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Rating scales in psychiatry 1st Edition Tyrer Digital
Instant Download
Author(s): Tyrer, Peter J.; Methuen, Caroline
ISBN(s): 9781598755800, 1598755803
Edition: 1
File Details: PDF, 1.11 MB
Year: 2007
Language: english
Selection of the best outcome measures is a crucial step in psychi­
atric research. There are excellent instruments available for most
areas of interest and researchers are often faced with a confusing Rating scales in
psychiatry
choice. Getting it right will save you time and money, affect the
validity and comparability of your results and, ultimately, improve
the impact of your publications.
This booklet, extracted from the third edition of Research Methods
in Psychiatry and with a new foreword and introduction, will help
guide you through the process of selecting the rating scales to use
in your research. Each scale is listed with its citation rate – a useful
guide to its popularity among the research community and the
potential comparability of results.

•• Choosing a rating scale

•• The most widely used rating scales across all fields of
psychiatric research, comprehensively referenced
•• Citation rates included for all scales

About the authors

Peter Tyrer is Editor of the British Journal of Psychiatry and Professor
of Community Psychiatry at Imperial College, London. He has been
involved in research in health services, common mental disorders
and personality since 1970. He is also the lead of the North London
Hub of the Mental Health Research Network, England, which aims
to improve the quality of research in ordinary clinical settings.
Caroline Methuen is Honorary Clinical Lecturer, Division of
Neurosciences and Mental Health, Imperial College London, with
a particular interest in medical education.
With a foreword by Simon Gilbody, who is is an editor within the
Cochrane Collaboration and Senior Lecturer in Health Services
Research at the University of York. He is a practising primary care
psychiatrist/cognitive therapist and researches strategies to improve
the quality and outcomes of depression in non-specialist settings.

Peter Tyrer
PUBLICATIONS and Caroline Methuen
This page has been left
blank intentionally
Rating Scales
in Psychiatry

Peter Tyrer & Caroline Methuen

with a foreword by
Simon Gilbody

RCPsych Publications
© The Royal College of Psychiatrists 2007

RCPsych Publications is an imprint of the Royal College of Psychiatrists,

17 Belgrave Square, London SW1X 8PG
http://www.rcpsych.ac.uk

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form
or by any electronic, mechanical, or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval system, without permission
in writing from the publishers.

British Library Cataloguing-in-Publication Data.

A catalogue record for this book is available from the British Library.

ISBN 9781904671534

Distributed in North America by Balogh International Inc.

The views presented in this book do not necessarily reflect those of the Royal College of
Psychiatrists, and the publishers are not responsible for any error of omission or fact.

The Royal College of Psychiatrists is a registered charity (no. 228636).

Printed by Bell & Bain Limited, Glasgow, UK.


Contents

Foreword iv
Introduction 1
Rating scales in psychiatry 2
Index 51

iii
Foreword

Stanley Smith Stevens defined measurement as ‘the assignment of num-

bers to objects and events according to rules’ (Stevens, 1951). This book
provides an ideal starting point for researchers and clinicians in search of
instruments with which to allocate ‘numbers’ in psychiatry.
There is a long an honourable tradition of measurement in psychiatry,
since psychiatry has had to think much harder than other specialties about
‘rules’. Psychiatry deals with concepts and phenomena that are important,
but not as readily observable or measurable as in other clinical specialties.
Notions of validity and reliability therefore need to be examined in some
detail before a measurement instrument can be claimed to be a measure-
ment of anything at all. Psychiatry’s gift to the rest of medicine has been
an appreciation of the importance of psychometrics and the development of
some very good instruments. Historically, several instruments have found a
place in wider medical practice (such as the Hospital Anxiety and Depression
Scale). There are excellent instruments available for most areas of psychiatric
practice, and clinicians and researchers are sometimes faced with a dizzying
choice. Part of this choice stems from a ‘measurement industry’, whereby
new instruments are continually developed and refined. Unfortunately,
much of this happens without due consideration of what has gone before,
and new is not necessarily better. In addition, some perfectly acceptable
instruments are freely available in the public domain, whereas newer instru-
ments sometimes come with an expensive price tag.
A little careful thought when choosing an instrument often saves time
and money further down the line. There is a temptation to measure every-
thing that is possible just because an instrument is available. The guiding
principles when choosing outcome measures are to pick only those that
measure what is important, and to choose instruments that are fit for pur-
pose. Please bear in mind the effort involved in administering and filling in
measurement instruments and always remember that ‘less is more’. This
book will help you in all these tasks.
Simon Gilbody
Stevens, S. (1951) Mathematics, measurement and psychophysics. In Handbook of
Experimental Psychology (ed. S. Stevens), pp. 1–14. Wiley.

iv
Introduction
Peter Tyrer and Caroline Methuen

Many years ago one of us (P.T.) was lecturing on the use of rating scales at a
conference on research methodology. In a light-hearted way, the well-known
acronym for the standard format of a rating scale, SPITZER, was introduced.
‘Of course’, went the explanation, ‘we all know that the initials of the
name stand for “Structured Psychiatric Interviews To Zealously Enhance
Research”, and the core of research methodology is to remember this, over
and over again, when carrying out your research’. This explanation was a
little too convincing because subsequently several people commented that
they did not realise that Spitzer was only an acronym, not a real person,
and it was an eye-opener to understand the real meaning of the word. We
hasten to remind you that Robert Spitzer is a real person, who has added
a great deal to the science of rating scales, and is mentioned several times
in this booklet. One of Bob Spitzer’s famous saws is, ‘if it exists, it can be
measured’, and these seven words offer both a rationale and a strategy for
using such scales. In this booklet we have unashamedly gone for a measure
of esteem that many find intensely irritating, the citation rate, because we
feel that the more a scale is cited the more value it is to the researcher,
and particularly the systematic reviewer. Such a reviewer measuring
temperature can accommodate the Fahrenheit and Celsius scales, but would
be very put out if there were forty other scales also measuring temperature
in completely different ways. By giving the citation rates (as of 2006) of each
scale we are not necessarily saying the most cited one is the best, but, other
things being equal, if most investigators chose a scale that is very widely
used it would be much appreciated by the reviewer and ultimately by the
researcher too. Nevertheless, the many-faceted presentations of psychiatry
mean that often a standard scale is not appropriate for the subject matter
and so a much less frequently cited scale would be better in a particular
project. So the exposition of several scales is sometimes necessary in order
to achieve the best fit, and very occasionally it may be necessary to construct
your own scale for a specific piece of research: as we make very clear, this
should be done only as a last resort.
So it only remains for you to look at the menu, ask the waiter and, if
needed, the cook – don’t be afraid to write to the author of the scale – to find
out the exact nature of the fare, and then make your choice. Bon appétit.
1
Rating scales in psychiatry†
Peter Tyrer and Caroline Methuen

One of the most difficult tasks for aspiring research workers is choosing
a rating scale. In an ideal world this should not be a difficult decision.
Certain problems require special evaluation and, provided the problem has
been recognised before, a suitable rating scale will exist for the purpose. If
the rating scale is well established and is clearly the leader in the area, it
will choose itself and there should be clear instructions on what training
and expertise the researcher will need before the scale (or questionnaire)
is applied. However, in practice choosing a rating scale is seldom this
straightforward. This is mainly because there are too many rating scales
and it is extremely difficult for the novice, and often even the expert, to
choose the right scale easily. The rating scales described here are only a
selection from a much larger pool; the abundance of new scales has made
it impossible to cover the territory adequately. This booklet is therefore
a general guide which should enable the researcher to identify the most
appropriate scales for their area of interest, but a little more research will be
required before the final choice of a scale is made. Hence we have given the
main references for a large number of scales in the absence of space for an
adequate review of each, on the premise that the wider the pool the better
the eventual selection.

Choosing a rating scale

Figure 1 indicates the bumpy journey that the researcher will have to take
before feeling confident that the right instrument has been chosen for the
problem under investigation. The scales published in this booklet are by no
means exhaustive so do not feel that it is unjustified for you to use a scale
of your own choosing if you cannot find a measure for the subject under
review in the pages below.

†
This was first published as chapter 11 in Freeman, C. & Tyrer, P. (2006) Research Methods
in Psychiatry (3rd edn). Gaskell.

2
 rating scales

What is being measured?


No
Is a rating scale most Use another
appropriate?  measure

Yes and instrument Yes but no instrument available

available  
Is the scale to be used
more than once to measure Construct own
change? rating instrument

No
Yes
 
Is scale to be used
Is scale to be used Yes to record changes
Use screening
for screening  instrument
in attitudes,
purposes only? behaviour and
relationships?

No  No

Is the scale to be Use diagnostic Is the scale to be
 instrument used for rating
used for diagnosis?
symptoms?

No Is the characteristic being rated a No

subjective experience that is likely to 

be both understood easily and reported
accurately by the patient?

  
Subjective Experience has
experience but not major impact on
Yes, definitely
always reported others that may
accurately not be appreciated
by patient


Rating scale given 
Select by trained observer
or use interview Use informant
questionnaire rating scale or
schedule for added
precision interview schedule

Fig. 1 Flow chart for selection of rating instruments in psychiatric research.

3
Tyrer & methuen

What is being measured?

Rating scales may not always be necessary in a study. As the use of rating
scales involves administering an interview to an individual (patient or
informant), the procedure is liable to natural attrition in any study, ranging
from refusal to take part through to inability to follow-up. However, some
other measures (e.g. admission to hospital) can be obtained from other
sources and are more likely to yield complete data. There is also a strong
and unnecessary tendency for junior researchers to collect as much data
as possible without regard to its purpose. Investigators should elect at the
design stage to ask whether every single item of information is essential,
with the objective of eliminating at least half. The main advantage of simpler
methods using few variables is that larger numbers of patients can often be
accessed and so more robust findings are likely to emerge. It is therefore
reasonable for the researcher to ask the question ‘Can I get away without
using a rating scale in this project?’ It will save a tremendous amount of
time and trouble if rating scales and questionnaires are avoided.

What is being measured and why?

There are three main uses for rating scales in psychiatry. The first is as a
screening instrument which identifies a population with the condition of
interest but could include some people without the condition. A screening
instrument should have high sensitivity even though this may be achieved
at the expense of low specificity.
The second reason for using a rating scale is to identify a feature that is
felt to be important. Quite often this is a psychiatric diagnosis, but it could
be any characteristic. The point of using the rating scale is to more accurately
measure this characteristic and thereby improve the quality of the research,
and also to compare the findings with other studies. First, for example, if
one wanted to assess whether a specific personality disorder was associated
with childhood physical abuse, the researcher might consider it necessary to
assess such abuse (e.g. using the Child Trauma Questionnaire) rather than
simply asking the patient a yes/no question.
The third reason for using an instrument is to record change, either
spontaneously or following some type of intervention. This raises several
other important questions. Is the instrument easy to administer, does
repeated assessment lead to practice effects and is the administration of the
instrument prone to bias of any sort?
The answer to these questions should determine the nature of the
rating instrument selected and whether it is to be self-administered (i.e. a
questionnaire) or administered by another person such as a researcher.

Source of information
Reliability always tends to increase with more structured scales and with
trained interviewers. There is an understandable tendency to select such

4
 rating scales

instruments (especially when trained interviewers are available) in order

to improve the quality of the study, but, long before this, it needs to be
asked who is providing the information and why. Thus, for example, if an
intervention designed to reduce depression is being tested, it is appropriate
to use a structured interview schedule of established reliability (e.g. Schedule
for Affective Disorders and Schizophrenia; Endicott & Spitzer, 1978) for
assessment, but if the person concerned has relatively mild symptoms that
could be hidden from a stranger, it would be more appropriate to assess the
patient with a self-rating scale (e.g. Hamilton Rating Scale for Depression;
Hamilton, 1960).
Almost all psychiatric symptoms have both a subjective element and an
objective one that is shown to others. In some instances there may be a
gross disparity between the two (e.g. in the features of psychopathy), but
it is rare to have one feature only. For this reason many investigators use
both self-rating questionnaires and more ‘objective’ rating scales, although
in practice these often show good levels of agreement.
One of the main advantages of the questionnaire is that it reduces the
potential for bias because a patient is more likely to describe their own
feelings accurately than an investigator who is involved in a comparison
of treatments and has some knowledge of what these are. Often bias is
unwitting and one advantage of recording both self-rated and observer-rated
symptoms is that similar results with both types of instrument suggest a
minimum of bias.

