Kurt Goldstein's test battery

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Historical paper

Kurt Goldstein's test battery Paul Eling* Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behavior, The Netherlands

article info

abstract

Article history:

Kurt Goldstein was a founder of clinical neuropsychology. This thesis is illustrated with a

Received 29 April 2014

description of Goldstein's test battery that he used as a screening instrument in a special

Reviewed 22 June 2014

clinic for soldiers in World War I. Parts of the battery were also used for neuropsychological

Revised 22 July 2014

rehabilitation. Goldstein's early work in Germany focused on both neuropsychological

Accepted 15 August 2014

assessment and rehabilitation. He was interested in how individuals go about compen-

Action editor Georg Goldenberg

sating for their deficits, The notion of ecological validity (Lebenswahr vs Lebensfremd), only

Published online 27 August 2014

becoming widely popular in the nineteen-eighties, played an important role in Goldstein's selection of test procedures.

Keywords:

© 2014 Elsevier Ltd. All rights reserved.

Kurt Goldstein Clinical neuropsychology Assessment Test battery Historical

1.

Early roots of neuropsychology

For centuries, scientists have described and analyzed the effects of brain injuries. From the beginning of the 19th century it was a crucial and heavily debated topic in the medical literature. Franz Joseph Gall (1758e1828), Paul Broca (1824e1880) and Carl Wernicke (1848e1905) played a central role in the debate on localization of psychological functions in the brain. This discussion may be regarded as the beginning of neuropsychology and the protagonists as the pioneers; neuropsychological text books usually take the 19th century history as a starting point (e.g., Heilman & Valenstein, 2003). In essence, this discussion on localization of function is about the relationship between behavior and the brain that is currently the central theme of research performed in the area

of cognitive neuroscience. Clinical neuropsychology, as an independent discipline, is generally assumed to have started in the period around 1960e1970 (Benton, 1988; Meier, 1992).
caen Benton (1994) described four pioneers: Henri He (1912e1983), Oliver Zangwill (1913e1987), Hans Lukas Teuber (1916e1977) and Norman Geschwind (1926e1984), with a further prominent figure in clinical neuropsychology being Alexander Luria (1902e1977). Interestingly, many (not to say most) pioneering neuropsychologists had a medical back
caen and Geschwind. ground, as was the case for He The number of neuropsychologists has grown considerably over the years and they are active in many areas of healthcare. They apply the theoretical framework inherited from the aforementioned 19th century developments in the study of the cognitive effects of brain disorders. They also use many neuropsychological tests that were developed decades ago.

* Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behavior, PO Box 9104, 6500 HE Nijmegen, The Netherlands. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.cortex.2014.08.002 0010-9452/© 2014 Elsevier Ltd. All rights reserved.

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Arthur Benton contributed significantly to this area with his tests in the area of visuospatial processing (Benton, Hamsher, Varney, & Spreen, 1983). Barr (2008) described the historical development of neuropsychological assessment, with an emphasis on test batteries developed by Ward Halstead and Alexander Luria. He also mentioned individual tests such as the Rorschach test and the Thematic Apperception Test. Evidently, then, Barr's focus was oriented primarily to the United States, thus missing developments of mental testing in the 19th century and around 1900 in Germany (Bondy, 1974). For instance, the Wisconsin Card Sorting test can be traced back to an experimental paradigm used by Ach in 1904 to study concept formation and it was adapted for clinical assessment by Gelb and Goodglass in (Eling, Derckx, & Maes, 2004). A further example is Ziehen's (1908) description of a test battery, presumably used for examining cognition. Some of the tests of this battery resemble those that are still widely used in clinical neuropsychology, for instance the Digits Forward and Backward, the Rey Auditory Verbal Learning test for memory recall and the subtest Similarities of the Wechsler Adult Intelligence Scale. These examples are a clear indication that some current neuropsychological tests have their roots in a rather distant past. To gain better insight into these roots and the original purpose of these instruments, it is important to study the history of the discipline and more particularly the role of their founders. Kurt Goldstein was one of the founders of this discipline and his work has been essential for the field of cognitive rehabilitation, the use of screening tests and the promotion of the notion of ecological validity as I will argue below. After a brief biography, the significance of Goldstein for clinical neuropsychology is illustrated by focusing on his activities in World War I. I will discuss specifically the test bat
mar Gelb (1887e1935), developed tery that he, along with Adhe to examine and treat the effects of brain injury, mostly gunshot wounds, with soldiers. Parts of this battery were also used for rehabilitation. I will not elaborate on more theoretical issues such as Goldstein's views on language and aphasia (de Bleser, 1994; Friedrich, 2006; Geschwind, 1964; Goldstein, 1948, 1926a; Noppeney & Wallesch, 2000), his objections to localization (Goldstein, 1927), his notion of concrete and abstract attitude (see Gurwitsch, 1966) and his holistic vision (Goldstein, 1934; see also Ludwig, 2012; Noppeney, 2001). For a discussion on Goldstein's view on rehabilitation see Frommer and Smith (1988) and Ben-Yishay and Diller (2011).

