117 example, on admission to hospital, the matrix test score of one man was 50. While he was in hospital his mother died ; he was much attached to her and became depressed. Seven weeks after admission he was re-tested. Instead of showing the usual rise of 2 points his score fell 8 points. A normal man would react in a similar way but he would tend to retain control over his depression and it is doubt- ful if his test score would fall at all. Since matrix tests are designed to measure mental activity at the time of the test as delicately as possible larly susceptible to variations in the control of mental activity; and in clinical work a test score does not always indicate the true level of a per- son’s mental ability. The test thus fails to tell us one of the things we wish to know from it, but on the other hand it is clinic- ally useful to know the vari- ability of mental .* 14 4 .. output. For this, however, an analysis of the results of a single test may be insufficient. For example, a score of 42 made up of the sub-test scores 11, 7, 5, 9, 10, when normally it should be made up of the sub-test scores 11, 10, 9, 8, 4, is clearly unreliable though the cause is not obvious. ’The man’s irregular score may be due to variability of mental output, to distraction early in the test (which would lower his total score) or to copying at the end (which would make his score higher -than it should be). To estimate the significance ofthis unreliable score, his score on a completely different type of test is needed. Performance tests can sometimes be employed but their range of usefulness is limited and their interpre- tation complex. A vocabulary test is more useful ; its range is wider and it can be highly reliable. Also, a person’s vocabulary tends to remain relatively constant throughout adult life and even after the onset of mental disease. For these reasons a vocabulary test is a useful complement to a test of the matrix type. . DISCUSSION The advantages of including a mental test as part of a man’s general examination for national service are now generally accepted, but the variability of mental test scores obtained by neurotic persons emphasises the need for caution. A mental test records an activity which varies with health, with incentive and with immediate or remote distractions. The successful use of mental-test data in practice depends on the clearness with which this is recognised. Many factors determine a man’s suitability for a particular type of work or degree of mental strain and it would be harmful if classification by any mental test were adopted as a rule-of-thumb method of grading men for national service. On the one hand, a record of the reason why a man is allocated to any kind of work is administratively useful ; on the other, success in using mental tests depends on the insight with which a psychologist is able to observe differences of individual response to standard test situations and to interpret their significance. For this it is more important to be thoroughly familiar with a few well-chosen tests than to have partial knowledge and casual experience of a large number, and clinical experi- ence suggests that a test such as Progressive Matrices, designed to record a man’s ability to learn from his immediate experiences, together with a vocabulary test designed to indicate his general level of intellectual attain- ment, can give more information about his mental consti- tution than a single test of general intelligence or a number of performance tests. But the ways in which neurotic persons react to mental tests present problems which merit fuller investigation with a view to improving the reliability of mental tests and increasing their diagnostic value. I would like to thank Dr. F. D. Turner of the Royal Eastern Counties Institution, and the staff of the Mill Hill Emergency Hospital, especially Dr. Aubrey Lewis. The work has been carried out under the auspices of the Medical Research Council. BIBLIOGRAPHY Buros, O. (1940) Mental Measurement Year Book, New Jersey. Hodgson, G. A. (1941) Lancet, ii, 791. Raven, J. C. (1936) Mental Tests used in Genetic Studies, University of London Library; (1938) Progressive Matrices, London; (1939) Brit. J. med. Psychol. 18, 916 ; (1940) Ment. Hlth, 1, 10; (1941) Brit. J. med. Psychol. 19, 137. Slater, P. (1942) Lancet, i, 101. Spearman, C. (1927a) The Nature of Intelligence and Principles of Cognition, London; (1927b) The Abilities of Man, London. Stephenson, W. (1931) Amer. J. educ. Psychol. 22, Terman, L. M. and Merrill, M. A. (1937) Measuring Intelligence, London. Vernon, P. E. (1940) The Measurement of Abilities, London. Esher, F. J. S. and Trist, E. L. (1941) Occup. Psychol. 