Devising your own instrument

Although there is a natural tendency for researchers to develop their own
instruments on the premise that there is no scale available to measure a
particular feature, this position is increasingly untenable as instruments
become available for all aspects of psychiatric illness and treatments. There
is also considerable concern that new and untested scales yield much
larger effect sizes than well-established scales (i.e. overstate the difference
between treatments; Marshall et al, 2000).
Although there are still circumstances when a new rating scale might be
necessary for a specific project, it is important for researchers to be aware
that such a scale should be evaluated and the results of the evaluation
should be published before the scale is used in the planned study. This will
invariably involve much more work than using an established scale. Nobody
should believe that using a specially derived scale for a project is going to
be a short cut to success.
In deciding on a new rating scale the investigator will have to make a
distinction between a simple dichotomous scale, an interval scale and a
visual analogue scale (Fig. 2). There is often a wish to modify an existing
scale and although under some circumstances this is justifiable, it must not
be done without a great deal of thought, as comparisons with data using the
original scale would thereby be rendered invalid.

5
Tyrer & methuen

Categorical scale
0 1
No depressive Pathological
symptoms depression

Interval scale

No depressive Mild Moderate Severe Very severe

symptoms depression depression depression depression

Visual analogue scale

No depression Very severe

whatsoever depression
10 cm line

Fig. 2 Examples of types of rating scale: categorical scale, interval scale (implying
dimensions, e.g. Likert scale) and visual analogue scale (the participant is asked to
place a vertical mark across the line at the point that best describes current feelings;
this is measured to give a ‘depression score’).

Finding a rating scale

The rest of this booklet lists the main scales for each area of psychiatry. This
is a repetitive exercise but it is clear from talking to novice researchers that
the listing of these scales is important. We decided that the main criterion
for the inclusion a scale should be the extent of its use (as the wider the
use of a scale the better will be comparability with other studies). We have
therefore calculated the citation rate per year of each scale since the year
of publication and only those scales that are widely cited in the literature
(with a cut-off point of 4.0 per year for general scales and 2.0 per year for
specific ones) have been included. Although we are well aware that some
of the most commonly used scales are not quite as good as some others
and have only achieved their status by a combination of primacy, luck and
salesmanship, their frequency of use is still the best single criterion for the
research worker in making a choice. Where the details of scales are not
available in the published references the researcher is advised to search for
these on the internet. This is now much easier with improved search engines
such as Google, and any scale which is searched for using the author’s name
and title of the scale should be found easily. The most popular scales are
frequently copyrighted and distributed by commercial publishers. For those
that are less widely used but seem to be appropriate for a study it does no
harm to get in touch with the originator(s). They will be flattered (unless of
course the scale is so widely used it has led to many previous enquiries) and
may offer extra help in starting the project. This may even be worthwhile

6
 rating scales

Table 1 Rating scales and questionnaires for depression

Author(s) Type of assessment Citation rate per year and

comments
Hamilton (1960) Hamilton Rating Scale for 199.5 (the original and, to many,
Depression (HRSD) still the best)
Beck et al (1961) Beck Depression Inventory 186.2 (competing for the crown
(BDI) with enthusiasm – generally
preferred in more recent studies)
Zigmond & Snaith Hospital Anxiety and 133.0 (currently the most frequently
(1983) Depression Scale (HAD) used self-rating scale, equally good
for anxiety)
Montgomery & Åsberg Montgomery–Åsberg 83.2 (derived from the
(1979) Depression Rating Scale Comprehensive Psychopathological
(MADRS) Rating Scale (CPRS) and may be
of special value when multiple
pathology is being assessed; very
often used in short-term studies of
interventions, particularly drugs)
Zung (1965) Zung Self-Rating Depression 78.9 (the original self-rating scale;
Scale still widely used)
Brink et al (1982) Geriatric Depression Scale 71.9 (clear preference for this scale
(GDS) in studies of older adults)
Beck et al (1974b) Hopelessness Scale 38.9 (very frequently used in
studies of suicide)
Cox et al (1987) Edinburgh Postnatal 33.1 (the established scale
Depression Scale (EPDS) for assessing depression in
relationship to childbirth) Also see
Cox & Holden (2003)
Seligman et al (1979) Attributional Style 22.4
Questionnaire
Alexopoulus et al (1988) Cornell Scale for Depression 22 (an example of a special area in
in Dementia which a general scale may not be
accurate)
Carney et al (1965) ECT Scale (Newcastle) 21.4 (was once very widely
used but less so recently, as the
distinction between depressive
syndromes is less often required)
Kandel & Davies (1982) Six-Item Depression Mood 15.4
Inventory
Brown & Harris (1978) Life Events and Difficulties 11.2 (the definitive life events
Scale (LEDS) assessment scale – needs prior
training – listed here as the work
was primarily concerned with
depression)
Zuckerman (1960) Multiple Affect Adjective 8.5. (checklists used to be very
Checklist (MAACL) common methods of assessing
mood states but are now less often
used)
continued

7
Tyrer & methuen

Table 1 continued
Author(s) Type of assessment Citation rate per year and
comments

Robinson et al (1993) Pathological Laughter and 8.2

Crying Scale

Raskin et al (1969) Raskin Three-Area 7.9

Depression Rating Scale
McNair & Lorr (1964) Profile of Mood States 7.63 (a very widely used simple
(POMS) scale, but not used so much in
recent years)
Snaith et al (1971) Wakefield Self-Assessment 6.97 (now replaced mainly by
Depression Inventory Hospital Anxiety and Depression
Scale)
Steiner et al (1980) Premenstrual Tension 6.8
Syndrome Scale (PMTS)
Snaith et al (1976) Leeds Scales for the Self- 6.71 (as for Wakefield Scale)
Assessment of Anxiety and
Depression
Lubin (1965) Depression Adjective Check- 6.3
List (DACL)
Sunderland et al (1988) Dementia Mood Assessment 5.6
Scale
Costello & Comfrey Costello’s Scales for 5
(1967) Measuring Depression and
Anxiety
Berrios et al (1992) Guilt Scale 3.9

Table 2 Rating scales for mania

Author(s) Type of assessment Citation rate per year and

comments

Young et al (1978) Young Mania Rating Scale 21.5 (a short scale now well
established in research studies
of all kinds and the clear leader)
Bech et al (1986) Bech–Rafaelsen Rating Scale 3.6 (particularly useful when
for Mania severe depression (melancholia)
also being measured, as
Bech–Rafaelsen Rating Scale for
Melancholia can also be used)
Altman et al (1994) Clinician-Administered 3.5 (good psychometric
Rating Scale for Mania properties but not widely used)
(CARS–M)

8
 rating scales

with the more established scales, and can sometimes lead to a great deal of
extra help in both using and analysing results.

Depression and mania

Depression (next to anxiety) is probably the most common psychiatric
symptom and so there are many scales for its measurement. However, only
five (Table 1) are used frequently in current research studies and the choice
is not as difficult as might have been expected. In contrast, mania is less
common and there are considerably fewer scales, of which the Young Mania
Rating Scale is the most often chosen (Table 2). For studies in which both
mania and depression are investigated the Bech–Rafaelsen scales for both
mania and melancholia (Bech et al, 1986) may be most appropriate. As
depression can occur in so many different clinical contexts there is scope
for many other instruments for its measurement. The Edinburgh Postnatal
Depression Scale (Cox et al, 1987) (Table 1) is probably the best example
of a more specialised scale, but all of the specialised scales closely correlate
with the general scales and have overlapping questions.

Cognitive function and impairment

(including assessments specific to old age)
Although mood disturbance may be the most common psychiatric symptom,
cognitive function, in its many forms, is probably most frequently assessed.
It is now accepted that something more than clinical questioning is needed
to assess cognitive functioning and this is demonstrated by the success of the
Mini Mental State Examination (MMSE; Table 3) and its modified form (3MS;
Teng & Chui, 1987) as part of clinical assessment (Aquilina & Warner, 2004).
The ordinary assessment of mental state is being supplemented by a more
formal measure that can be scored and helps to quantify any impairment. As
the average age of the population increases, so will the use of these scales.

Eating disorders
The symptomatology and related clinical features of eating disorders show
important differences from other syndromes in psychiatry and require
assessment with appropriate specialised scales. Although self-rating scales
are commonly used, there is a problem with their validity at some stages
of illness, particularly in severe anorexia when patients often deny obvious
symptomatology (Halmi, 1985). The two most frequently used scales are the
Eating Attitudes Test (Garner & Garfinkel, 1979) and the Eating Attitudes
Inventory (Garner et al, 1983), but bulimia is often assessed using different
scales (Halmi et al, 1981; Henderson & Freeman, 1987) (Table 4). However,
no one scale achieves clear primacy in this area.

9
Tyrer & methuen

Table 3 Scales for assessment of cognitive function and old age

symptomatology
Author(s) Name of scale Citations per year
and comments

Folstein et al (1975) Mini Mental State Examination 528.9 (The ultimate

(MMSE) success of a rating
scale is to be
incorporated into
standard clinical
practice. The MMSE
has now achieved this
status – at least for
the time being.)

Hughes et al (1982) Clinical Dementia Rating (CDR) 68.1

Hachinski et al (1975) Ischemia Score 66.1
Blessed et al (1968) Blessed Dementia Rating Scale 62.7
(BDRS) Information – Memory
– Concentration Test (IMCT)
Gottfries et al (1982a,b) Gottfries–Brane–Steen Dementia 61
Rating Scale (GBS)
Reisberg et al (1982) Global Deterioration Scale (GDS) 55.7
Katz et al (1963) Index of Activities of Daily Living 52.7 (included here
as this assessment
is so often linked to
cognitive assessment
but could also be
included under social
function)
Cummings et al (1994) Neuropsychiatric Inventory (NPI) 50.4
Mohs et al (1983) Alzheimer’s Disease Assessment 42.5
Scale (ADAS)
Lawton & Brody (1969); Instrumental Activities of Daily 41.3 (as for Katz et al
Lawton (1988a,b) Living (IADL) Scale 1963)
Pfeiffer (1975) Short Portable Mental Status 41.2
Questionnaire (SPMSQ)
Plutchik et al (1970) Geriatric Rating Scale (GRS) 34
Teng & Chui (1987) Modified Mini-Mental State 26.7
(3MS) Examination
Neugarten et al (1961) Life Satisfaction Index (LSI) 19.5
Roth et al (1988) Cambridge Mental Disorders of the 17.7 (increasingly
Elderly Examination (CAMDEX) being used in non-US
studies)
Katzman et al (1983) Orientation–Memory–Concentration 17
Test (OMCT)
Broadbent et al (1982) Cognitive Failures Questionnaire 16.8
(CFQ)
Lawton et al (1982) Multilevel Assessment Instrument 16.5
(MAI)
continued

10
 rating scales

Table 3 continued
Author(s) Name of scale Citations per year
and comments
Copeland et al (1976) Geriatric Mental State Schedule 15.8
(GMS)
Copeland et al (1986) Geriatric Mental State Schedule 15.7
and Diagnostic Schedule (AGECAT)

Teri et al (1992) Revised memory and behaviour 14.8

checklist
Hodkinson (1972) Mental Test Score 14.3

Lawton (1975) Philadelphia Geriatric Center Morale 13.9

Scale

Wells (1979) Checklist Differentiating Pseudo- 13.7

Dementia from Dementia

Gelinas & Gauthier Disability Assessment for Dementia 12.6

(1999) (DAD)

Inouye et al (1990) Confusion assessment method 11.9

(CAM)

Greene et al (1982) Relative’s Stress Scale 10.1

Greene et al (1982) Behaviour and Mood Disturbance 10

Scale

Knopman et al (1994) Clinicians Interview-Based Impression 10

(CIBI)

Soloman et al (1998) Seven minute neurocognitive 9.8

screening battery

Pattie & Gilleard (1979) Clifton Assessment Procedures for 9.6

the Elderly (CAPE)

Reisberg (1988) Functional Assessment Staging 9.6

(FAST)