2.

Short biography

Kurt Goldstein (1878e1965) is probably familiar to most neuropsychologists. In neuropsychological textbooks, he is mostly depicted as one of the opponents of the 19th century idea of localization and a supporter of a holistic approach (e.g., Ben-Yishay & Diller, 2011). Through his work with brain injury patients he developed a vision on the behavior of these people that was very different from what he had learned from his teacher Carl Wernicke. It also changed his views on how one should investigate human behavior, both in neurological and psychiatric patients. His views fitted in a broader cultural development, especially in Germany, where the Gestalt psychology of Max Wertheim (1880e1943), Kurt Koffka

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€ hler (1887e1967) and the (1886e1941) and Wolfgang Ko personalistic psychology of William Stern (1871e1938) rebelled against the analytical approach of Wilhelm Wundt (1832e1920). Goldstein's work had a significant impact on the emergence of humanistic psychology in America. Much has been written about Kurt Goldstein, including by himself (Goldstein 1967). There are several biographies, many of which seem to be based on that of Shakow (1966; for more details see Simmel, 1968; Eling, 2012). I restrict myself here to a brief sketch. Goldstein was born in 1878 in Katowice in southern Poland. He studied medicine in Breslau, specialized in neurology and psychiatry under Carl Wernicke and became a physician in 1903. Subsequently he became an assistant to Ludwig Edinger (1855e1918) in the Senkenbergische Neurologisches Institut in Frankfurt. Edinger was the leading comparative anatomist at that time and head of the neurological clinic. Goldstein considered him, besides Wernicke, as his main teacher. From 1906 to 1914 Goldstein worked in the € nigsberg (now Kaliningrad, Russia). He psychiatric clinic in Ko returned to Frankfurt, where Edinger gave him the opportunity to become director of the newly founded Institut fu¨r die Erforschung der Folgeerscheinungen von Hirnverletzungen (Institute for the study of aftereffects of brain lesions), a special clinic for soldiers with brain damage (see Kreft, 2005). When Edinger died in 1918, Goldstein took over his chair. In 1930 he accepted a professorship in Berlin (see also Holdorff, 2004) but because of the rising Hitler regime, he had to leave, as did many other Jewish scientists, including the aforementioned Gestalt psychologists. He spent a brief period in Amsterdam, where he put his holistic vision on paper in six weeks (Goldstein, 1934). He then emigrated to the United States with support from the Rockefeller Foundation, which played an important role in the emigration of German Jews. There he received an appointment as Professor of Neurology at Columbia University and later at Tufts Medical School. He remained active after his retirement and has written more than 200 articles and books that, at that time, were popular among the many adherents of a holistic and humanistic psychology. In August 1965 he suffered a cerebral hemorrhage and died on 19 September of that year in New York City. Goldstein was trained as a medical doctor and specialized in psychiatry and neurology. Driven by his experiences in the clinic, he paid special attention to the more personal matters of patients with brain injury. This interest in the psychological component was important for him and characteristic of his work. His interest in psychology is illustrated by the fact that in 1922 he was one of the founders - and long time editor e of the journal Psychologische Forschung (Psychological Research), then popular among Gestalt psychologists.

3. Neuropsychological rehabilitation in Germany In the 19th century, many ‘neuropsychological’ articles dealt with quite specific cognitive deficits. In general, patients stayed in hospitals or psychiatric institutions: neurological clinics did not exist. But the situation changed significantly through the work of Walther Poppelreuter (1886e1939) and Kurt Goldstein (Poser, Kohler, & Schoenle, 1996). During World War I large

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Fig. 1 e Villa Sommerhof.

numbers of soldiers with brain injuries entered the hospitals and special military hospitals were set up dealing with these patients. In the fall of 1914, Walther Poppelreuter, known among neuropsychologists for Poppelreuter's overlapping figures test (see Sells and Larner (2011) for a recent study using this test), started such a clinic in Cologne. He described his clinical observations in 1917, mainly focusing on visual disorders (Poppelreuter, 1917). He later used his expertise and tests in his work in the area of occupational psychology. As mentioned above, Goldstein was appointed as head of a new clinic with 100 beds for soldiers with brain damage in Frankfurt. The Villa Sommerhof was used for this purpose, with several buildings in the park that were used for psychological assessment, and for different types of therapeutical activities such as carpentry, bookbinding, production of brooms, shoes and small leather objects such as bags and wallets (see Figs. 1 and 2 and for a detailed description, Kreft, 2005). Goldstein soon realized that patients not only suffered from aphasia, agnosia or amnesia, but were also confronted with a challenging situation they did not know how to handle. This resulted in his description of the catastrophic response (see also Goldstein, 1934, 1942). Often, patients tried to make the best of it and they looked for alternative activities to remain active in society and to earn money. Based on these observations, Goldstein concluded that the traditional localization theories of brain functioning were completely inadequate for analyzing the consequences of brain lesions as they did not take into account emotional responses nor potential compensatory strategies. Goldstein (1919) also criticized his colleague Poppelreuter. According to Goldstein, Poppelreuter focused too much on everyday life situations in his assessment procedures and made insufficient use of experimental test procedures that were more sensitive for examining cognitive deficits (see below). However, Goldstein did recognize the importance of examining patients in everyday situations and also of offering rehabilitation activities to enable patients to return to a social