15, 107. BRITISH ORTHOPÆDIC ASSOCIATION THE annual general meeting of this society took place at Oxford on Jan. 1 and 2 under the presidency of Prof. T. P. McMURRAY (Liverpool), who pleaded for a renewal of interest in non-operative treatment in orthopaedic surgery. The programmes of the association for the last fifteen years demonstrated the interest every new opera- tion aroused. Orthopaedic surgeons were in danger of forgetting their descent from men who used less spectac- ular methods to immobilise joints antl restore function. This apparent neglect might lead to the growth of a new branch of medicine. The modern tendency was to forget that the operation was only an incident-and not necessarily the most important incident-in treatment. Professor McMurray went on to give examples where emphasis on operative procedures had, in his opinion, caused neglect of orthopaedic principles. Low backache was correctly treated by applying the mechanical prin- ciples of muscular balance and posture ; but wrongly treated by devising an open operation for each segmental pain. Again, when union in fractures of the tibia was delayed there was a tendency to rush to bone-grafting, without recalling that since 1867 the principle of chronic venous congestion had been known, the principle now revived in the walking calliper. Professor McMurray urged - caution before deciding on open operations on knee-joints, especially in soldiers, without sufficient evidence of cartilage lesions. It was a mistake to ask the patient the direct question : " Does your knee lock ? " Too often the answer was " Yes," although the question had not been really understood. The good results obtained by conservatism in some cases of chronic arthritis should be considered before deciding on opera- tion. In tuberculous disease of the spine, Professor McMurray thought it had been shown fairly conclusively that conservative methods should hold the field. A com- prehensive survey of cases in this country had produced no proof that the recovery of any patient was hastened by operation. Wherever it was applied he urged that conservative treatment should be given a fair chance. It did not imply a patient " kicking about in bed in a convalescent home but was a definite treatment, including fixation and splinting, and required a long period of care and skilful supervision. Prof. PHILIP WILSON (New York) described the results he had obtained in the treatment of arthritis of the hip- joint with the vitallium cup. This is a method evolved by Smith-Petersen, in an attempt to re-establish painless movement between the arthritic joint surfaces by inter- position of a metallic cup, moulded over the head of the femur, Re-operation i6 some of the cases had shown that the bone surfaces in contact with the cup become covered with a considerable layer of fibrocartilage.- The method, he considered, contrasted favourably with arthroplasty by interposition of a fascial graft, and was particularly suitable for arthritis following congenital dislocation of the hip, post-traumatic arthritis and some cases of osteo-arthritis. It was simpler than fascial grafting, and the postoperative recovery was quieter and less painful. He had used the vitallium cup for only three years, and could not express an opinion on long- range results, but so far a satisfactory proportion of good and excellent results had been obtained. Mr. ARTHUR ROCYN-JoNES (London) reported a case of Paget’s disease of a single long bone in a woman of
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example, on admission to hospital, the matrix test scoreof one man was 50. While he was in hospital his motherdied ; he was much attached to her and became depressed.Seven weeks after admission he was re-tested. Insteadof showing the usual rise of 2 points his score fell 8 points.A normal man would react in a similar way but he wouldtend to retain control over his depression and it is doubt-ful if his test score would fall at all.
Since matrix tests are designed to measure mentalactivity at the time of the test as delicately as possible
larly susceptibleto variations inthe control ofmental activity;and in clinicalwork a test scoredoes not alwaysindicate the truelevel of a per-son’s mentalability. The testthus fails to tellus one of thethings we wishto know from it,but on the otherhand it is clinic-ally useful toknow the vari-ability of mental.* 14 4 ..output. For this, however, an analysis of the results of a
single test may be insufficient. For example, a score of42 made up of the sub-test scores 11, 7, 5, 9, 10, whennormally it should be made up of the sub-test scores 11,10, 9, 8, 4, is clearly unreliable though the cause is notobvious. ’The man’s irregular score may be due tovariability of mental output, to distraction early in thetest (which would lower his total score) or to copying atthe end (which would make his score higher -than itshould be). To estimate the significance ofthis unreliablescore, his score on a completely different type of test isneeded. Performance tests can sometimes be employedbut their range of usefulness is limited and their interpre-tation complex. A vocabulary test is more useful ; itsrange is wider and it can be highly reliable. Also, aperson’s vocabulary tends to remain relatively constantthroughout adult life and even after the onset of mental
disease. For these reasons a vocabulary test is a usefulcomplement to a test of the matrix type.
.