Trzepacz et al (1988) Delirium Rating Scale (DRS) 9.3

Jorm & Jacomb (1989) Informant Questionnaire on Cognitive 9.3
Decline in the Elderly (IQCODE)

Shader et al (1974) Sandoz Clinical Assessment–Geriatric 8.2

(SCAG) Scale
Cohen-Mansfield et al Cohen-Mansfield Agitation 8.1
(1989) Inventory (CMAI)
Kopelman et al (1990) Autobiographical Memory Interview 7.4
(AMI)
continued

11
Tyrer & methuen

Table 3 continued
Author(s) Name of scale Citations per year
and comments

Gurland et al (1976, 1977) Comprehensive Assessment and 6.7

Referral Evaluation (CARE)
Logsdon & Gibbons (1999) Quality of Life in Alzheimer’s Disease 6.6
(QoL–AD)
Hall et al (1993) Bilingual Dementia Screening 5.6
Interview
Reisberg & Ferris (1988) Brief Cognitive Rating Scale (BCRS) 4.7
Spiegel et al (1991) Nurses’ Observation Scale for 4.6
Geriatric Patients (NOSGER)
Hope & Fairburn (1992) Present Behavioural Examination 4.6
(PBE)
Patel & Hope (1992) Rating Scale for Aggressive 4.5
Behaviour in the Elderly – The RAGE
Wilkinson & Graham-White Edinburgh Psychogeriatric 4.5
(1980) Dependency Rating Scale (PGDRS)
Jorm et al (1995) Psychogeriatric Assessment 4.2
Scales (PAS)
Allen et al (1996) Manchester and Oxford Universities 4 (close to getting an
Scale for the Psychopathological award for the most
Assessment of Dementia inventive acronym for
(MOUSEPAD) a scale)
Qureshi & Hodkinson (1974) Abbreviated Mental Test (AMT) 4
Helmes et al (1987) Multidimensional Observation Scale 3.6
for Elderly Subjects (MOSES)
Adshead et al (1992) Brief Assessment Schedule 3.4 (simple
Depression Cards (BASDEC) assessment using
cards in similar
situations to those
for Cornell Scale
for Depression in
Dementia)
Sclan & Saillon (1996) BEHAVE–AD 3.1
Kendrick et al (1979) Kendrick Battery for the Detection 2.8
of Dementia in the Elderly
Meer & Baker (1966) Stockton Geriatric Rating Scale 2.7
(SGRS)
Kuriansky & Gurland Performance Test of Activities of 2.6
(1976) Daily Living (PADL)
Bucks et al (1996) Bristol Activities of Daily Living 2.6
Scale
Schwartz (1983) Geriatric Evaluation by Relative’s 2.5
Rating Instrument (GERRI)
Hersch (1979) Extended Scale for Dementia 2.3
(ESD)

12
 rating scales

Table 4 Instruments for the measurement of symptoms and attitudes in eating

disorders
Author(s) Name of scale Citations per year and
comments

Garner et al (1983) Body Dissatisfaction 56.7 (The EDI is the most

Subscale of the Eating commonly used measure with a
Disorder Inventory (EDI) range of sub-scales – better for
anorexia than bulimia)
Stunkard & Messick Eating Inventory 42.1
(1985)
Garner & Garfinkel Eating Attitudes Test 40.8
(1979) (EAT)
Halmi et al (1981) Binge Eating 22
Questionnaire
Cooper et al (1987) Body Shape 16.5
Questionnaire
Van Strien et al (1986) Dutch Eating Behaviour 16.1
Questionnaire (DEBQ)
Cooper & Fairburn Eating Disorders 15.9 (semi-structured interview
(1987) Examination (EDE) covering both bulimia and
anorexia)
Morgan & Russell (1975) Morgan–Russell 15.9 (often used in long-term
Assessment Schedule outcome studies)
(MRAS)
Gormally et al (1982) Binge Eating Scale 12.7
Henderson & Freeman Bulimic Investigatory Test, 12.2 (short (33-item)
(1987) Edinburgh (BITE) questionnaire suitable for
surveys)
Hawkins & Clement Binge Scale 11.8
(1980)
Smith & Thelen (1984) Bulimia Test (BULIT) 8.6
Slade & Russell (1973) Anorexic Behaviour 7.0
Scale (ABS)
Johnson (1985) Diagnostic Survey for 5.5
Eating Disorders (DSED)
Slade et al (1990) Body Satisfaction Scale 3.1
(BSS)
Fichter et al (1989) Structured Interview for 3
anorexia and Bulimia
Nervosa (SIAB)
Ben-Tovim & Walker Ben-Tovim Walker Body 2.9
(1991) Attitudes Questionnaire
(BAQ)
Slade & Dewey Setting Conditions for 2.3
(1986) Anorexia Nervosa
(SCANS)

13
Tyrer & methuen

General functioning and symptomatology

Psychiatry as a discipline used to be criticised because it did not use
the language of science and measurement and so could be interpreted
in so many different ways. The discipline responded (some might say
overreacted) to this criticism by introducing a much more rigid and
reliable set of diagnoses, the Diagnostic and Statistical Manual for Mental
Disorders (3rd edn) (DSM–III) (American Psychiatric Association, 1980).
By introducing operational criteria for the definition of each diagnosis
a much greater level of reliability was achieved, but it is well known
that improvements in reliability are often achieved at the expense of
validity. This was a central issue of the life work of Robert Kendell
(1925–2002), who pointed out that the only valid diagnosis was the one
that demonstrated a ‘point of rarity’ between it and other diagnoses, in
the same way that many organic diagnoses do in medicine. In fact, almost
every psychiatric diagnosis is best perceived as a continuum or dimension
rather than a separate and discrete category. This is not a criticism of the
diagnostic process, since the identification of a psychiatric diagnosis may
still be extremely useful in clinical practice; what must not be assumed
is that clinical utility is the same as clinical validity (Kendell & Jablensky,
2003). This basic understanding of psychiatric diagnoses as a continuum
is one of the reasons why scales measuring general functioning and
symptomatology are becoming more popular; they are recording the
dimensions.
Researchers will also wish to measure global psychopathology when
the population being studied is a heterogeneous one in which all aspects
of symptomatology need to be detected. Epidemiological studies of whole
populations and cohort studies that examine change and new pathology
over time are the most common examples. Many of the scales are linked
to diagnoses, particularly DSM ones, and this probably explains why the
SCID group (Structured Clinical Interviews for DSM Diagnoses) are so
popular (Table 5). However, research workers should note that DSM–V is
going to be very different from its predecessors and it is wise not to be too
attached to measurement scales that are related to a changing system.

Satisfaction and needs

There is now a realisation of the importance of the consumer in mental
health services, and although the word ‘user’ is not entirely satisfactory,
the balance of influence is gradually shifting towards those who receive
treatment from those who do the treating. We therefore have a range of
relatively new instruments to measure need and satisfaction with services
that are now becoming de rigeur in many research arenas. The best known
of these is probably the Camberwell Assessment of Need (CAN; Phelan

14
 rating scales

Table 5 Scales for general functioning and symptomatology

Author(s) Name of scale Citations per year and comments

Spitzer et al (1990a,b, d) Structured Clinical 165.6 (simple and straightforward

Interview for DSM–III–R scales that lack some subtlety but are
(SCID) widely used because of their DSM
links)
Spitzer et al (1990c) Structured Clinical 162.7
Interview for DSM–III–R
personality disorders
(SCID–II)
Robins et al (1981) Diagnostic Interview 135.1
Schedule (DIS)
Wing et al (1974) Present State 112.4 (now being replaced by SCAN,
Examination and which incorporates much of the old
Catego Program (PSE) PSE)
Endicott et al (1976) Global Assessment 76.3 (a scale that is now an axis
Scale (GAS), later of pathology – Axis 5 in the DSM
to become Global classification) (may be separated into
Assessment of symptomatology and functioning
Functioning (GAF) components)
Goldberg (1972) General Health 59.0 (the doyen of quick screening for
Questionnaire (GHQ) common mental disorders)
Scheier & Carver (1985) Life Orientation Test 53.6
(LOT)
Derogatis et al (1973) Symptom Check-List 50.8 (very popular quick assessment
(SCL-90) of psychopathology but coming to the
end of its useful life)
Derogatis et al (1974) Hopkins Symptom 45.2 (linked to SCL-90)
Checklist (HSCL)
Robins et al (1988) The Composite 44.0 (rapidly becoming the
International benchmark for national
Diagnostic Interview epidemiological studies (except in the
(CIDI) UK, where CIS–R is still used)
Åsberg et al (1978) Comprehensive 33 (has the advantage of being linked
Psychopathological to sub-scales for depression, anxiety,
Rating Scale (CPRS) and obsessional and schizophrenic
pathology)
Wing et al (1990) SCAN – Schedules for 30.9 (the successor to the PSE,
Clinical Assessment in shortly to come out in a revised form
Neuropsychiatry (SCAN–II))
McGuffin et al (1991) Operational criteria for 28.5 (useful when information needs
psychotic illnesses to be obtained from notes and other
records – may be converted to several
diagnostic systems)
Millon (1981) Millon Clinical 27 (a very popular personality
Multiaxial Inventory assessment even though it does not
(MCMI) match with DSM or ICD)
continued

15
Tyrer & methuen

Table 5 continued
Author(s) Name of scale Citations per year and comments

Goldberg et al (1970) Clinical Interview 20.4 (see also CIS–R)

Schedule (CIS)
Aitken (1969) Visual Analogue 20.1 (these are often useful when
Scales making self-ratings or in contructing
one’s own scales)

Dupuy (1984) Psychological General 19

Well-Being (PGWB)
Index
Lewis et al (1992) Clinical Interview 17.8 (a scale specially developed
Schedule – Revised for epidemiological studies with
(CIS–R) lay interviewers – has now mainly
replaced the CIS)
Raskin & Crook (1988) Relative’s Assessment 7
of Global
Symptomatology (RAGS)

Spitzer et al (1970) Psychiatric Status 6.7

Schedule (PSS)

Brodman et al (1949) Cornell Medical Index 6.6

Spanier (1987) Dyadic Adjustment 5.4
Scale
Luborsky (1962) Health Sickness Rating 5.3 (the forerunner of the GAF)
Scale (HSRS)
Burnam et al (1983) Spanish Diagnostic 5.1
Interview Schedule
Helzer & Robins Renard Diagnostic 4.8
(1981) Interview
Endicott & Spitzer (1972) Current and Past 4.7
Psychopathology Scales
(CAPPS)

Marmar et al (1986) California Psychotherapy 3.8

Alliances Scales
(CALPAS–T/P)

Power et al (1988) Significant Others Scale 3.8

(SOS)

Parloff et al (1954) Symptom Check-List 3.6

(SCL)
Lorr et al (1962) Lorr’s Multidimensional 2.3
Scale for Rating
Psychiatric Patients
Spitzer et al (1967) Mental Status Schedule 2.3
(MSS)

16
 rating scales

Table 6 Scales for the assessment of need and satisfaction

Author(s) Name of scale Citations per year and comments

Phelan et al (1995) Camberwell Assessment 16.1 (now the most widely used
of Need (CAN); CANE scale in the area; the sub-scales
(Elderly), CANDID have yet to be widely used)
(Intellectual Disability),
CANFOR (Forensic
Psychiatry), CANSAS (Short
Appraisal Schedule)

Beecher (1959) Measurement of 15.1 (useful in assessing the

Subjective Responses placebo effect)
(MSR)
Larsen et al (1979) Consumer Satisfaction 14.5 (is rapidly becoming the
Questionnaire (CSQ) most commonly used scale for
measuring general satisfaction)
Amador et al (1993) Scale to Assess 13.1
Unawareness of Mental
Disorder
Harding et al (1980) Self Report Questionnaire 11.7
(SRQ)
Bech (1993) Psychological General 11.4
Well-Being Schedule
(PGWBS)
Bunney & Hamburg (1963) Bunney–Hamburg Mood 10.8
Check-list
Brewin et al (1987) MRC Needs for Care 7.9 (the predecessor to CAN and
Assessment probably its catalyst)

Ruggeri & Dall’Agnola Verona Service 6.2 (specifically developed for

(1993) Satisfaction Scale measuring satisfaction with
(VSSS) mental health services)

Birchwood et al (1994) Insight Scale 6.1 (the measurement of insight is

(for Psychosis) becoming increasingly important
in research studies)

Markova & Berrios (1992) Insight Scale 3.8

Shipley et al (2000) Patient Satisfaction 2.3
Questionnaire

Tantam (1988) The Express Scale and 2.3

Personality Questionnaire

17
Tyrer & methuen

et al, 1995) and its many successors (CANSAS, CANFOR, CANDID, etc.),
the latest being CAN–M for mothers. However, there are many others
that attempt to assess patients’ experiences and feelings towards their
condition and treatment in a variety of settings (Table 6).