mar Gelb, an life, as we shall see later. With the help of Adhe adept of Gestalt psychology, Goldstein developed a comprehensive, systematic protocol for care, assessment and treatment. It also included an assessment of the chances of returning to work by identifying professions that could be performed with the remaining assets (see Fig. 3). With such a focus on cognitive rehabilitation, it is clear that this practice was not first developed in the nineteen-eighties, as many would believe.

4.

The test battery

Goldstein (1919) has described many facets of the practice in his clinic in great detail in a little known book, Die Behandlung, Fu¨rsorge und der Begutachtung der Hirnverletzten (The care for treatment and assessment of brain-injured patients). To some extent, Goldstein's (1942) Aftereffects of Brain Injuries in War. Their Evaluation and Treatment; The Applications of Psychologic Methods in the Clinic deals with the same topic but it clearly is not a straightforward translation of the original German book (see below). My description of the clinical procedures and tests is based on the original German book, which is largely devoted to diagnostic examination procedures. Goldstein deals only briefly with effective psychological treatments or exercises, but the text clearly reveals his view that the diagnostic phase is essential for the planning of the treatment. In his 1919 book, Goldstein discussed in separate chapters 1) medical treatment 2) psychological-pedagogical treatment 3) occupational therapy (Arbeitsbehandlung), 4) the results of this program and 5) the assessment for return to work and its benefits. All questionnaires, protocols and forms used in the clinic are reproduced in appendices in the book. To give the reader an idea of his neuropsychological approach, I will describe the contents of the chapter on the psychologicalpedagogical treatment in some detail. Compared to the other chapters, it is quite extensive: 15 pages on medical

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Fig. 2 e Plan of the clinic.

treatment, 153 pages on the psychological treatment, and 42 pages for the remaining three chapters. It shows that Goldstein was quite familiar with the topics which in the clinic were the area of expertise of the psychologist Gelb. The two worked closely together, as demonstrated by a number of detailed case studies (Gelb & Goldstein, 1920). As part of their collaborative investigations they developed a color sorting test (Goldstein & Scheerer, 1941), which formed the basis for the Wisconsin Card Sorting Test (Eling et al., 2004), but it was not part of the test battery that was commonly used in their clinic. Goldstein distinguished between a general and a special examination. The general examination may be regarded as a screening battery for cognitive functions, consisting of experimental-psychological laboratory tests, and what Goldstein called €higkeit), and this may performance capacity tests (Leistungsfa be considered the neuropsychological test battery. In case of


mar Gelb. Fig. 3 e Kurt Goldstein (left) and Adhe

distinct disorders in the areas of oral language, reading, writing or arithmetic, a special assessment was performed. Goldstein has provided a systematic description of the psychological test battery in an appendix and I present this battery in Table 1 with examples of the materials used. The battery covered 14 domains, such as orientation and attention, language functions, perception, praxis, calculation, higher order cognitive processes and fatigue. It is important to note that Goldstein strongly believed that the assessment of deficits should not be based on test scores (norm scores were hardly available), but on clinical impressions. For most tests, only a few items were presented, indicating that the test was a screening instrument. For some tests, Goldstein specified that the examiner should look for omissions or for specific strategies, for example reading word by word or with comprehension. However, no specific procedures are given to calculate or evaluate test scores, i.e. norms or cut-off scores are not provided. Furthermore, validity of test procedures is not discussed, although this is not uncommon for that time. Screening started with the experimental-psychological tests, reaction time tests, using tachistoscopic presentation: simple detection tasks and choice reaction tasks (see Fig. 4). Goldstein stated that for the simple reaction time tasks visual, auditory or tactile stimuli could be used equally well, but according to experience, the auditory modality was often intact and therefore used mostly. A patient had to press and hold a key and, upon hearing a sound, release the key, interrupting the electrical circuit and thus stopping the reaction time measuring device. The device used by Goldstein was a € bner in Berlin. Some ‘1/100 sec. stop-watch’ constructed by Lo practice trials were given: two or three. Subsequently a series of trials was presented until the patient showed signs of fatigue. This procedure was different from that used in studies

