might be better that the term reflex should be kept for purely physiological reflexes, which contribute no element to consciousness, or at least no discriminable element; as for example the eye pupil reflex and some visceral reflexes. It would even then be an open question whether varying aspects of bodily sensation not discriminable by introspection, might not be factors in determining the reflex.

Finally, the fact that a reflex may occur in a decerebrated animal, or in a dead man, does not prove that the (superficially) same action is not influenced in some way by consciousness when it occurs in the living man or the whole animal. Indeed, one of the most significant things which recent physiological work goes to show is the difference between some reflexes in the intact organism as contrasted with the corresponding reflexes in the decerebrated.

My best thanks are due to Dr C. S. Myers, for reading the typescript of this paper, and for making a number of valuable comments.

AN ATTEMPT TO INVESTIGATE AND TREAT PSYCHO-NEUROSES AND PSYCHOSES AT AN OUT-PATIENT CLINIC1

BY THOMAS S. GOOD

THE Oxford Clinic for Nervous Disorders was opened for out-patients in 1918 at the Radcliffe Infirmary and County Hospital, Oxford.

The total number of pensioners and civilians treated from 1918 to the end of 1926 was 1101, made up as follows: civilians, 673; pensioners, 428. The number of civilians under treatment in 1918 was 33. The number of civilians under treatment in 1926 was 154. In 1919, 138 Pensioners attended; in 1926 only 5.

These patients include people suffering from all forms of nervous and mental ailments, who attend in the same waiting hall as the other medical and surgical cases.

The clinic was designated the Department for Nervous Disorders for the following reasons:

1. Mental patients would more readily attend for advice and treatment if they could do so without being singled out as mental.

2. As the difference between the neuroses and psychoses is possibly only one of degree (the so-called borderline), it was hoped that treatment could be given and the cases alleviated or even cured in the incipient stages.

3. It was felt that in all probability friends would bring patients, and others would attend of their own accord, at a clinic in a general hospital, whereas they would shun attending at a mental hospital because of the fancied stigma and disgrace attaching to the latter institution.

4. It was considered essential that organic and functional nervous diseases and disorders should be investigated as a whole and that the medical man in charge of the clinic should have a knowledge of all forms of mental and nervous illness.

Further reasons for choosing the General Hospital were:

1. That a general hospital is more accessible for the greater number of the inhabitants of a district than any other institution.

1 A paper read before the Medical Section of the British Psychological Society on January 26th, 1927.

2. That specialists in all branches of medical science are there available, surgeons, orthopaedists, physicians, radiographers, masseurs, etc. Therefore a case can be referred at once to a colleague or vice versa-there is team work.

3. That it is obviously the most economical method as it saves duplication of expensive apparatus.

4. That the psychiatrist is brought into closer touch with the other members of the profession to their mutual advantage.

5. That it is an advantage for the general practitioners in the area to be able to send any patient for treatment or opinion and therefore increases their knowledge as to the diagnosis and treatment of nervous and mental diseases and disorders.

The clinic has no beds definitely allotted to it, for the reason that, in the present state of the law, certifiable cases cannot be treated on unlicensed premises for the purpose of gain, and as the Radcliffe Infirmary has a paying scheme, which is called the Twopenny Scheme, it cannot, till the law is altered, be definitely used as an in-patient department for cases showing marked mental symptoms which cannot be treated at an out-patient department. Though there is no definite number of beds allotted, cases are, wherever practicable, treated in the wards, and cases showing mental symptoms, which have been admitted for other diseases, do have psychotherapeutic treatment while inpatients at the hospital. Experience seems to show that even very severe cases of mental abnormality will and do improve as out-patients providing there is no marked organic disability, and if they require admission as in-patients their mental disability is usually of such a degree that they are only fit to be treated in a hospital specially equipped to deal with advanced cases of mental derangement, namely, a mental hospital. There are, however, a large number of people who are suffering from various forms of toxaemia, as for instance puerperal cases, cases of encephalitis, and also cases showing marked malnutrition, in other words exhaustion psychoses, which could with great advantage be treated if there were beds attached to the clinic. Many of these cases are treated under different physicians in the wards of the General Hospital, but this is possible only when the disease is of a mild form, and it would be a great advantage if beds could be provided for these cases, most of whom are certifiable, in the wards of the General Hospital. But as the law stands at present this is impracticable.

The question of treatment bristles with difficulties in deciding whether each case should be dealt with as in- or out-patient. It is difficult, if not

almost impossible, to lay down any hard and fast rules, but among the poor people where there are indications of severe physical illness and the home conditions are such that the patient cannot get the required rest and nursing, the case should be admitted as an in-patient, whereas the most severe mental symptoms will in certain circumstances clear up with out-patient treatment. In fact in many of these cases it would almost appear that in-patient treatment is contra-indicated. To make this point clear, in neuroses there is always an unconscious psychic cause, e.g. some decision the sufferer fears to make or wishes to avoid, and the illness is an attempt at evading the issue. Such patients fear what can only be termed their own psychic death, i.e. loss of reason. Their symptoms are an unconscious question to the medical man, a question which they fear he will answer in the affirmative. In their own mind they fear that they will lose their reason, that they will become mad. At the back, probably, of all cases which have been called 'nervous' or designated 'nervous breakdown' there is the idea in the patient's mind that eventually he will lose the power of thought and of normal self-control. Insanity in fact might almost be termed a psychological condition which the patient is unable to express in words; and because of this failure of expressive power he fears he will become worse and worse, and will eventually have to be confined in a mental hospital and will cease to be able to think at all. Our hypothesis that this must be the mental attitude of the patient to his illness is borne out by the following facts gleaned from experience:

(1) All cases of neuroses complain that they cannot remember the commencement of their illness. They will often make a vague statement that it started at such and such a time, but a very few questions soon elicit the fact that the exact date is not clearly known, the patients often complaining that they "cannot think why they are like this." They frequently state that their minds are blank. The psychological reason for these symptoms is that the origin of the illness is always in the far past and that the blanks are due to breaking of the associative train of thought, to dissociation.

(2) Experience seems to show that at the back of all sufferers' minds there is a fear that they will become like someone else who either was mad or whom they thought mad-it may be a relative, it may be a dear friend. They identify themselves with these people who have had to go to a mental hospital and be shut up because they were mad, and picture themselves in a like predicament.

(3) These hypotheses are borne out by experience in the most severe cases of psychoses, namely, those of patients in mental hospitals who