Self-harm
Self-harm has come to replace the earlier term ‘parasuicide’ and the
misleading one ‘attempted suicide’ as a description of the behaviour of
those who do not usually carry out their acts of harm with the intention
of killing themselves, but who might do so by accident and are at much
greater risk of successful suicide in the future (Jenkins et al, 2002; Zahl
& Hawton, 2004). The chances of repeat attempts and successful suicide
are greater when suicidal intent is greater (Zahl & Hawton, 2004) and so
measures of this and other elements of risk are useful) (Table 7). There
is evidence that such scales are successful in predicting self-harm (Tyrer
et al, 2003).

Sexual behaviour
Although sexual behaviour has rarely been measured systematically
in many psychiatric studies when it is clearly relevant (e.g. in patients
with schizophrenia on antipsychotic drugs), such measurement is now

Table 7 Scales for the assessment of self-harm

Author(s) Name of scale Citations per
year

Beck et al (1974a) Beck Hopelessness Scale 43.71

Beck et al (1979) Scale for Suicide Ideation (SSI) 12.7
Beck et al (1974b) Suicidal Intent Scale (SIS) 12
Motto et al (1985) Risk Estimator for Suicide 4.2
Pallis et al (1982) Post-Attempt Risk Assessment 2.6
Scale
Plutchik et al (1989) Suicide Risk Scale (SRS) 2.5
Buglass & Horton (1974) Risk of Repetition Scale 2.3
Tuckman & Youngman (1968) Scale for Assessing Suicide Risk 2.3
of Attempted Suicides
Kreitman & Foster (1991) Parasuicide Risk Scale 2.3
1. By far the most quoted and used scale, although hopelessness not strictly a self-harm
measure.

18
 rating scales

becoming both more accepted and acceptable in research studies. For

this reason a greater number of scales is given in Table 8 than is strictly
necessary as their citation rate has been fairly low.

Substance use, dependence and withdrawal

The assessment of substance misuse is prone to error, mainly because
the reliability of the information is often so uncertain. Hence there is an
increasing tendency to use modern techniques such as hair analysis to
obtain independent evidence of drug use. Table 9 includes some scales
that are becoming established assessments for research studies; AUDIT,
MAST, CAGE and SDS are the most frequently used. Most scales in Table
9 are concerned with dependence.
Increasingly it is becoming necessary to record symptoms of withdrawal
following the cessation of illicit or prescribed drugs. Because each group of
substances has different withdrawal effects (in addition to many common
ones) it is probably preferable to select a scale to suit the substance (Table
10) rather than use a general scale.

Personality assessment and persistent behaviours

Personality assessment is one of the more difficult subjects to tackle in
research. Like IQ, we like to think of personality as stable, but empirical
studies have shown it is much less stable than we would like to think.
However, when assessing personality we are not just assessing present

Table 8 Scales for the assessment of sexual function and behaviour

Author(s) Name of scale Citations

per year

Lopiccolo & Steger (1974) Sexual Interaction Inventory 50

Wilhelm & Parker (1988) Intimate Bond Measure (IBM) 4
Hoon et al (1976) Sexual Arousal Inventory (SAI) 3.9
Nichols & Molinder (1984) Multiphasic Sex Inventory (MSI) 2.8
Eysenck (1971) Eysenck Inventory of Attitudes 1.9
to Sex
Golombok & Rust (1985) Golombok–Rust Inventory of 1.6
Sexual Satisfaction (GRISS)
Derogatis (1978) Derogatis Sexual Functioning 1.3
Inventory (DSFI)
Frenken & Vennix (1981) Sexual Experience Scales (SES) 1.2

19
Tyrer & methuen

Table 9 Scales for the assessment of substance use and dependence

Author(s) Name of scale Citations per year and
comments

Saunders et al (1993) Alcohol Use Disorders Identification 45.3 (used for the
Test (AUDIT) identification of
hazardous and harmful
alcohol consumption)
Selzer (1971) Michigan Alcoholism Screening 42.1
Test (MAST)
Mayfield et al (1974) CAGE Questionnaire 27.6
Gossop et al (1995) The Severity of Dependence Scale 13.8 (used in heroin,
(SDS) amphetamine and
cocaine dependence)
McLennan et al (1980) Addiction Severity Index 5
Skinner & Allen (1983) Alcohol Dependence Scale (ADS) 2.8
Chick (1980) Edinburgh Alcohol Dependence 2.3
Scale
Halikas et al (1991) Minnesota Cocaine Craving Scale 2.2
Smith et al (1996) Paddington Alcohol Test (PAT) 2.1 (used to detect
hazardous drinking in
patients presenting as
emergencies)
Horn et al (1974) Alcohol Use Inventory 2.1
Litman et al (1983) Coping Behaviour Inventory (CBI) 2
Litman et al (1984) Effectiveness of Coping Behaviour 1.9
Inventory (ECBI)
Washton et al (1988) Cocaine Abuse Assessment Profile 1.1
(CAAP)
Skinner & Goldberg (1986) Drug Abuse Screening Test (DAST) 1.1

Table 10 Scales for the assessment of substance use withdrawal problems

Author(s) Name of scale Citations

per year

Chaney et al (1978) Situational Competency Test (SCT) 8.7

Gross et al (1973) TSA and SSA 5.9
Raistrick et al (1983) Short Alcohol Dependence Data (SADD) 4.4
Tyrer et al (1990) Benzodiazepine Withdrawal Symptom Questionnaire 4.2
Handelsman et al (1987) Objective Opiate Withdrawal Scale (OOWS) 3.5
Handelsman et al (1987) Subjective Opiate Withdrawal Scale 3.5
Annis (1986) Situational Confidence 2.7
Questionnaire
Sutherland et al (1986) Severity of Opiate Dependence Questionnaire 2.4
(SODQ)/Opiate Subjective Dependence
Questionnaire (OSDQ)

20
 rating scales

personality function but characteristic function over a long period.

This cannot be done easily but there are many attempts to shorten the
assessment process in order to fit in with the multiple assessments being
performed over a short time period. Most assessments are carried out
using the DSM recommendations for personality disorders, even though
these are now recognised to be grossly unsatisfactory and redundant in
research terms (Livesley, 2001). Persistent behavioural problems such as
aggression are also included in Table 11. There is also a very important
group of instruments that measure risk of violence and these are becoming
more commonly used in research studies as their predictive quality
improves. The Psychopathy Checklist–Revised (PCL–R; Hare, 1991) is the
best known but there are also many others (Dolan & Doyle, 2000).

Anxiety and associated disorders

Anxiety is ubiquitous, easy to measure but difficult to interpret. There
has been much argument over the differences between state and trait
anxiety and their significance, the meaning of the association of anxiety
and depression (the two are intimate) and the importance of anxiety to
the course and development of phobic, obsessional, hypochondriacal, pain,
post-traumatic and fatigue disorders. These subjects are therefore included
in Tables 12 and 13.

Sleep
Despite being somewhat relegated to the sidelines of psychiatry in recent
years, sleep problems remain very prominent symptoms of mental illness.
It is always possible to assess sleep problems from individual items in
scales for depression and anxiety but for general sleep satisfaction and
performance it is preferable to use one of the scales in Table 14.

Schizophrenia and related psychotic disorders

Although there continues to be debate over the issues of insight, adherence
to therapy and the relationship between schizotypy and schizophrenia,
the core assessment of schizophrenic pathology involves assessment with
relatively few instruments, of which the Schedule for Affective Disorders
and Schizophrenia (SADS) and Scales for the Assessment of Positive and
Negative Symptoms (SAPS and SANS) are the most popular, and are
gradually replacing the Brief Psychiatric Rating Scale (BPRS; Overall &
Gorham, 1962) from the lead position it has held for most of the past 40
years (Table 15). The major change has been in the recognition of positive
and negative symptoms and the need to record them separately. The
different therapeutic profile of drugs such as clozapine has helped in this

21
Tyrer & methuen

Table 11 Scales for assessing personality and persistent behavioural problems

Authors Name of scale Citations per year

and comments

Spitzer et al (1990c) Structured Clinical Interview for 162.7

DSM–III–R Personality Disorders
(SCID–II)
Buss & Durkee (1957) Buss–Durkee Hostility and Guild 23.6
Inventory
Spielberger et al (1985) State–Trait Anger Expression 23.2
Inventory (STAXI)
Pfohl et al (1983) Structured Interview for DSM–III 17.9
Personality Disorders (SID–P)
Yudofsky (1986) Overt Aggression Scale (OAS) 17.3 (may also be
used in modified
form as the
Modified Overt
Aggression Scale
(MOAS) (Sorgi et al,
1991))
Hathaway & McKinley (1967) Minnesota Multiphasic 16.6
Personality Inventory (MMPI)
Gunderson et al (1981) Diagnostic Interview for 15.6
Borderline Patients
Loranger et al (1985) Personality Disorder 14
Examination (PDE)
Tyrer & Alexander (1979) Personality Assessment 13.8
Schedule (PAS)
Rosenbaum (1980) Self Control Schedule 13.2
Barron (1953) Barron Ego Strength 10.9
Hare (1980) Psychopathy Checklist 10.2 (the best
(PCL) predictor of
aggressive
behaviour in
psychiatric patients
(Monahan et al,
2001); was revised
in 1990 (PCL–R)
and again in 2004;
special training
is required which
is unlikely to be
possible within the
budget of simple
research projects)
Hyler & Reider (1987) Personality Diagnostic 9.8
Questionnaire – Revised
(PDQ–R)
Morey et al (1985) Modified Minnesota Multiphasic 9.1
Personality Inventory (MMPI)
continued

22
 rating scales

Table 11 continued
Authors Name of scale Citations per year
and comments
Schwartz & Gottman (1976) Assertiveness Self-Statement 6.3
Test (ASST)
Glass et al (1982) Social Interaction Self-Statement 6.2
Test (SISST)
Palmstierna & Wistedt (1987) Staff Observation and 5.8
Aggression Scale (SOAS)
Baron et al (1981) Schedule for Interviewing 5.2
Schizotypal Personalities (SSP)
Conte et al (1980) Borderline Syndrome Index 5
(BSI)
Robson (1989) Robson’s Self-Esteem Scale 4.3
Bell (1981) Bell Object Relations Self-Report 3.8
Scale
Mann et al (1981) Standardized Assessment of 3.7
Personality (SAP)
Hyler et al (1982) Personality Diagnostic 3.5
Questionnaire (PDQ)
Galissi et al (1981) Checklist of Positive and 3.2
Negative Thoughts
Lorr & Youniss (1983) Interpersonal Style Inventory 2.1
(ISI)

Table 12 Scales for hypochondriasis, health anxiety, pain and fatigue

Author(s) Name of scale Citations per year

Fukuda et al (1994) Chronic Fatigue Syndrome – case- 87.4 (important

defining symptoms for examining
chronic fatigue
and formalising
description of cases)
Melzack (1987) McGill Pain Questionnaire (MPQ) 29.6
Chalder et al (1993) Fatigue Scale 22.6
Pilowsky & Spence Illness Behaviour Questionnaire (IBQ) 7.4
(1975)
Kellner (1987) Symptom questionnaire 7.2 (now mainly of
historical interest)
Barsky et al (1990) Somatosensory Amplification 7.1 (may be useful to
Scale (SSAS) detect health anxiety)
Salkovskis et al (2002) Health Anxiety Inventory (HAI) 2.3 (specifically
used for health
anxiety, which is not
quite the same as
the old concept of
hypochondriasis)