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Table 1 e Protocol of the psychological test battery. 1. Orientation Ten questions are asked about orientation with respect to person, time and place. 2. Attention test (Bourdon cancellation test) There are three tests, a, b and c. In test a, a short text of four paragraphs on horses was presented on paper and the patient had to cross the letters r and f. In test b a short text on a boy playing in the garden, also of four paragraphs, was presented and the patient had to cross the letter i. In test c, four vertical rows of 36 digits, 1 to 9, were presented and the patient was asked to cross the digits 7 and 4. The number of omissions and commission errors was noted for each paragraph or row. Test d in this section concerned a picture, ‘On the land’ from Nielsen's Anschauungsbilder (Pictures), a scene with meadows, roads and a mill. The patient had to indicate the number of sheep, cows and horses. Test e was constructed in analogy with the Bourdon procedure (cancellation test, PE). A short text was presented and the patient had to indicate typing errors. 3. Language A. Speech a) Spontaneous speech The patient is asked to talk about his life experiences. Subsequently he is told a story and he has to recall it. b) Reproduction The patient is asked to reproduce 11 speech sounds, vowels and consonants, 4 words, and 3 sentences. c) Series (‘serial speech’) The patient is asked to produce the numbers 1 to 20, days of the week, months, alphabet and a poem. d) Conjunctions The patient is asked to produce sentences beginning with ‘I have … ’ and ‘I am … ’. e) Word finding 1. For 9 real objects in the office (chair, cup, boot). 2. For 28 pictures (animals and artifacts) 3. For colors B. Speech comprehension The patient is asked to execute 3 commands, increasing in complexity (number of actions). 4. Reading The patient is asked to read a text from a high school reading book. There is a text printed in ‘Deutschdruck’ or old German font (Gothic) and in ‘Lateindruck’ or Latin font. It is noted whether the patient reads word by word or with good comprehension. 5. Writing a) Spontaneous writing. The patient is asked to write about some life experiences. b) Writing to dictation: 8 letters, 5 words and 1 sentence. c) Copying. The patient is asked to copy a text from a reading book. 6. Tactile recognition a) Form recognition of 4 geometrical figures (cube, prism, pyramid, cylinder) b) Object recognition of 9 concrete objects (e.g., notebook, wallet, key) 7. Comprehension a) For concrete objects: lighting a cigarette, sharpening a pencil (Note PE: this looks like a test of actions for apraxia) b) For scenes in pictures c) Of drawings d) Of actions produced by the examiner: military salute, threatening, nodding, lighting a cigar 8. Praxis The patient is asked to perform the same actions that had been produced by the examiner in the last subtest (Comprehension d). 9. Description of objects from memory (to test imagery). Eight questions, e.g., a) Tell me how your father and mother looked like. b) What does a lion look like? c) Describe the way to the exit of the clinic h) What color has a a) citron b) egg yolk c) tram in Frankfurt 10. Association test (no further description in the protocol given) 11. Construction and drawing a) Spontaneous construction with wooden sticks b) Copying a construction with wooden sticks c) Spontaneous drawing of a tree d) Copying a drawing of the head of a horse 12. Memory €higkeit’, retention) A Memory span and direct recall (‘Merkfa Following acoustic presentation a) For digits; series increasing in length from 4 to 6 b) For nonsense syllables; series increasing in length from 3 to 6 c) For words; series increasing in length from 4 to 5 Following visual presentation a) For nonsense syllables b) For meaningless patterns A picture is presented to the patient and after 1 min the patient is asked to describe what he has seen on the picture. He is presented a written story and is asked to read the story and subsequently has to reproduce it.