DISCUSSION
The advantages of including a mental test as part of aman’s general examination for national service are nowgenerally accepted, but the variability of mental testscores obtained by neurotic persons emphasises the needfor caution. A mental test records an activity whichvaries with health, with incentive and with immediate orremote distractions. The successful use of mental-testdata in practice depends on the clearness with which thisis recognised. Many factors determine a man’s suitabilityfor a particular type of work or degree of mental strainand it would be harmful if classification by any mentaltest were adopted as a rule-of-thumb method of gradingmen for national service.On the one hand, a record of the reason why a man is
allocated to any kind of work is administratively useful ;on the other, success in using mental tests depends onthe insight with which a psychologist is able to observedifferences of individual response to standard testsituations and to interpret their significance. For thisit is more important to be thoroughly familiar with a fewwell-chosen tests than to have partial knowledge andcasual experience of a large number, and clinical experi-ence suggests that a test such as Progressive Matrices,designed to record a man’s ability to learn from hisimmediate experiences, together with a vocabulary testdesigned to indicate his general level of intellectual attain-ment, can give more information about his mental consti-tution than a single test of general intelligence or a numberof performance tests. But the ways in which neuroticpersons react to mental tests present problems which meritfuller investigation with a view to improving the reliabilityof mental tests and increasing their diagnostic value.
I would like to thank Dr. F. D. Turner of the Royal EasternCounties Institution, and the staff of the Mill Hill EmergencyHospital, especially Dr. Aubrey Lewis. The work has beencarried out under the auspices of the Medical ResearchCouncil.
BIBLIOGRAPHY
Buros, O. (1940) Mental Measurement Year Book, New Jersey.Hodgson, G. A. (1941) Lancet, ii, 791.Raven, J. C. (1936) Mental Tests used in Genetic Studies, University
of London Library; (1938) Progressive Matrices, London;(1939) Brit. J. med. Psychol. 18, 916 ; (1940) Ment. Hlth, 1, 10;(1941) Brit. J. med. Psychol. 19, 137.
Slater, P. (1942) Lancet, i, 101.Spearman, C. (1927a) The Nature of Intelligence and Principles of
Cognition, London; (1927b) The Abilities of Man, London.Stephenson, W. (1931) Amer. J. educ. Psychol. 22,Terman, L. M. and Merrill, M. A. (1937) Measuring Intelligence,
London.Vernon, P. E. (1940) The Measurement of Abilities, London.
— Esher, F. J. S. and Trist, E. L. (1941) Occup. Psychol. 15, 107.
BRITISH ORTHOPÆDIC ASSOCIATIONTHE annual general meeting of this society took place
at Oxford on Jan. 1 and 2 under the presidency of Prof.T. P. McMURRAY (Liverpool), who pleaded for a renewalof interest in non-operative treatment in orthopaedicsurgery. The programmes of the association for the lastfifteen years demonstrated the interest every new opera-tion aroused. Orthopaedic surgeons were in danger offorgetting their descent from men who used less spectac-ular methods to immobilise joints antl restore function.This apparent neglect might lead to the growth of a newbranch of medicine. The modern tendency was toforget that the operation was only an incident-and notnecessarily the most important incident-in treatment.Professor McMurray went on to give examples whereemphasis on operative procedures had, in his opinion,caused neglect of orthopaedic principles. Low backachewas correctly treated by applying the mechanical prin-ciples of muscular balance and posture ; but wronglytreated by devising an open operation for each segmentalpain. Again, when union in fractures of the tibia wasdelayed there was a tendency to rush to bone-grafting,without recalling that since 1867 the principle of chronicvenous congestion had been known, the principle nowrevived in the walking calliper. Professor McMurrayurged - caution before deciding on open operations onknee-joints, especially in soldiers, without sufficientevidence of cartilage lesions. It was a mistake to askthe patient the direct question : " Does your kneelock ? " Too often the answer was " Yes," althoughthe question had not been really understood. The goodresults obtained by conservatism in some cases of chronicarthritis should be considered before deciding on opera-tion. In tuberculous disease of the spine, ProfessorMcMurray thought it had been shown fairly conclusivelythat conservative methods should hold the field. A com-prehensive survey of cases in this country had producedno proof that the recovery of any patient was hastenedby operation. Wherever it was applied he urged thatconservative treatment should be given a fair chance.It did not imply a patient " kicking about in bed in aconvalescent home but was a definite treatment,including fixation and splinting, and required a longperiod of care and skilful supervision.