23
Tyrer & methuen

Table 13 Scales for assessment of anxiety and related symptoms

Authors Name of scale Citations per year and comments

Zigmond & Snaith Hospital Anxiety and 133.0 (the anxiety version (HADS–A)
(1983) Depression Scale can also be combined with the
(HADS) depression component (HADS–D)
to score mixed anxiety–depressive
symptoms (cothymia) (Tyrer, 2001))
Spielberger et al Spielberger State–Trait 121.4 (commonly used in repeated
(1983) Anxiety Inventory (STAI) measures studies – in which both
present state and trait anxiety are
measured separately)
Goodman et al Yale–Brown Obsessive 81.1 (the standard scale for
(1989a,b) Compulsive Scale measurement of obsessive–
(Y–BOCS) compulsive symptoms – clearly now
pre-eminent)
Beck et al (1988) Beck Anxiety Inventory 49.8 (beginning to usurp the
(BAI) Hamilton scale)
Hamilton (1959) Hamilton Anxiety Scale 45.6 (an observer-rated scale that
(HAS) remains standard but has been
criticised for its emphasis on somatic
symptoms that may reflect physical
illness)
Taylor (1953) Taylor Manifest Anxiety 44.4 (really a measure of trait
Scale (TMAS) anxiety)
Marks & Mathews Brief Standard Self-Rating 36.2 (the most common self-rating
(1979) Scale for Phobic Patients for common phobic symptoms)
Keane et al (1988) Mississippi Scale for 35.8
Combat-Related Post-
traumatic Stress Disorder
Watson & Friend Fear of Negative Evaluation 28.3
(1969) Scale (FNE)
Watson & Friend Social Avoidance and 28.3
(1969) Distress Scale (SAD)
Chambless et al Body Sensations 20
(1984) Questionnaire and the
Agoraphobic Cognitions
Questionnaire
Chambless et al Mobility Inventory for 18.8
(1985) Agoraphobia
Wolpe & Lang (1964) Fear Survey Schedule 14.9
(FSS)
Zung (1971) Zung’s Anxiety Status 13.6
Inventory (ASI)
Alderman et al (1983) Crown-Crisp Experiential 13.1
Index (CCEI)
Hodgson & Rachman Maudsley Obsessional- 13.1
(1977) Compulsive Inventory
continued

24
 rating scales

Table 13 continued

Authors Name of scale Citations per year and comments

Beck et al (1987) Cognitions Checklist– 10.8 (relevant in monitoring

Anxiety (CCL–A) cognitive–behavioural therapy)
Davidson et al (1997) Davidson Trauma Scale 10.6
(DTS)
Cooper (1970) Leyton Obsessional 9.6
Inventory
Sanavio (1988) Padua Inventory 8.3

Steinberg et al (1990) Structured Clinical 7

Interview for DSM–III–R
Dissociative Disorders
(SCID–D)
Crown & Crisp (1966) Middlesex Hospital 6.9
Questionnaire (MHQ)

Endler et al (1962) Stimulus Response 6.6

Inventory
Foa et al (1998) Obsessive–Compulsive 6.0 (42-item inventory that has
Inventory (OCI) recently been introduced in
shortened form (Foa et al, 2002)
which may be superseding the
original)

Snaith et al (1982) Clinical Anxiety Scale 5.5 (an attempt to compensate for
the over-somatic representation of
the Hamilton scale)
Gelder & Marks (1966) Gelder–Marks Phobia 5.1
Questionnaire
Bandelow (1995) Panic and Agoraphobia 5.1
Scale
Davidson & Miner Brief Social Phobia Scale 5.0
(1997)
Tyrer et al (1984) Brief Anxiety Scale 4.2 (linked to Comprehensive
Psychopathological Rating Scale
(CPRS))
Snaith et al (1978) Irritability–Depression– 3.7 (probably the only measure of
Anxiety Scale (IDA) irritability available)

25
Tyrer & methuen

Table 14 Scales for the assessment of sleep disorders

Author(s) Name of scale Citations

per year

Carskadon (1986) Multiple Sleep Latency Test (MSLT) 30.1

Guilleminault (1982) Sleep Questionnaire and Assessment 7.5
of Wakefulness (SQAW)
Ellis et al (1981) St Mary’s Hospital Sleep Questionnaire 3.6
Parrott & Hindmarch (1978) Sleep Evaluation Questionnaire (SEQ) 3.1
Hoddes et al (1972a,b) Stanford Sleepiness Scale (SSS) 3.1

differentiation, as has the focus of psychological treatments on negative

symptoms (Sensky et al, 2000). Standard scales for the measurement
of adverse effects are also included here. The clear preference for the
measurement of akathisia is the Barnes scale (1989) and for tardive
dyskinesia the Tardive Dyskinesia Rating Scale (TDRS; Simpson, 1988),
but there are several competitors for primacy when other abnormal
movements are being measured.

Childhood disorders
There are an astonishingly large number of scales in child and adolescent
psychiatry; this is as much an expression of wonderment as one of crit­
icism. It is a pity that for so many areas there are no clear preferences or
obvious front-runners. For specific areas the scales may select themselves.
The Parental Bonding Instrument (PBI; Parker et al, 1979) is one such
example; it has almost become a sine qua non of the assessment of early
relational attachment. For other subjects it has become common for
scales developed in adult practice to be adapted for children. Well-known
examples include the Kiddie–SADS (K–SADS; Puig-Antich & Chambers,
1978) and the Leyton Obsessional Inventory – Child Version (Berg et al,
1986; Table 16). There has been considerable recent interest in attention-
deficit hyperactivity disorder in children and in the autistic spectrum
of disorders, and some recently introduced instruments are likely to be
widely used (e.g. Holmes et al, 2004; Hansson et al, 2005).
When choosing instruments in child psychiatry it is important to
ensure that the age range over which the instrument has been validated
is the same as the population for which the researcher requires the
instrument.

26
 rating scales

Table 15 Scales for the assessment of schizophrenia and related psychotic

disorders (including adverse effects)
Author(s) Name of scale Citations per year and
comments

Endicott & Spitzer (1978) Schedule for Affective 146.8

Disorders and Schizophrenia
(SADS)
Overall & Gorham (1962) Brief Psychiatric Rating Scale 123.3 (the oldest scale
(BPRS) but still has many
merits and is likely to
be relevant however
diagnostic practice
changes)
Bernstein & Putnam (1986) Dissociative Experiences 44.4
Scale (DES)
Andreasen (1982a,b) Scale for the Assessment of 42.7 (steadily increasing
Negative Symptoms (SANS) in use as the importance
of negative symptoms
in treatment outcome
grows)
Barnes (1989) Barnes Akathisia Rating Scale 34.1 (the standard scale
(BARS) for recording akathisia)
Andreasen (1984) Scale for the Assessment of 22.5
Positive Symptoms (SAPS)
Andreasen et al (1992) Comprehensive Assessment of 20.7
Symptoms and History CASH)
Simpson (1988) Tardive Dyskinesia Rating 12.9
Scale (TDRS)
Andreasen (1979) Thought, Language and 11.2
Communication Rating
Scale (TLC)
Claridge & Broks (1984) Schizotypy Questionnaire 10.6
(STQ)
Birchwood et al (1990) Social Functioning Schedule 5.5 (included here as it
(SFS) was specially prepared
for the measurement
of social function in
schizophrenic patients)
Kendler et al (1983) Dimensions of Delusional 3.7
Experience Scale

27
Tyrer & methuen

Table 16 Scales for the assessment of childhood disorders

Author(s) Name of scale Citations per year

Conners (1969) Conners Rating Scales 33.1

Herjanic & Campbell Diagnostic Interview for Children & 33.1
(1977) Adolescents (DICA)
Parker et al (1979) Parental Boding Instrument (PBI) 33
Puig-Antich & Chambers Kiddie–SADS (K–SADS) 27.2
(1978)
Kovacs (1985) Children’s Depression Inventory (CDI) 26.3
Reynolds & Richmond Revised Children’s Manifest Anxiety 26.3
(1978) Scale
Wechsler (1949) Wechsler Intelligence Scale for 23.3
Children
Achenbach (1978); Child Behaviour Check-List (CBCL) 21.7
Achenbach & Edelbrock
(1979)
Puig-Antich et al (1980) Kiddie–SADS–E (K–SADS–E) 19.9
Ward et al (1993) Wender Utah Rating Scale (WURS) 18.7
Achenbach & McConaughy Empirically-Based Assessment of Child 14
(1987a,b) and Adolescent Psychopathology
Hodges et al (1982) Child Assessment Schedule (CAS) 12.4
Harris (1963) Goodenough–Harris Figure Drawing 12.3
Test
Castaneda et al (1956) Children’s Manifest Anxiety Scale 10.1
(CMAS)
Birleson (1981) Depression Self-Rating Scale (DSRS) 9.4
Costello et al (1984) Diagnostic Interview Schedule for 7.7
Children (DISC)
Richman & Graham Behavioural Screening Questionnaire 7.2
(1971) (BSQ)
Berg et al (1986) Leyton Obsessional Inventory – Child 6.2
Version
Poznanski et al (1979) Children’s Depression Rating Scale 6
(CDRS)
Carey (1970) Carey Infant Temperament Scale 5.7
Ambrosini et al (1989) Kiddie–SADS–III–R (K–SADS–III–R) 5.1
Lefkowitz & Tesing Peer Nomination Inventory for 5
(1980) Depression
Elliott et al (1983) British Ability Scales – Revised 4.9
(BAS–R)
Ullman et al (1984) ADD–H Comprehensive Teacher Rating 4.3
Scales (ACTeRS)
Reynolds et al (1985) Child Depression Scale (CDS) 4
continued

28
 rating scales

Table 16 continued
Author(s) Name of scale Citations per year
Wing & Gould (1978) Handicap, Behaviour and Skills (HBS) 3.9
Rutter (1967) Rutter B(2) Scale 3.7
Quay & Peterson (1975) Behavior Problem Checklist (BPC) 3.3
Zatz & Chassin (1983) Children’s Cognitive Assessment 2.9
Questionnaire (CCAQ)
Matson et al (1991) Diagnostic Assessment for the Severely 2.1
Handicapped (DASH)

Social and behavioural measurement

The recording of social function is becoming a much more prominent part
of measurement generally as it is now realised that functioning is probably
more important than symptoms in determining the extent of pathology
(Tyrer & Casey, 1993). Whether patients are admitted to hospital, either
voluntarily or compulsorily, is determined much more by their general roles
in society and their general functioning than by any independent measure of
‘illness’ per se. This is now recognised in multi-axial classification systems, in
which social function and disability are given an axis for their domain, and in
the growth of scales for recording social function in every medical condition.
The scale that is cited more than any other is SF–36, the shortened form
of an original medical outcomes scale which is so constructed as to record
function in any disorder (Ware & Sherbourne, 1992). It is therefore used
in many conditions, which explains its wide usage. It basically comprises
one multi-item scale assessing eight health concepts: limitations in physical
activities because of health problems; limitations in social activities because
of physical or emotional problems; limitations in usual role activities
because of physical health problems; bodily pain; general mental health
(psychological distress and well-being); limitations in usual activities
because of emotional problems; vitality (energy and fatigue); and general
health perceptions. Sleep may also be included here. SF–36 is not always
ideal for many psychiatric studies but is now such a benchmark measure that
it should always be considered if general functioning is being measured.
Table 17 gives a comprehensive list of scales that encompass the range of
subjects covered by social function and behaviour. Some of these are highly
specific, if not idiosyncratic, but because of the frequent need for a specific
instrument all are included.