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Table 1 e (continued ) B Recognition a) The patient is presented a paper with a 3  3 matrix with a nonsense figure in each cell for 15 min. Following a period of 15 min, he is presented with a matrix of 5  5 and a nonsense syllable in each cell. The patient has to indicate on this matrix which figures he had seen before. Correct recalls, omissions and commissions are noted. The procedure was copied from Bybakow. b) Following acoustic presentation of nonsense syllables (procedure from Rupp) c) Following tactile presentation (see test 6 above) C Encoding and Recall (following acoustic presentation). a) A list of 6 words, for instance, monk, child, peace b) A list of 12 words c) A list of 12 words (different from b) d) A list of 12 words (different from b and c) e) A list of 12 words (different from b, c and d) D Memory for the past The patient is asked 5 questions about the (recent) past, e.g., when did you arrive in the clinic, when were you wounded; how long have you been back in Germany. E General knowledge The patient is asked, e.g., to indicate where he lived (city, region, state), what happened in 1870/1871, who was Bismarck; what Eastern means and whether it is always on the same day and what he knows about the Danube 13. Higher intellectual processes A Arithmetic 1) The patient is presented, verbally, with sums: addition, subtraction, multiplication and division, and fractures. 2) The patient is presented in written form with one or two examples of the same kind of sums. 3) The patient is asked to read numbers. 4) The patient is asked to write numbers to dictation. 5) The patient is asked to solve word problems involving calculations, verbally. 6) And the same type of sums in written form. B Combination a) Differences. The patient is asked to indicate the difference between pairs of words, e.g., Child and Dwarf; Lake and River; Error and Lie. b) The Ebbinghaus Method (text according to Ziehen). A text is presented with some words omitted and the patient has to complete the sentences. c) Equation method (according to Ziehen). The patient is asked 5 questions like: to which number I have to add 3 to get 6? d) Sentence construction test. The patient is given a set of words with which he has to construct a sentence. e) Recall numbers. f) The pictures from Heilbronn: Fish, Lamp, Church. Note: no further explanation of the procedure is given. g) A set of pictures is given in random order and the patient has to put the pictures in the correct order for a story. h) Sentence completion test. A clause is presented and the patient has to finish the sentence with the main clause. There are 3 sentences. i) Correcting errors. The patient has to detect logical errors in sentences, for instance: ‘One has to go to bed, although one is ill.’. j) Logical order. The patient is presented with two sets of words and each set has to be put in a logical order by putting numbers to the words. For instance: Healing, Doctor, Bandage, Wound, Carelessness, Scar. 14. Fatigue a) Calculation test from Kraepelin b) Small ergograph. Note PE: no further details given here. c) Large ergograph. Note PE: no further details given here.

Fig. 4 e Patient looking at the screen on which stimuli were presented tachistoscopically.

on healthy participants; in those cases presentation of stimuli was commonly stopped before a participant showed signs of fatigue, as stated by Goldstein. In describing the choice reaction time paradigm, Goldstein gives an example of a task with two lights, a large and a small one (perhaps referring to a dim and a bright light), presented through a hole in a board. The participant held two keys, one in each hand associated with one of the lights, and was instructed to release the key associated with the light presented. Goldstein also used a complex task, reminiscent of an office or factory situation: a large board was attached to the wall, with a number of instruments on it and a light under each instrument. These were, for instance, an electric switch, a light switch, a telephone, keys and a gas handle. The patient was required to operate an instrument as soon as the light under it was illuminated (see Fig. 5). Response time was measured in a similar manner with the 1/100 sec. stop-watch. Several other tasks were presented using the tachistoscope (see also Table 1). Words and visual patterns were projected

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Fig. 6 e An ergograph to measure muscle fatigue.

Fig. 5 e The complex reaction time task.

onto a frosted glass plate, from which the patient sat 1 m. He was looking at a fixation point and had to report what he saw. With this procedure it was established whether the patient suffered from a general slowing of mental processes, from memory problems, attention problems, perseveration, various optical disorders, alexia, agnosia, visual field defects, amnestic aphasia, learning disabilities, impaired color perception or arithmetic problems. Goldstein did not indicate how exactly general mental slowing was determined or distinguished from more specific disturbances. To measure sustained attention or concentration, Kraepelin's calculation test was used. Goldstein referred to it as Ketten rechnen (chain calculation; in Aftereffects it is called Addition Test): a series of digits was printed on a sheet of paper and a patient had to continuously add two consecutive digits quickly for a period of one whole hour. After each minute, a mark was placed on the paper at the number that the patient had arrived and so performance (or variation in performance) could be recorded over the entire session. Goldstein had to adjust the sequence of numbers Kraepelin had used to ensure that the sum did not exceed 15, making the task too difficult and producing too much fluctuation. This test may be seen as the forerunner of a familiar neuropsychological test, the Paced Auditory Serial Addition Test, or Pasat (Gronwall & Sampson, 1974). Within the set of performance tests (Leistungspru¨fungen) we also find tests focusing on fine motor skills, such as pulling capacity and muscular fatigue of the fingers, as it was measured by the then commonly used ergograph, originally developed by the Italian physiologist Angelo Mosso (1846e1910; see Fig. 6). The pulling power was recorded on paper and normally, after several trials, power slowly diminished according to a characteristic pattern. Goldstein also used a gross motor test that focused more on physical strength, as needed, for example, when lifting boxes. He used an instrument, reminiscent of an oldfashioned bicycle pump, with a handle, attached to a spring that had to be lifted with two hands repeatedly (see Fig. 7). With this procedure the reduction of performance capacity could also be recorded, but, according to Goldstein, data from

this test were less reliable and difficult to interpret. Based on all the findings of these tests the psychologist made an analysis of impaired and spared functions and the possibility of compensation estimated (for a discussion of Goldstein's views on compensation, see Adler, 1959).

