This test has been applied by Kent and Rosanoff to one thousand, normal subjects, and all reactions thus obtained arranged in frequency tables for all the stimulus words; these frequency tables were published in connection with their study. In the examination of a test record obtained by this method the first step is to compare it with the frequency tables and thereby distinguish the common reactions, which are to be found in the tables and which are for the most part normal, from individual reactions, which are not to be found in the tables and which contain the great majority of those that are of pathological significance. Normal subjects seldom give over 10% individual reactions; insane subjects very often give over 25%. Moreover, certain varieties are to be distinguished among the individual reactions which are more or less characteristic of the various clinical types of mental disorder.

Standards have also been made available for the ages of childhood from 4 to 15 years.1 Feeblemindedness is recognizable with the aid of this test, and its degree may be roughly determined by refer

1 Isabel R. and A. J. Rosanoff. A Study of Association in Children. Psychol. Review, Jan., 1913.

ence to the standards for normal children.1 The results of this test are by no means always conclusive, for many cases of frank mental disorder have furnished practically normal records; on the other hand, it is sometimes capable of revealing mental abnormality where other methods of examination yield only negative results.

In cases in which it is desired to use the association test for the purpose of detecting pathogenic subconscious ideas or complexes that may be suspected to exist, the examiner's familiarity with the case will suggest to him special stimulus words adapted to the particular case; these stimulus words may be given together with those regularly employed, being introduced, say, after every fifth or every tenth one. In such cases it is also advisable to record in each instance the reaction time in fifths of a second, taken by means of a stop watch; subconscious ideas or complexes are said to be indicated either by abnormal types of reaction or by instances of reaction time much above the average for the individual.

2

Other tests. Many other tests, both physical and mental, have been more or less thoroughly standardized and are available both for clinical work and for psychiatric research: weight discrimination tests, calculation tests, cancellation tests, substitution tests, etc. For descriptions of these the student must be referred to special works.

1 Eastman and Delinquent Children. 2 G. M. Whipple. Manual of Mental and Physical Tests. Second edition. Baltimore, 1915. Woodworth and Wells. Association Tests. The Psychol. Monographs, No. 57, Dec., 1911.-S. I. Franz. Handbook of Mental Examination Methods. Nerv. and Ment. Dis. Monogr. Series, No. 10. New York, 1912.

Rosanoff. Association in Feeble-minded and
Amer. Journ. of Insanity, July, 1912.

CHAPTER VII

THE PRACTICE OF PSYCHIATRY (Continued).

GENERAL THERAPEUTIC INDICATIONS: INSTITUTION. - COMMITMENT. — TREATMENT OF EXCITEMENT, OF SUICIDAL TENDENCIES, AND OF REFUSAL OF PSYCHOTHERAPY. PAROLE AND DIS

FOOD.
CHARGE.

THERE is no general treatment for all mental affections any more than there is for all affections of the stomach or kidneys. Certain therapeutic indications, however, are of such importance and arise so often that it will be advisable to make a general study of them.

Some pertain to the surroundings in which patients should be placed, others to certain particularly grave manifestations of mental affections: excitement, suicidal tendencies, and refusal of food.

Surroundings; institution; commitment. — In most of the psychoses it is necessary to secure for the patient complete physical and mental rest and to relieve him as far as possible from his preoccupations, delusional or rational.

It is difficult to carry out these indications in the ordinary conditions of life. The difficulties are of a nature both physical and mental: physical, because only few families can afford the expense involved in the treatment of an insane patient at home; and

mental, because the relatives, inexperienced in the treatment of mental diseases, are not likely to carry out properly all the orders of the physician, and may cause an aggravation of the patient's condition by yielding to all his caprices, being under the impression that he must not be contradicted, and by wearying him in their attempts to reason with him or to divert his mind.

The removal to an institution is therefore in most cases inevitable.

All insane patients may be grouped in two classes: the inoffensive and the dangerous.

For the first class of cases the institution does not present any particular features and the admission of the patient is effected with no more formality than that into a general hospital.

The patients of the second class must be committed; this must be accomplished under the supervision and responsibility of a public authority, and entails certain formalities.

Of all these formalities only one is of interest to us here: the physician's certificate.

The certificate, intended to establish the legitimacy of the commitment, need not contain any detailed observations and does not necessarily involve a precise clinical diagnosis. It is of little importance here whether the patient does or does not present inequality of the pupils or abolition of the patellar reflexes. It is also unimportant whether he suffers from mania or from dementia præcox, as long as the symptoms which he presents render him a menace to himself, to others, or to the public peace.

The indications for commitment are chiefly to be based on the dangerous tendencies of the patient: a senile dement who is quiet and tractable can without any inconvenience be cared for at home or in a home for the aged; another who is on the contrary irritable and violent should be committed without hesitation.

In a general way the following symptoms should be considered as indications for commitment: impulsive tendencies; suicidal ideas; ideas of persecution and hallucinations which bring about violent reactions; states of dementia associated with phenomena of excitement.

The character and intensity of the symptoms should, however, not be the only factors governing the action of the physician. He should also take into account their probable duration. If the mental disorder is not likely to persist for more than several days and has no tendency to recur frequently, commitment is not justifiable; such is the case in febrile deliria.

Transfer of the patient to the institution. — Undoubtedly it is the physician's duty to induce the patient to go to a hospital. Unfortunately this is not always easy or even possible when the question is one of commitment. This question, at times delicate, cannot of course have a universal solution.

TREATMENT OF EXCITEMENT.

Perhaps the greatest progress in the therapeutics of mental diseases within the past twenty years has been in our methods for the treatment of excitement.