29
Tyrer & methuen

Table 17 Scales for the assessment of social functioning

Author(s) Name of scale Citations per

year
Ware & Sherbourne (1992) Short Form 36 (SF–36) of Medical 365.5
Outcomes Scale (MOS)
Holmes & Rahe (1967) Social Readjustment Rating Scale 107.5
Kanner et al (1981) Hassles Scale 49.9
Kanner et al (1981) Uplifts Scale 49.9
Crowne & Marlowe (1960) Marlowe–Crowne Social Desirability 47.8
Scale (M–CSDS)
Sarason et al (1983) Social Support Questionnaire (SSQ) 35.1
Russell et al (1978) University of California, Los Angeles 30.5
Loneliness Scale
Horowitz et al (1988) Inventory of Personal Problems 25.8
Weissman & Bothwell (1976) Social Adjustment Scale Self-Report 25.2
(SAS–SR)
Jarman (1983) Jarman Index 20.1
Paykel et al (1971) Interview for Recent Life Events 12.5
Vaughan & Leff (1976) Camberwell Family Interview (CFI) 11.6
Katz & Lyerly (1963) Katz Adjustment Scale–Relatives Form 10.6
(KAS–R)
Honigfeld & Klett (1965) Nurses’ Observation Scale for 9.5
Inpatient Evaluation (NOSIE)
Aman et al (1985) Aberrant Behavior Checklist 8.6
Derogatis (1976) Psychosocial Adjustment to Illness 8.4
Scale (PAIS)
Morosini & Magliano (2000) Social and Functioning Assessment 7.9
Scale (SOFAS)
Henderson et al (1980) Interview Schedule for Social 7.9
Interaction (ISSI)
Wykes & Sturt (1986) Social Behaviour Schedule (SBS) 7.8
Gurland et al (1972) Structured and Scaled Interview to 6.1
Assess Maladjustment (SSIAM)
Kellner & Sheffield (1973) Symptom Rating Test (SRT) 6.1
Doll (1965) Vineland Social Maturity Scale 5.7
Tennant & Andrews (1976) Life Events Inventory 5.6
Clare & Cains (1978) Social Maladjustment Schedule (SMS) 4.9
Holmes et al (1982) Disability Assessment Schedule (DAS) 4.5
Platt et al (1980) Social Behaviour Assessment 4.3
Schedule (SBAS)
Connor et al (2000) Social Phobia Inventory (SPIN) 4
Margolin et al (1983) Areas of Change Questionnaire (ACQ) 3.8
McFarlane et al (1981) Social Relationship Scale (SRS) 3.5
continued

30
 rating scales

Table 17 continued
Author(s) Name of scale Citations per
year
Jenkins et al (1981) Social Stress and Support Interview 2.9
(SSSI)
Tyrer (1990); Tyrer et al (2005) Social Functioning Questionnaire 2.8
(SFQ)
Paykel et al (1971) Social Adjustment Scale (SAS) 2.8
Levenstein et al (1993) Perceived Stress Questionnaire (PSQ) 2.8
Hurry & Sturt (1981) MRC Social Role Performance 2
Schedule (SRP)
Olson et al (1978) Family Adaptability and Cohesion 1.9
Evaluation Scale (FACES)
Affleck & McGuire (1984) Morningside Rehabilitation Status 1.9
Scales (MRSS)
Baker & Hall (1983) Rehabilitation Evaluation Hall and 1.8
Baker (REHAB)
Linn et al (1969) Social Dysfunction Rating Scale 1.7
(SDRS)
Strauss & Harder (1981) Case Record Rating Scale (CRRS) 1.7
Remington & Tyrer (1979) Social Functioning Schedule (SFS) 1.7
Schooler et al (1979) Social Adjustment Scale 11 (SAS 11) 1.6
Crandall et al (1992) Undergraduate Stress Questionnaire 1.6
(USQ)
Moos (1974) Ward Atmosphere Scale (WAS) 1.6
Ditommaso & Spinner (1993) Social and Emotional Loneliness Scale 1.4
for Adults (SELSA)
Brugha et al (1987) Interview Measure of Social 1.4
Relationships (IMSR)
Cohen & Sokolowsky (1979) Network Analysis 1.3

Neuropsychological assessment
This is another rapidly expanding area and in most instances there will be a
clear indication that will help in the choice of instrument. The measurement
of intelligence was one of the first ratings in psychology and it has a worthy
tradition in the WAIS, for which special training is required. However,
many of the other scales can be used by research trainees but it is wise to
seek advice for most of these first as they are not ‘off the shelf’ instruments
(Table 18).

31
Tyrer & methuen

Table 18 Scales for neuropsychological assessment and intellectual disability

Authors Name of scale Citations per year and

comments

Wechsler (1958) Wechsler Adult Intelligence 299.9 (the established

Scale (WAIS) successor to the early IQ
tests; the latest version of
this is WAIS–III; Fjordbak
& Fjordback, 2005)
Teasdale & Jennett (1974) Glasgow Coma Scale 98.7
Benton et al (1983) Digit Sequence Learning 50.8
Nelson (1982) National Adult Reading Test 46 (a good measure of
(NART) verbal intelligence that is
quick to measure)
Wechsler (1945) Wechsler Memory Scale 38.8
(WMS)
Goodglass & Kaplan (1972) Boston Diagnostic Aphasia 35.5
Examination (BDAE)
Nelson (1976) Modified Card Sorting Test 33.1
(MCST)
Reitan & Davison (1974) Finger Tapping Test (FTT) 30.8
Benton & Hamsher (1976) Multilingual Aphasia 18.7
Examination
Buschke (1973) Selective Reminding Test 17.0
Raven (1960) Raven Progressive Matrices 13.5 (an IQ equivalent
(RPM) that can be administered
without special training
– e.g. by a junior
psychiatrist)
Kertesz (1979) Western Aphasia Battery 12.2
Levin et al (1979) Galveston Orientation and 9.4
Amnesia Test (GOAT)
Annett (1967) Handedness Inventory 8.1 (an established test
for lateralisation)
Graham & Kendall (1960) Graham–Kendall Memory 7.7
for Designs Test
Berg (1948) Wisconsin Card Sorting Test 7.4
(WCST)
Banks (1970) Signal Detection Memory 7.2
Test (SDMT)
Warrington & James (1967) Visual Retention Test (metric 5.1
figures)
continued

32
 rating scales

Table 18 continued
Authors Name of scale Citations per year and
comments
Moss et al (1998) Psychiatric Assessment 5.0 (rapidly becoming
Schedule for Adults with a a standard screening
Developmental Disability test for assessment of
(PAS–ADD) Checklist symptoms in learning
disability – is couched
in simple language so
those without specialised
knowledge can readily
use the scales)
Thurstone (1944) Hidden Figures Test 4.2
Armitage (1946) Trail Making Test (TMT) 3.5
Ferris et al (1980) Facial Recognition and Name 3.3
–Face Association Test
Smith (1968) Symbol Digit Modalities Test 3.3
(SDMT)
Dixon (1988) Metamemory in Adulthood 3.2
(MIA)
Lingjaerde et al (1987) UKU (Udvalg for Kliniske 3.2 (mainly used for
Undersolgelser) Side Effect detecting adverse effects
Rating Scale with antipsychotic drugs)
Holland (1980) Communication Abilities in 3.1
Daily Living

Acknowledgements
We thank Elena Garralda for advice and Sheila McKenzie for secretarial
help.

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34
Exploring the Variety of Random
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noble allies that struggled on with us, without one token of
resistance.
Fulano suffered least. He turned his brave eye back, and
beckoned me with his ear to listen, while he seemed to say: “See,
this is my Endurance! I hold my Power ready still to show.”
And he curved his proud neck, shook his mane like a banner, and
galloped the grandest of all.
We came to a broad strip of sand, the dry bed of a mountain-
torrent. The trail followed up this disappointing path. Heavy
ploughing for the tired horses! How would they bear the rough work
down the ravine yet to come?
Suddenly our leader pulled up and sprang from the saddle.
“Look!” he cried, “how those fellows spent their time, and saved
ours. Thank Heaven for this! We shall save her, surely, now.”
It was water! No need to go back to Pindar to know that it was
“the Best.”
They had dug a pit deep in the thirsty sand, and found a lurking
river buried there. Nature never questioned what manner of men
they were that sought. Murderers flying from vengeance and
planning now another villain outrage,—still impartial Nature did not
change her laws for them. Sunshine, air, water, life,—these boons of
hers,—she gave them freely. That higher boon of death, if they were
to receive, it must be from some other power, greater than the
undiscriminating force of Nature.
Good luck and good omen, this well of water in the sand! It
proved that our chase had suffered as we, and had been delayed as
we. Before they had dared to pause and waste priceless moments
here, their horses must have been drooping terribly. The pit was
nearly five feet deep. A good hour’s work, and no less, had dug it
with such tools as they could bring. I almost laughed to think of the
two, slowly bailing out the sliding sand with a tin plate, perhaps, and
a frying-pan, while a score of miles away upon the desert we three
were riding hard upon their tracks to follow them the fleeter for this
refreshment they had left. “Sic vos non vobis!” I was ready to say
triumphantly; but then I remembered the third figure in their group,
—a woman, like a Sibyl, growing calmer as her peril grew, and
succor seemed to withdraw. And the pang of this picture crushed
back into my heart any thoughts but a mad anxiety and a frenzy to
be driving on.
We drank thankfully of this well by the wayside. No gentle beauty
hereabouts to enchant us to delay. No grand old tree, the shelter
and the landmark of the fountain, proclaiming an oasis near. Nothing
but bare, hot sand. But the water was pure, cool, and bright. It had
come underground from the Sierra, and still remembered its parent
snows. We drank and were grateful, almost to the point of pity. Had
we been but avengers, like Armstrong, my friend and I could
wellnigh have felt mercy here, and turned back pardoning. But
rescue was more imperative than vengeance. Our business tortured
us, as with the fanged scourge of Tisiphone, while we dallied. We
grudged these moments of refreshment. Before night fell down the
west, and night was soon to be climbing up the east, we must
overtake,—and then?
I wiped the dust and spume away from Fulano’s nostrils and
breathed him a moment. Then I let him drain deep, delicious
draughts from the stirrup-cup. He whinnied thanks and undying
fealty,—my noble comrade! He drank like a reveller. When I mounted
again, he gave a jubilant curvet and bound. My weight was a feather
to him. All those leagues of our hard, hot gallop were nothing.
The brown Sierra here was close at hand. Its glittering, icy
summits, above the dark and sheeny walls, far above the black
phalanxes of clambering pines, stooped forward and hung over us as
we rode. We were now at the foot of the range, where it dipped
suddenly down upon the plain. The gap, our goal all day, opened
before us, grand and terrible. Some giant force had clutched the
mountains, and riven them narrowly apart. The wild defile gaped,
and then wound away and closed, lost between its mighty walls, a
thousand feet high, and bearing two brother pyramids of purple cliffs
aloft far above the snow line. A fearful portal into a scene of the
throes and agonies of earth! and my excited eyes seemed to read,
gilded over its entrance, in the dead gold of that hazy October
sunshine, words from Dante’s inscription,—
“Per me si va tra la perduta gente;
Lasciate ogni speranza voi, ch’ entrate!”
“Here we are,” said Brent, speaking hardly above his breath. “This
is Luggernel Alley at last, thank God! In an hour, if the horses hold
out, we shall be at the Springs; that is, if we can go through this
breakneck gorge at the same pace. My horse began to flinch a little
before the water. Perhaps that will set him up. How are yours?”
“Fulano asserts that he has not begun to show himself yet. I may
have to carry you en croupe, before we are done.”
Armstrong said nothing, but pointed impatiently down the defile.
The gaunt white horse moved on quicker at this gesture. He seemed
a tireless machine, not flesh and blood,—a being like his master,
living and acting by the force of a purpose alone.
Our chief led the way into the cañon.
 CHAPTER XX.

