port of his entire family, it would be fatal to a neuropathic individual. Unemployment is a great cause of mental disease. The number of cases in institutions depends largely upon the fluctuations in industrial conditions. If the evils of unemployment could be obviated by insurance or other means, many breakdowns would be avoided. Regarding the marriage of susceptible persons, the speaker thinks that they should not marry. Marriage is only an added burden to them. Whenever a case of mental disorder is even suspected, the advice of the speaker is to send the individual at once to a state hospital where he may be thoroughly examined to find out the cause of the breakdown. If his case is not acute, environment outside is provided for him until he recovers. Or it may be advisable for him to remain temporarily in an institution. He should be committed permanently to an institution when after two or three failures of parole, his case is recognized as incurable. TUNE-DRINK TO ME ONLY WITH THINE EYES Give me but childhood's steps to guide Along the paths of truth, Let me but place her flaming torch Within the hands of youth; Go, fame and fortune, where you will, I'll count you ever kind If to my lot it fall to train Sweet childhood's heart and mind. Give me to sow the seeds of peace M. J. Doyle, P. S. II Manhattan. THE DIAGNOSIS OF THE HIGHER GRADES OF MENTAL DEFECT* By WALTER E. FERNALD, M.D., Superintendent Massachusetts School for the Feeble-minded, Waverley, Mass. (Concluded) The Binet tests, in the hands of competent examiners, usually corroborate the results of clinical examination in the recognition of all degrees of mental defect in children under ten, and of pronounced defect in older persons. These tests are not so effective in detecting slight mental defect in world-wise adolescents and adults. In other words, the Binet tests corroborate where we do not need corroboration, and are not decisive where the differential diagnosis of the high grade defective from the normal is in question. The Binet tests are not supposed to furnish an index to the education of the individual, but to measure his capacity for edu cation. But would not many ignorant normal persons fail to be able to tell the difference between pleasure and honor, evolution and revolution, event and advent, poverty and misery, pride and pretention, as required by the adult test? The revised Binet tests require a person to listen to the following story, and then to repeat its substance: One hears very different judgments on the value of life. Some say it is good, others say it is bad. It would be more correct to say that it is mediocre; because on the one hand it brings us less happiness than we want, while on the other hand the misfortunes it brings us are less than others wish for us. It is the mediocrity of life that makes it endurable; or, still more, that keeps it from being positively unjust. The words "mediocre" and "mediocrity" are usually unfamiliar to any person likely to be examined for mental defect. The Binet tests are psychological experiments and to give results of definite value should be conducted with all the precautions against error which are observed in other psychological experiments. There is still some question as to the invariable fairness of these tests, in subjects with which the patient has had no practical experience, as a measure of native mental ability. The mere appearance of the unfamiliar apparatus or test material may so confuse the patient that he will not be able * Reprinted from American Journal of Insanity. to do himself justice. The results of any formal tests should accord with clinical findings and with pedagogical measurements and social and economic reactions. The determination of mental defect cannot be made by the automatic application of any method and scale. In the borderline adult cases the Binet tests are of value as additional evidence, but they are not conclusive and should not be relied upon in the absence of clinical and other evidence. The Binet test does not register as defective certain persons who present plain evidence of mental defect in their personal history, school history, and performance, social and economic reactions, etc., while on the other hand, certain individuals who fail to come up to the requirements of the Binet test do not present the usual personal, social and economic reactions of mental defect. The layman, especially the social worker and the teacher, is profoundly impressed with the findings of any formal tests. The facility with which the pronounced case of mental defect can be roughly indicated with these tests is largely responsible for the present great popular interest in feeble-mindedness. The Binet tests are most effective as first aids to teachers and social workers in selecting suspected cases to be referred to the physician. A bit of personal experience illustrates the difficulty of eliminating irregular test conditions, and the futility of absolutely following any system of scoring. On one of my out-patient days, I had examined eight patients, one after the other. I had no luncheon and was fatigued physically and mentally. At 5 o'clock a social worker insisted that I examine, as I had agreed to do, her 15-year-old patient. I pleaded weariness and disinclination, but finally decided to give the Binet tests. The patient