Prof. PHILIP WILSON (New York) described the resultshe had obtained in the treatment of arthritis of the hip-joint with the vitallium cup. This is a method evolvedby Smith-Petersen, in an attempt to re-establish painlessmovement between the arthritic joint surfaces by inter-position of a metallic cup, moulded over the head of thefemur, Re-operation i6 some of the cases had shownthat the bone surfaces in contact with the cup becomecovered with a considerable layer of fibrocartilage.-The method, he considered, contrasted favourably witharthroplasty by interposition of a fascial graft, and wasparticularly suitable for arthritis following congenitaldislocation of the hip, post-traumatic arthritis and somecases of osteo-arthritis. It was simpler than fascial -
grafting, and the postoperative recovery was quieter andless painful. He had used the vitallium cup for onlythree years, and could not express an opinion on long-range results, but so far a satisfactory proportion of goodand excellent results had been obtained.
Mr. ARTHUR ROCYN-JoNES (London) reported a caseof Paget’s disease of a single long bone in a woman of
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thirty. It was the consensus of opinion among thosepresent that healing of fractures in Paget’s disease wasnot at all delayed. Mr. Rocyn-Jones showed that thiswas because the bone callus by which union was effectedwas normal and histologically unchanged by the diseasein the adjacent bone-ends.
Mr. A. L. EYRE-BROOK (Bristol) showed a specimenof recurrent dislocation of the shoulder-joint, obtainedfrom a patient who had died during operation for repairof the disability. The specimen showed only one lesion-detachment of the capsule from the anterior lip of thegleiaoid. This is the lesion described by Mr. BlundellBankart 1 which has not received the general support oforthopaedic surgeons as the cause of recurrent dislocation,though, as Mr. Eyre-Brook said, ever since the paperappeared there have been a few believers, and their faithhad steadily grown with their experience of the lesion.The technical difficulty of reattachment of the capsulehad, however, discouraged many from performing theoperative cure described by Bankart.-Professor WILSONasked Mr. Bankart what he did about the subscapularis.The anterior exposure described by him was excellent,but it did seem to involve extensive division of the sub-scapularis.-Mr. BANKART replied that he felt there wasno objection to free division of the muscle. Musclealways recovered from cutting so long as the nervesupply was intact. In every case in which he operatedfor recurrent dislocation he found this lesion, which wasnot surprising, since it was the cause of recurrent dis-location. After trying various methods of reattachingthe capsule he had adopted that of drilling the neck ofthe’ scapula by means of a dental drill with a right-angledattachment and threading the suture material throughthe drill-hole.
Squadron-Leader J. R. ARMSTRONG, R.A.F.V.R.,described his method of treating fractures of the carpalscaphoid by drilling and the insertion of bone-grafts.Even with prolonged immobilisation in plaster, in 20%of old cases and 10% of recent fractures the lesion didnot unite. In civil life this did not necessarily matterso much, but there was a real urgency to get R.A.F.personnel back on duty. Drilling and grafting, hefound, hastened union, and in every case that he hadfollowed had led to union by bone.. For radiographyand operation he used an oblique position of the forearm,
, maintained by supporting it on a wooden frame in whichit lay in 45° of pronation, with the palm upwards andthe hand in the mid-position between dorsiflexion andpalmar flexion.2 The oblique view of the wrist obtainedby radiography in this position was a true lateral of thescaphoid. Also, the drill could be driven in straightthrough both fragments of the bone at right angles tothe fracture-line. A 2 mm. guide was first inserted byan electric drill, and a radiogram taken before the bonewas bored for the insertion of the graft. Grafting wasnot justifiable in the presence of arthritis of the wrist-joint, because it never relieved the pain which was themain indication for operation in fractured scaphoid.
Mr. GEOFFREY HYMAN (Leeds) had investigated 67consecutive cases of ossification around the elbow-joint.Of these, 45 had followed dislocation of the elbow (32without fracture, 6 with fracture of the head of theradius, and 7 with multiple fractures). A -further 13cases had followed a tear of ligaments around the joint,demonstrated in the radiogram by the presence of flakesof bone. Only one patient was under. the age of 10years, probably because in young children the commoninjury is supracondylar fracture, and dislocation is rare.The age-groups showing most lesions were at 10-20 and40-50. Delayed reduction, repeated and forcible mani-pulations and early movement were important factorsin causation. Ossification in the lateral ligaments, evenwhen it produced a well-marked shadow in the radio-gram, did not produce much limitation of movement.Full flexion in all these cases had been regained ; 20’ ofextension had been lost in a few cases. The significanceof a bony mass in front of the joint depended almostentirely on its position. If in immediate contact withthe anterior part of the capsule it was more serious thanif well above the level of the articular surfaces. Articularossification could occur even where treatment had beenearly and adequate, but adequate treatment did limit theextent of the ossification. The method of fixation Mr.