A HORSE.
Yes, John Brent, you were right when you called Luggernel Alley a
wonder of our continent.
I remember it now,—I only saw it then;—for those strong scenes
of nature assault the soul whether it will or no, fight in against
affirmative or negative resistance, and bide their time to be admitted
as dominant over the imagination. It seemed to me then that I was
not noticing how grand the precipices, how stupendous the
cleavages, how rich and gleaming the rock faces in Luggernel Alley.
My business was not to stare about, but to look sharp and ride hard;
and I did it.
Yet now I can remember, distinct as if I beheld it, every stride of
that pass; and everywhere, as I recall foot after foot of that fierce
chasm, I see three men with set faces,—one deathly pale and
wearing a bloody turban,—all galloping steadily on, on an errand to
save and to slay.
Terrible riding it was! A pavement of slippery, sheeny rock; great
beds of loose stones; barricades of mighty boulders, where a cliff
had fallen an æon ago, before the days of the road-maker race;
crevices where an unwary foot might catch; wide rifts where a shaky
horse might fall, or a timid horseman drag him down. Terrible riding!
A pass where a calm traveller would go quietly picking his steps,
thankful if each hour counted him a safe mile.
Terrible riding! Madness to go as we went! Horse and man, any
moment either might shatter every limb. But man and horse neither
can know what he can do, until he has dared and done. On we
went, with the old frenzy growing tenser. Heart almost broken with
eagerness.
No whipping or spurring. Our horses were a part of ourselves.
While we could go, they would go. Since the water, they were full of
leap again. Down in the shady Alley, too, evening had come before
its time. Noon’s packing of hot air had been dislodged by a mountain
breeze drawing through. Horses and men were braced and cheered
to their work; and in such riding as that, the man and the horse
must think together and move together,—eye and hand of the rider
must choose and command, as bravely as the horse executes. The
blue sky was overhead, the red sun upon the castellated walls a
thousand feet above us, the purpling chasm opened before. It was
late, these were the last moments. But we should save the lady yet.
“Yes,” our hearts shouted to us, “we shall save her yet.”
An arroyo, the channel of a dry torrent, followed the pass. It had
made its way as water does, not straightway, but by that potent
feminine method of passing under the frowning front of an obstacle,
and leaving the dull rock staring there, while the wild creature it
would have held is gliding away down the valley. This zigzag channel
baffled us; we must leap it without check wherever it crossed our
path. Every second now was worth a century. Here was the sign of
horses, passed but now. We could not choose ground. We must take
our leaps on that cruel rock wherever they offered.
Poor Pumps!
He had carried his master so nobly! There were so few miles to
do! He had chased so well; he merited to be in at the death.
Brent lifted him at a leap across the arroyo.
Poor Pumps!
His hind feet slipped on the time-smoothed rock. He fell short. He
plunged down a dozen feet among the rough boulders of the
torrent-bed. Brent was out of the saddle almost before he struck,
raising him.
No, he would never rise again. Both his fore-legs were broken at
the knee. He rested there, kneeling on the rocks where he fell.
Brent groaned. The horse screamed horribly, horribly,—there is no
more agonized sound,—and the scream went echoing high up the
cliffs where the red sunlight rested.
It costs a loving master much to butcher his brave and trusty
horse, the half of his knightly self; but it costs him more to hear him
shriek in such misery. Brent drew his pistol to put poor Pumps out of
pain.
Armstrong sprang down and caught his hand.
“Stop!” he said in his hoarse whisper.
He had hardly spoken, since we started. My nerves were so
strained, that this mere ghost of a sound rang through me like a
death yell, a grisly cry of merciless and exultant vengeance. I
seemed to hear its echoes, rising up and swelling in a flood of thick
uproar, until they burst over the summit of the pass and were
wasted in the crannies of the towering mountain-flanks above.
“Stop!” whispered Armstrong. “No shooting! They’ll hear. The
knife!”
He held out his knife to my friend.
Brent hesitated one heart-beat. Could he stain his hand with his
faithful servant’s blood?
Pumps screamed again.
Armstrong snatched the knife and drew it across the throat of the
crippled horse.
Poor Pumps! He sank and died without a moan. Noble martyr in
the old, heroic cause.
 I caught the knife from Armstrong. I cut the thong of my girth.
The heavy California saddle, with its macheers and roll of blankets,
fell to the ground. I cut off my spurs. They had never yet touched
Fulano’s flanks. He stood beside me quiet, but trembling to be off.
“Now Brent! up behind me!” I whispered,—for the awe of death
was upon us.
I mounted. Brent sprang up behind. I ride light for a tall man.
Brent is the slightest body of an athlete I ever saw.
Fulano stood steady till we were firm in our seats.
Then he tore down the defile.
Here was that vast reserve of power; here the tireless spirit; here
the hoof striking true as a thunderbolt, where the brave eye saw
footing; here that writhing agony of speed; here the great promise
fulfilled, the great heart thrilling to mine, the grand body living to
the beating heart. Noble Fulano!
I rode with a snaffle. I left it hanging loose. I did not check or
guide him. He saw all. He knew all. All was his doing.
We sat firm, clinging as we could, as we must. Fulano dashed
along the resounding pass.
Armstrong pressed after,—the gaunt white horse struggled to
emulate his leader. Presently we lost them behind the curves of the
Alley. No other horse that ever lived could have held with the black
in that headlong gallop to save.
Over the slippery rocks, over the sheeny pavement, plunging
through the loose stones, staggering over the barricades, leaping the
arroyo, down, up, on, always on,—on went the horse, we clinging as
we might.
It seemed one beat of time, it seemed an eternity, when between
the ring of the hoofs I heard Brent whisper in my ear.
“We are there.”
 The crags flung apart, right and left. I saw a sylvan glade. I saw
the gleam of gushing water.
Fulano dashed on, uncontrollable!
There they were,—the Murderers.
Arrived but one moment!
The lady still bound to that pack-mule branded A. & A.
Murker just beginning to unsaddle.
Larrap not dismounted, in chase of the other animals as they
strayed to graze.
The men heard the tramp and saw us, as we sprang into the
glade.
Both my hands were at the bridle.
Brent, grasping my waist with one arm, was awkward with his
pistol.
Murker saw us first. He snatched his six-shooter and fired.
Brent shook with a spasm. His pistol arm dropped.
Before the murderer could cock again, Fulano was upon him!
He was ridden down. He was beaten, trampled down upon the
grass,—crushed, abolished.
We disentangled ourselves from the mêlée.
Where was the other?
The coward, without firing a shot, was spurring Armstrong’s
Flathead horse blindly up the cañon, whence we had issued.
We turned to Murker.
Fulano was up again, and stood there shuddering. But the man?
A hoof had battered in the top of his skull; blood was gushing
from his mouth; his ribs were broken; all his body was a trodden,
massacred carcass.
He breathed once, as we lifted him.
Then a tranquil, childlike look stole over his face,—that well-
known look of the weary body, thankful that the turbulent soul has
gone. Murker was dead.
Fulano, and not we, had been executioner. His was the stain of
blood.
 CHAPTER XXI.