5.

Holism

The reader might wonder how this battery relates to Goldstein's holistic views. Apparently, the psychological investigation focused on cognition and deficits in cognitive processes. No specific examination of emotion, motivation or personality was performed although clinical impressions were clearly very important and noted during the examination. Goldstein is primarily remembered for his holistic ideas with respect to rehabilitation, where the emphasis is on the person, rather than on the deficit. The test battery, however, seems to fit much better the classical approach as propagated by his teacher Carl Wernicke. Tasks are used that tap cognitive processing in different modalities and at different levels of representation, trying to determine precisely the nature of the deficit. Presumably, this battery was developed at the beginning of his work in this rehabilitation clinic, and Goldstein at that time had not yet converted to his holistic approach. His work with these soldiers led him to change his mind about

Fig. 7 e The gross motor test.

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various aspects. He realized that the ‘traditional’ way of thinking was not adequate for describing how patients attempted to deal with their problems. This line of thinking developed slowly and is articulated in some detail in his Der Aufbau des Organismus (Goldstein, 1934), where Goldstein indicates that only then had he found the time to elaborate on his new views; the clinical work during the war was probably too time consuming. Moreover, in a paper by Bolles and Goldstein (1938) it is stated that the in-depth studies of some patients at the beginnings of the 1920's, together with
mar Gelb, suggested the idea that task performance does Adhe not simply reveal a specific deficit, but the way a patient is attempting to deal with a problem. And this insight was developed into his notion of abstract and concrete attitude. Some of the first papers where Goldstein criticizes the traditional view of symptoms were published in 1925 and 1926 (Goldstein, 1925; 1926b). A thorough study of how Goldstein changed his mind in the period between 1919 and 1934 could shed more light on this issue. Taken together, it appears that the battery indeed does not reveal Goldstein's holistic views, as these had not yet been developed at that time.

6.

Rehabilitation

As is also indicated in the title of the Goldstein's (1919) book, the focus of the clinical work was not on careful assessment, but on rehabilitation and return to either the army or a place in society, where the patient could live an independent life and earn a living. In a first section Goldstein describes the laboratory tests (reaction time tests, tests for fatigue and chain calculation). He elaborates on the neuropsychological aspects in a second section, titled ‘The psychologicalpedagogical exercise treatment’. He also indicates that assessment was performed with an eye on rehabilitation. In case of an impairment of general psychological capacities, the patient is offered education that might be compared to a high school program. In case of focal deficits, specific assessment was performed and treatment given. Goldstein raised the question whether it would be best to teach the patient to perform a lost function in the same way or not and he argued that it might depend on the degree of the impairment. The issue of function training versus compensatory training was clearly a topic under debate. For rehabilitation exercises the above mentioned tests were also applied, for example, as language or arithmetic exercises, or as concentration exercises. Treatment programs were directed at the individual characteristics of a patient. Goldstein provided in his book some examples, for instance of a number of patients with language disorders and forms of aphasia, with problems in calculation, reading or writing. No examples are given of patients with visual or visual-spatial disorders. The general way of working was shortly described (Goldstein, 1919, p 73). First, it is estimated whether the brain will function properly after practice or not. If not, was there an ‘ı´ndirect’ route to improvement? If so, the intact functions formed the basis for an alternative path. Often, only during treatment did it become clear what the most effective treatment plan would be, and it was thus frequently a matter of trial and error.

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Patients were also stimulated to practice real work in so-called workshops, as mentioned above. This topic is discussed in Chapter 3 on ‘Labor treatment’. Goldstein stressed that it had to be work the patient could actually perform after his return in the community; it should not be merely occupational therapy.

7.

Ecological validity

In his discussion of the performance tests, Goldstein pointed out that the ‘traditional’ (still quite young at the time) ergograph was an ‘abstract’ laboratory test: Goldstein calls it lebensfremd (out of touch with daily life). The more complex performance test (the board with instruments and lights) was in his eyes lebenswahr (‘real life’), a clear early argument for the ecological validity of neuropsychological test procedures He did not provide any evidence that these tasks were ecologically valid, but it must be noted that psychometric notions about test construction and validity had not yet been developed at the time. It is remarkable to see that the issue of ecological validity was so important for Goldstein. He discussed this issue in the context of reaction time tasks and apparently the more complex reaction time task was an attempt to develop a more ecological procedure. He also described the advantages and disadvantages of the two types of tests. Although the laboratory test was lebensfremd, it also had some benefits: it was precise; it was relatively independent of a person's attitude (attitude or Einstellung was a crucial concept in the Wu¨rzburg Psychology of Thinking and in Gestalt psychology, with which Goldstein was very familiar); it allows for a better understanding of elementary processes; one can measure many times because the procedure is short and simple; the task could be used in many patients; and comparison among patients was possible and meaningful. And a final argument, that may also surprise the modern neuropsychologist, was that the patient would not realize that these measurements had something to do with his work capacity and therefore he would not attempt to simulate a deficit. At the same time Goldstein indicated that it was not clear what one could conclude from these tests with respect to labor capacity in daily life. The results of the more complex, lebenswahre or ecological test showed that the data were not very precise, were unreliable and did not mean much. For the ecological task the examiner had to rely on his observations. All things considered, Goldstein concluded that each test had its advantages and disadvantages, but the results should not be simply added up, each should be evaluated on its merits.