had waited hours for her examination and was tired and unhappy. After much effort she utterly failed to achieve the 10 or 11 year Binet tests. I declined to give an opinion, but made another appointment for the next morning, when, after the patient had been put at ease and got acquainted, she readily tested up to her full age. The result the night before was really a record of my own mental state. Healy has formulated a tentative series of psychological tests for the estimation of native mental ability and the results of formal education in adults and adolescent delinquents not definitely feeble-minded. They are of great practical value in demonstrating various shadings of the borderline zones of mental defect, as well as certain types of delinquent personality not yet generally recognized as variations of mental deficiency or of limited responsibility. The generalizations from the application of this admirably flexible and comprehensive method of examination should furnish data of great value in diagnosis and classification. The differentiating tests of Dr. G. G. Fernald form another notable addition to the methods of scientific precision for the diagnosis of variations of lesser mental defect as found in adolescent delinquents, presumably differing in no way from the degrees of defect in non-criminal individuals. Dr. Healy and Dr. G. G. Fernald both emphasize the fact that the application of psychological tests should not constitute the exclusive method of examination, but that it is one method available among others, and to be supplemented by them. Indeed, as Dr. Fernald says, in the present state of our knowledge any attempt to classify any group of subjects based solely on the findings from psychological tests would commit grave errors. Practically all of the special tests for the diagnosis of doubtful cases that are not decided by usual tests are of doubtful value because no age norms are given, and no practical method of scoring worked out. We can draw no exact conclusions from the results of tests in any given case when we do not know what results we would get with these tests on normal persons. Absolute standards should be used with great caution. There are many grades of intelligence among normal people. Normality of intelligence is not a fixed strength of intellect, and feeblemindedness is not merely a question of intelligence. The psychologists have been so interested in the diagnostic application of the Binet and other tests that while we are now familiar with certain rather empirical negative age standards and landmarks applicable to children and to cases of pronounced defect, we still possess no really scientific understanding of the exact psychological status of the ordinary cases of feeblemindedness. We know that these different groups are, in varying degree, low in the power of voluntary attention, in discriminatory power, in constructive imagination, etc., but we know this only empirically, not in terms to be expressed qualitatively and quantitatively. The psychology of mental defect is yet to be written. The patient work of G. E. Johnson, Kuhlman and Norsworthy along these lines should be followed up by intensive psychological study and analysis of a large series of carefully selected cases. The work cannot be done adequately in a small institution laboratory, but requires the personelle and resources of the psychological department of a great university. Such research would accumulate data for generalizations which would form a basis for the formulation of tests of enormous value in the diagnosis of puzzling cases, especially of the borderline class. It is probable that the scientific mind will not be content until these upper zones of mental defect have been explored and charted, and definite diagnostic tests evolved. From a clinical point of view the borderline case of the "moron" grade differs from the case of actual imbecility quantitatively rather than qualitatively. Even in cases with very slight mental defect some of the cardinal symptoms and conditions of imbecility are usually found in lesser degree. There are generally evidences of physical inferiority, certain physical stigmata of degeneracy and defective muscular co-ordination. There is usually a history of delayed dentition, late walking, delayed speech and relatively long continuance of untidy habits. The patient lacks the appearance of expression of normal mentality. There is usually a history of mental defect or disease in the family. Unmoral and anti-social tendencies are rarely absent. There is a history of school retardation and poor scholastic ability on examination, with special difficulty in arithmetical and practical computations, and lack of general knowledge and information. The patient is unable to apply himself continuously in any one direction and is willing to risk severe penalties for some very small gain. His actions and conduct indicate a lack of good common sense. These facts and observations may usually be corroborated by psychological tests, but there is no justification for the popular belief that a psychological examination alone will quickly, accurately and fully determine the degree of mental efficiency or inefficiency, educational and social needs, and the prognosis of patients who have puzzled and baffled parents, teachers, family physicians and alienists. |