1. Brit. J. Surg. 1938, 26, 23. 2. See Lancet 1941, i, 537.
Hyman used was a posterior plaster splint, maintainingthe elbow-joint at an angle of 70°. Immobilisation wasmaintained till flexion was possible without pain, usuallyabout three weeks. Results were obtained by this methodat least as good as by immobilisation till no furtherossification was apparent by X-ray control.-Mr. H. A. T;FAIRBANK (London) had found immobilisation moreeffective in the treatment of myositis ossificans inchildren than in adults.
Mr. R. G. TAYLOR (Sheffield) had treated 29 cases ofpelvic dislocation between October, 1937, and June; 1941,which Prof. H. J. SEDDON said was the most compre-hensive and carefully documented series so far reported.Of the 29 cases, 22 were dislocations or subluxations, orboth, of the symphysis pubis and the sacro-iliac joints ;while 7 were dislocations or subluxations of the sym-physis pubis alone. Most of the patients were in thesecond decade. The injury occurred by indirectleverage. There was no evidence that direct violencewas a cause. Hyperextension and abduction probablyproduce the displacement, and reduction was obtainedby flexion, adduction and internal rotation. All typesof operation had been tried, but the conclusion reachedwas that closed manipulation was to be preferred. Rapidreduction was effected within the first hour or two afterthe accident. Improvement in the general symptomsof -shock was evident as soon as the displacement wasreduced. The pelvis was slung with weights pulling theends of the sling across the body, about 30 lb. on each side. <The legs were extended on Braun splints, with about15 lb. pulling on each’leg. After reduction, immobilisa-tion was maintained for 8-12 weeks. Of the 22 cases,3 died (there were often severe concomitant injuries). Ofthe 19 who recovered 16 were walking well and werewithout pain ; 2 were good results but had some pain ;and 1 was classed as a fair result only.
Mr. G. K. McKEE (Norwich) showed a film illustratingthe treatment of compound fractures of the leg. Thedeformity was corrected by means of Steinmann pinsinserted into the bone above and below the fracture.The upper pin was clamped to the sides of a Thomassplint which supported the limb. Manual traction wasexerted on the lower pin and the clamp applied whehsufficient extension had been obtained. During theplastering process, done a few days after the reduction,the limb was kept in position on the Thomas splint, andthe lower pin was included in the plaster. The healingof the wound and the return of function, as shown in thefilm, were most impressive. .
At the Wingfield Orthopaedic Hospital, Mr. J. C.ScoTT and Sister WALKER showed cases and radiogramsillustrating the stages of reduction of congenital dislocationaf the hip by gradual traction and increasing abductionon a frame. Most satisfactory results are being obtained.
Plans for the establishment of a complete accident ser-vice for the country were discussed at the business meeting.
MEDICINE AND THE LAW
Property in RadiogramsA PATIENT .writes to ask about her rights in the X-ray
photographs taken in the course of professional treat-ment. Her medical attendant, Dr. A, recommendedX-ray examination of her knees ; this revealed arthritis ;.radiant heat was successfully applied and she was advisedto repeat the treatment periodically. Later, havingoccasion to move to a different part of the country andknowing that she would have to consult a doctor beforeobtaining further treatment, she asked for the films inorder to show them to him. Dr. A’s secretary repliedthat it was not customary or desirable to give patientsfilms, but, if she were consulting a doctor and he desireda report on her X-ray examination, Dr. A would bepleased to furnish one. The patient, not surprisinglyperhaps, fails to understand why the films for which shehas paid cannot readily be handed to her and why she isobliged by Dr. A’s attitude to have two doctors in what isreally a simple case. She mentions that she knows threecases in which radiograms were sent to patients withouttheir being asked for. She herself wrote to the hospitalwhere the X-ray examination had been made. Thehospital sent her the films next day, but Dr. A’s secretary,having apparently been informed by the hospital, wrotethat this was done " without Dr. A’s knowledge or