8.

Aftereffects

In the Preface of the English description of the test battery, Goldstein (1942) wrote that shortly after World War II had started, he had decided to share his experiences as a neurologist in a war situation with his English speaking colleagues. He also indicated that being a clinical neurologist is completely different from acting as a neurologist in a clinic for victims of war accidents. He had experienced that the

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customary procedures were inadequate and that new procedures had to be developed for the examination and treatment of soldiers with gunshot wounds. He was stimulated to write this book by some colleagues such as Derek Denny-Brown (1901e1981) and Stanley Cobb (1887e1968). The subtitle of the book indicates that it is more a neuropsychological than a medical or neurological book: The application of psychological methods in the clinic. The first four chapters deal with symptoms and were not present in the 1919 book. Among these symptoms, Goldstein discussed general (vasomotor, genital (e.g., ‘Impairment of potency is not rare in these patients’ and ‘Here we may meet the characteristic picture of dystrophia genitalis with obesity’; p. 31) and metabolic dysfunctions; chapter 1), neurological (motor, sensory, frontal lobe, cerebellar and vestibular problems; chapter 2). For the current neuropsychologist it is remarkable to see that aphasia, agnosia and apraxia are mentioned in the section on frontal lobe lesions. Moreover, aphasia is merely mentioned and the reader is referred to the chapter on treatment. Chapter 3 deals with mental symptoms, i.e., psychogenic functional symptoms, and in chapter 4 Goldstein discusses the origin of symptoms, also elaborating on the ‘struggle of the organism with the defect’. Also of interest in this chapter is Goldstein's description of Hughlings-Jackson’s principle of negative and positive symptoms. Berrios (1991) has drawn attention to the fact that originally, these terms had been introduced by John Russell Reynolds (1828e1896). For Reynolds, these terms referred to different symptoms. Jackson saw the negative and positive symptoms as related to a lesion, they are different sides of the same coin: a lesion results in an impairment of a function and ‘releases’ the activity of an underlying, older layer of functioning. Goldstein appears to follow Jackson in the use of these terms. The final chapter of Part I is titled Psychological Laboratory Examinations and deals with the main substance of the 1919 book. It is about 50 pages long, but seems to contain more or less the same material as the chapter on the psychological assessment in the 1919 book. Here Goldstein also discusses the issue of abstract and concrete tests, but does not provide English analogs for ‘lebenswahr’ and ‘lebensfremd’ Perhaps this can explain why Goldstein's interest in ecological validity has been overlooked. Part II deals with treatment, physical and neurological therapy (chapter 6) and social adjustment (chapter 7). Most of the material was discussed in the chapter on psychological assessment in the 1919 book. Relatively much attention is devoted to language therapy (word finding, speech, grammar, reading and writing). Interestingly, Goldstein does not go into the classical syndromes, restricting himself to motor and sensory aphasic disturbances as well as higher order problems like grammatical and syntactic problems. Broca is not mentioned, Wernicke's aphasia only twice. Goldstein's ideas on social adjustment were also discussed in the 1919 book.

9.

A founder of neuropsychology

The idea that Goldstein was one of the founders is illustrated by judgments of some key figures in the history of neuropsychology. In his foreword in The Organism (Goldstein, 1939)

Karl Lashley wrote to ‘the student of behavior who seeks an understanding of the relations of the body and the mind’: ‘Dr. Goldstein considers the problem of neural and behavioral organization from a broadly biological point of view. On such questions he is qualified to speak as one of the world's greatest authorities' (p. V). This was just shortly after Goldstein had emigrated to the United States. Denny-Brown (1966, p. 293) wrote: ‘Despite the large number of Goldstein's contributions and the originality of his thinking, he has had less impact on current neurology than he deserved. This, we believe, was partly because neurological thinking in the last 30 years has been dominated by very practical issues stemming from advances in electrical recording and neurosurgical techniques….The originality of Goldstein's approach, derived as it was from immense clinical experience of combined neurological examination and psychological testing, has still a very great deal to offer’. Hans Lukas Teuber, who played an important role in the development of neuropsychology as a separate scientific and clinical discipline in the 1960's, wrote: ‘The incredibly rapid development of our field in the 50's and 60's of this century was bound to make Goldstein an historical figure.’ (Teuber, 1966, p. 299). Teuber also stressed Goldstein's role in the development of neuropsychological tests: ‘We have already stressed how surprisingly strong Goldstein's influence has been on the development of behavioral tests of concept formation in monkeys, and we have pointed out how these non-verbal quantified versions of Goldstein's and Weigl's task [ i.e., the Wisconsin Card sorting Test, PE] have found their way back into the neuropsychological laboratory’ (p.305). But, according to Teuber, the main contribution of Goldstein lies in his clinical assessment procedures: ‘Most of all, however, his living contribution to the field at present lies in his and Gelb's continued insistence on analysis of performance (‘Leistungsanalyse’), the exploration of the nature of disordered function by continual variation in the experimental task.’(p. 306). One of the best known neuropsychologists, Alexander Luria stated: ‘There is every reason to regard Kurt Goldstein as one of the founders of contemporary neuropsychology, and every scholar who took part in the development of this new science has felt his influence’ (Luria, 1966, p. 311). Gerald Goldstein (1990, p. 3) in his Presidential Address to the Division of Clinical Neuropsychology of the American Psychological Association, argued that ‘Kurt Goldstein was a pioneer of neuropsychology’ and the entire speech was directed at illustrating this claim. He discussed Kurt Goldstein's views on symptoms as not merely revealing deficits, his studies on the frontal lobes, his notion of abstract attitude, his extensive work on aphasia and his pioneering work on cognitive rehabilitation. Finally, I refer to Ben-Yishay and Diller (2011) who discussed Goldstein's holistic approach to the management of traumatically brain-injured individuals, which formed the conceptual framework for rehabilitation approaches developed in the early 1970's. These statements from colleagues of Goldstein and key figures in the field of neuropsychology and rehabilitation clearly show that Goldstein was a pioneer in the field of neuropsychology. He was originally trained to use Wernicke's framework, but in his clinical work he realized that this framework, aimed at locating deficits, was insufficient. A patient is not a complex machine with one defective

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mechanism but an organism that attempts to deal with reality, including his own impairments, with all the possibilities he has at his disposal. This insight led him in the direction of a holistic approach. When dealing with a patient, Goldstein not only took the findings of the neurological examination into account, but also attempted to get an insight in the details of intact and disturbed cognitive processes, using a broad range of tests. Finally, in his clinic for braininjured soldiers, where this development essentially starts, Goldstein was clearly aware of the necessity to see how patients could be trained in order to survive in society. Rehabilitation was not only aimed at practicing basic cognitive processes but also aptitudes that could be useful for a more or less independent life in society. Considering his role in developing theoretical views with respect to brain functioning and deficits, the development of an elaborated neuropsychological battery and his efforts to develop rehabilitation treatments, it is clear that Goldstein was a founder of neuropsychology and in my view, his works are still very valuable for current neuropsychologists.

10.

Conclusion

Kurt Goldstein was a man of the old and the new world, in two senses (Eling, 2012). First, after he had made a career in Germany, he immigrated to America where he again made his name, having his own vision of what the consequences of brain injury and psychiatric disorders mean for patients in everyday life. Secondly, he himself switched from the classic 19th century-oriented approach looking at the localization of functions in the brain, as his teacher Carl Wernicke strongly advocated, to a more individual-centered approach (see also Rimpau, 2009; for an analysis of the crisis in neurology in Germany in the 1930's). However, it would be incorrect to classify Goldstein merely as a holist. Much of the classical views were incorporated in his own views as was clearly shown by Geschwind (1964). Describing his own switch from the non-localizationist view to the Wernicke approach, Geschwind elaborated on Goldstein's paradoxical position with respect to aphasia, showing that many statements fitted well in the classical theories. With this switch, Goldstein played a major role in the emergence of Humanistic Psychology in America. But apart from these aspects of his contribution to neurology and psychiatry, based mainly on his overall conceptual framework, he was also important for the development of clinical neuropsychology. In his clinic in
mar Gelb, a Frankfurt, he developed, with his colleague Adhe neuropsychological test battery that he used for the assessment and rehabilitation of brain injury patients. This makes him one of the key founders of clinical neuropsychology. Unfortunately, it is not clear what happened with these procedures after World War I; were these neuropsychological test procedures simply thrown away? Were they applied to other patient populations? Was that job considered to be a task of a psychologists? And when was the neuropsychological test battery re-introduced in the clinics? Further studies may reveal that modern clinical neuropsychology developed to a significant extent already in the beginning of the 20th century.

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Acknowledgment I would like to thank the two anonymous reviewers for their constructive and valuable comments and suggestions. I also thank Daniel Shepard for correcting my language.

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