LUGGERNEL SPRINGS.
“I am shot,” gasped Brent, and sank down fainting.
Which first? the lady, or my friend, slain perhaps for her sake?
“Her! see to her!” he moaned.
I unbound her from the saddle. I could not utter a word for pity.
She essayed to speak; but her lips only moved. She could not
change her look. So many hours hardening herself to repel, she
could not soften yet, even to accept my offices with a smile of
gratitude. She was cruelly cramped by her lashings to the rough
pack-saddle, rudely cushioned with blankets. But the horror had not
maddened her; the torture had not broken her; the dread of worse
had not slain her. She was still unblenching and indomitable. And still
she seemed to rule her fate with quiet, steady eyes,—gray eyes with
violet lights.
I carried her a few steps to the side of a jubilant fountain lifting
beneath a rock, and left her there to Nature, kindliest leech.
Then I took a cup of that brilliant water to my friend, my brother.
“I can die now,” he said feebly.
“There is no death in you. You have won the right to live. Keep a
brave heart. Drink!”
And in that exquisite spot, that fair glade of the sparkling
fountains, I gave the noble fellow long draughts of sweet
refreshment. The rescued lady trailed herself across the grass and
knelt beside us. My horse, still heaving with his honorable gallop,
drooped his head over the group. A picture to be remembered!
Who says that knighthood is no more? Who says the days of
chivalry are past? Who says it, is a losel.
Brent was roughly, but not dangerously, shot along the arm. The
bullet had ploughed an ugly path along the muscles of the fore-arm
and upper-arm, and was lodged in the shoulder. A bad wound; but
no bones broken. If he could but have rest and peace and surgery!
But if not, after the fever of our day, after the wearing anguish of
our doubtful gallop; if not?—
Ellen Clitheroe revived in a moment, when she saw another
needed her care. Woman’s gentle duty of nurse found her ready for
its offices. My blundering good-will gave place willingly to her fine-
fingered skilfulness. She forgot her own weariness, while she was
magnetizing away the pangs of the wounded man by her delicate
touch.
He looked at me, and smiled with total content.
“My father?” asked the lady, faintly, as if she dreaded the answer.
“Safe!” said I. “Free from the Mormons. He is waiting for you with
a friend.”
Her tears began to flow. She was busy bandaging the wound. All
was silent about us, except the pleasant gurgle of the fountains,
when we heard a shot up the defile.
The sharp sound of a pistol-shot came leaping down the narrow
chasm, flying before the pursuit of its own thundering echoes. Those
grand old walls of the Alley, facing each other there for the shade
and sunshine of long, peaceful æons, gilded by the glow of
countless summers, splashed with the gray of antique lichens on
their purple fronts, draped for unnumbered Octobers with the scarlet
wreaths of frost-ripened trailers,—those solemn walls standing there
in old silence, unbroken save by the uproar of winter floods, or by
the humming flight of summer winds, or the louder march of
tempests crowding on,—those silent walls, written close with the
record of God’s handiwork in the long cycles of creation, lifted up
their indignant voices when the shot within proclaimed to them the
undying warfare of man with man, and, roaring after, they hurled
that murderous noise forth from their presence. The quick report
sprang out from the chasm into the quiet glade, where the lady
knelt, busy with offices of mercy, and there it lost its vengeful tone,
and was blended with the rumble of the mingled rivulets of the
springs. The thundering echoes paused within, slowly proclaiming
quiet up from crag to crag, until one after another they whispered
themselves to silence. No sound remained, save the rumble of the
stream, as it flowed away down the opening valley into the haze,
violet under gold, of that warm October sunset.
I sprang up when I heard the shot, and stood on the alert. There
were two up the Alley; which, after the shot, was living, and which
dead?
Not many moments had passed, when I heard hoofs coming, and
Armstrong rode into view. The gaunt white horse galloped with the
long, careless fling I had noticed all day. He moved machine-like, as
if without choice or volition of his own, a horse commissioned to
carry a Fate. Larrap’s stolen horse trotted along by his old master.
Armstrong glanced at Murker’s body lying there, a battered mass.
“Both!” he whispered. “The other was sent right into my hands to
be put to death. I knew all the time it would be sent to me to do
killing. He was spurring up the Alley on my own horse. He snapped
at me. My pistol did not know how to snap. See here!”
And he showed me, hanging from his saddle horn, that loathliest
of all objects a man’s eyes ever lighted upon, a fresh scalp. It
sickened me.
“Shame!” said I. “Do you call yourself a man, to bring such a
thing into a lady’s presence?”
“It was rather mean to take the fellow’s hair,” says Armstrong. “I
don’t believe brother Bill would have did it. But I felt orful ugly, when
I saw that fat, low-lived devil, and thought of my brother, a big, hul-
hearted man as never gave a bad word to nobody, and never held
on to a dollar or a slug when ayry man wanted it more ’n him.
Come, I’ll throw the nasty thing away, if you say so.”
“Help me drag off this corpse, and we’ll bury man and scalp
together,” I said.
We buried him at the gate of the Alley, under a great cairn of
stones.
“God forgive them both,” said I, as I flung the last stone, “that
they were brutes, and not men.”
“Brutes they was, stranger,” says Armstrong, “but these things is
ordered somehow. I allow your pardener and you is glad to get that
gal out of a Mormon camp, ef it did cost him a horse and both on
you an all day’s tremble. Men don’t ride so hard, and look so wolfish,
as you two men have did, onless their heart is into it.”
“It is, indeed, strange,” said I, rather thinking aloud than
addressing my companion, “that this brute force should have
achieved for us by outrage what love failed in. Fate seems to have
played Brute against Brute, that Love might step between and claim
the victory. The lady is safe; but the lover may have won her life and
lost his own.”
“Look here, stranger,” says Armstrong, “part of this is yourn,”
pointing to the money-belt, which, with the dead man’s knife and
pistol, he had taken from the corpse. “Halves of this and the other
fellow’s plunder belongs to your party.”
I suppose I looked disgusted; yet I have seen gentle ladies
wearing boastfully brooches that their favorite heroes had taken
from Christian men dead on the field at Inkermann, and shawls of
the loot of Delhi cover many shoulders that would shudder over a
dead worm.
“I’m not squimmidge,” said Armstrong. “It’s my own and my
brother’s money in them belts. I’ll count that out, and then, ef you
wont take your part, I’ll pass it over to the gal’s father. I allowed
from signs ther was, that that thar boss Mormon had about tuk the
old man’s pile. Most likely these shiners they won last night is some
of the very sufferins Sizzum got from him. It’s right he should hev
’em back.”
I acknowledged the justice of this restitution.
“Now,” said Armstrong again, “you want to stay by your friend
and the gal, so I’ll take one of the pack mules and fetch your two
saddles along before dark lights down. It was too bad to lose that
iron gray; but there’s more ’n two horses into the hide of that black
of yourn. He was the best man of the lot for the goin’, the savin’, and
the killin’. Stranger, I’ve ben byin’ and sellin’ and breedin’ kettrypids
ever since I was raised myself; but I allow I never seed a horse till I
seed him lunge off with you two on his back.”
Armstrong rode up the Alley again. Another man he was since his
commission of vengeance had been accomplished. In those lawless
wilds, vendetta takes the place of justice, becomes justice indeed.
Armstrong, now that his stern duty was done, was again the kindly,
simple fellow nature made him, the type of a class between pioneer
and settler, and a strong, brave, effective class it is. It was the
education, in youth, in the sturdy habits of this class, that made our
Washington the manly chief he was.
I returned to my friends by the Springs.
Emerging from the austere grandeur of the Alley, dim with the
shadows of twilight, the scene without was doubly sweet and almost
domestic. The springs, four or five in number, and one carrying with
it a thread of hot steam, sprang vigorously out along the bold edges
of the cliffs. All the ground was verdure,—green, tender, and
brilliant, a feast to the eyes after long staring over sere deserts. The
wild creatures that came there every day for refreshment, and
perhaps for intoxication in the aerated tipple of the Champagne
Spring, kept the grass grazed short as the turf of a park. Two great
spruce-trees, each with one foot under the rocks, and one edging
fountainward, stood, pillar under pyramid. Some wreaths of drooping
creepers, floating from the crags, had caught and clung, and so
gone winding among the dark foliage of the twin trees; and now
their leaves, ripened by autumn, shook amid the dusky green like an
alighting of orioles. Except for the spruces posted against the cliffs,
the grassy area of an acre about the springs was clear of other
growth than grass. Below, the rivulet disappeared in a green thicket,
and farther down were large cottonwoods, and one tall stranger
tree, the feminine presence of a drooping elm, as much unlooked-for
here as the sweet, delicate woman whom strange chances had
brought to dignify and grace the spot. This stranger elm filled my
heart with infinite tender memories of home, and of those early
boyish days when Brent and I lay under the Berkeley College elms,
or strayed beneath the elm-built arches up and down the avenues of
that fair city clustered round the College. In those bright days,
before sorrow came to him, or to me my harsh necessity, we two in
brotherhood had trained each other to high thoughts of courtesy and
love,—a dreamed-of love for large heroic souls of women, when our
time of full-completed worthiness should come. And his time had
come. And yet it might be that the wounded knight would never
know his lady, as much loving as beloved; it might be that he would
never find a sweeter soothing in her touch, than the mere touch of
gratitude and common charity; it might be that he would fever away
his beautiful life with the fever of his wound, and never feel the holy
quiet of a lover’s joy when the full bliss of love returned is his.
I gave a few moments to the horses and mules. They were still to
be unsaddled. Healthy Fulano had found his own way to water, and
now was feasting on the crisp, short grass along the outlet of the
Champagne Spring, tickling his nose with the bubbles of gas as they
sped by. Sup, Fulano! This spot was worth the gallop to see Sup,
Fulano, the brave, and may no stain of this day’s righteous death-
doing rest upon your guiltless life!
Brent was lying under the spruces, drowsing with fatigue,
reaction, and loss of blood. Miss Clitheroe sat by watching him.
These fine beings have an exquisitely tenacious vitality. The
happiness of release had suddenly kindled all her life again. As she
rose to meet me, there was light in her eyes and color in her cheeks.
Her whole soul leaped up and spoke its large gratitude in a smile.
“My dear friend,” she said; and then, with sudden tearfulness,
“God be thanked for your heroism!”
“God be thanked!” I repeated. “We have been strangely selected
and sent,—you from England, my friend and I, and my horse, the
hero of the day, from the Pacific,—to interfere here in each other’s
lives.”
“It would seem romance, but for the sharp terror of this day,
coming after the long agony of my journey with my poor, errant
father.”
“A sharp terror, indeed!”
“But only terror!” and a glow of maidenly thankfulness passed
over her face. “Except one moment of rough usage, when I slipped
away my gag and screamed as they carried me off, those men were
considerate to me. They never halted except to dig a well in the
sand of a riverbed. I learned from their talk that they had made an
attempt to steal your horses in the night, and, failing, dreaded lest
you, and especially Mr. Brent, would follow them close. So they rode
hard. They supposed that, when I was found missing, whoever went
in pursuit, and you they always feared, would lose time along the
emigrant road, searching eastward.”
“We might have done so; but we had ourselves ridden off that
way in despair of aiding you,”—and I gave her a sketch of the events
of the morning.
“It was the hope of succor from you that sustained me. After
what your friend said to me last evening, I knew he could not
abandon me, if he had power to act.” And she looked very tenderly
at the sleeper,—a look to repay him for a thousand wounds.
“Did you find my glove?” she asked.
 “He has it. That token assured us. Ah! you should have seen that
dear wounded boy, our leader, when he knew we were not astray.”
I continued my story of our pursuit,—the lulling beat of the
stream undertoning my words in the still twilight. When I came to
that last wild burst of Fulano, and told how his heroic charge had
fulfilled his faithful ardor of the day, she sprang up, thrilled out of all
weariness, and ran to the noble fellow, where he was taking his
dainty banquet by the brookside.
She flung her arms around his neck and rested her head upon his
shoulder. Locks of her black hair, escaping into curls, mingled with
his mane.
Presently Miss Clitheroe seemed to feel a maidenly consciousness
that her caresses of the horse might remind the horse’s master that
he was not unworthy of a like reward. She returned to my friend. He
was stirring a little in pain. She busied herself about him tenderly,
and yet with a certain distance of manner, building a wall of delicate
decorum between him and herself. Indeed, from the beginning of
our acquaintance yesterday, and now in this meeting of to-day, she
had drawn apart from Brent, and frankly approached me. Her fine
instinct knew the brother from the lover.
Armstrong presently rode out again.
When he saw his brother’s sorrel horse feeding with the others,
he wept like a child.
We two, the lady and I, were greatly touched.
“I’ve got a daughter myself, to home to the Umpqua,” said
Armstrong, turning to Miss Clitheroe; “jest about your settin’ up, and
jest about as many corn shuckins old. Ellen is her name.”
“Ellen is my name.”
“That’s pretty” (pooty he pronounced it). “Well, I’ll stand father to
you, just as ef you was my own gal. I know what a gal in trouble
wants more ’n young fellows can.”
 Ellen Clitheroe gave her hand to Armstrong in frank acceptance of
his offer. He became the paternal element in our party,—he
protecting her and she humanizing him.
We lighted our camp-fire and supped heartily. Except for Brent’s
uneasy stir and unwilling moans, we might have forgotten the
deadly business of that day.
We made the wounded man comfortable as might be with
blankets, under the sheltering spruces. After all, if he must be hurt,
he could not have fallen upon a better hospital than the pure open
air of this beautiful shelter; and surely nowhere was a gentler nurse
than his.
Armstrong and I built the lady a bower, a little lodge of bushes
from the thicket.
Then he and I kept watch and watch beneath the starlight.
Sleeping or waking, our souls and our bodies thanked God for this
peace of a peaceful night, after the terror and tramp and battle of
that trembling day.
 CHAPTER XXII.

CHAMPAGNE.
How soundly I slept, in my sleeping hours, after our great victory,
—Courage over Space, Hope over Time, Love over Brutality, the
Heavenly Powers over the Demon Forces!
I sprang up, after my last morning slumber, with vitality enough
for my wounded friend and myself. I felt that I could carry double
responsibility, as Fulano had carried double weight. God has given
me the blessing of a great, vigorous life. My body has always been a
perfect machine for my mind’s work, such as that may be; and never
a better machine, with every valve, crank, joint, and journal in good
order, than on that dawn at Luggernel Springs.
If I had not awaked alive from top to toe, from tip to tip, from
end to end, alive in muscle, nerve, and brain, the Luggernel
Champagne Spring would have put life into me.
Champagne of Rheims and Epernay! Bah!
Avaunt, Veuve Clicquot, thou elderly Hebe! Avaunt, with thy
besugared, begassed, bedevilled, becorked, bewired, poptious
manufacture! Some day, at a dull dinner-party, I will think of thee
and poison myself with thy poison, that I may become deaf to the
voice of the vulgar woman to whom some fatal hostess may consign
me. But now let no thought of Champagne, even of that which the
Veuve may keep for her moment most lacrymose of “veuvage,”
interfere with my remembrance of the Luggernel Spring.
 Champagne to that! More justly a Satyr to Hyperion; a stage-
moon to Luna herself; an Old-World peach to a peach of New
Jersey; a Democratic Platform to the Declaration of Independence; a
pinching, varnished boot to a winged sandal of Mercury; Faustina to
Charlotte Corday; a senatorial speech to a speech of Wendell
Phillips; anything crude, base, and sham to anything fine, fresh, and
true.
Ah, poor Kissingen! Alas, unfragrant Sharon! Alack, stale
Saratoga! Ichabod! Adieu to you all when the world knows the
virtues of Luggernel!
But never when the O-fartunatus-nimium world has come into
this new portion of its heritage,—never when Luggernel is renowned
and fashion blooms about its brim,—never when gentlemen of the
creamiest cream in the next half-century offer to ladies as creamy
beakers bubbling full of that hypernectareous tipple,—never will any
finer body or fairer soul of a woman be seen there about than her
whom I served that morning. And, indeed, among the heroic
gentlemen of the riper time to come, I cannot dream that any will
surpass in all the virtues and courtesies of the cavalier my friend
John Brent, now dismounted and lying there wounded and patient.
Oranges before breakfast are good. There be who on awakening
gasp for the cocktail. And others, who, fuddled last night, are limp in
their lazy beds, till soda-water lends them its fizzle. Eye-openers
these of moderate calibre. But, with all the vigorous vitality I have
claimed, perhaps I might still have remembered yesterday with its
Gallop of Three, its suspense, its eager dash and its certainty, and
remembered them with new anxieties for to-day, except for my
morning draught of exhilaration from the unbottled, unmixed
sources of Luggernel. Thanks La Grenouille, rover of the wilderness,
for thy froggish instinct and this blissful discovery!
I stooped and lapped. Long ago Gideon Barakson recognized the
thorough-going braves because they took their water by the
throatful, not by the palmful. And when I had lapped enough, and
let the great bubbles of laughing gas burst in my face, I took a
beaker,—to be sure it was battered tin, and had hung at the belt of a
dastard,—a beaker of that “cordial julep” to my friend. He was
awake and looking about him, seeking for some one.
“Come to your gruel, old fellow!” said I.
He drank the airy water and sat up revived.
“It is like swallowing the first sunbeam on the crown of a snow-
peak,” he said.
Miss Clitheroe dawned upon us with this. She came forth from her
lodge, fresh and full of cheer.
Brent stopped looking about for some one. The One had entered
upon the scene.
I dipped for her also that poetry in a tin pot.
“This,” said she, “is finer balm than the enchanted cup of Comus;
never did lips touch a draught
‘To life so friendly, or so cool to thirst.’
To-day my life is worthy of this nepenthe. My dear friend, this is the
first night of peaceful, hopeful rest I have had, since my poor father
was betrayed into his delusion. Thank you and God for it!”
And again her eyes filled with happy tears, and she knelt by her
patient. While she was tenderly and deftly renewing the bandages,
Armstrong stood by, and inspected the wound in silence. Presently
he walked off and called me to help him with our camp-fire.
“Pretty well ploughed up, that arm of his’n,” said he.
“I have seen amputation performed for less.”
“Then I’m dum glad there’s no sawbones about. I don’t believe
Nater means a man’s leg or arm to go, until she breaks the solid
bone, so that it ain’t to be sot nohow. But what do you allow to do?
Lamm ahead or squat here?”
 “You are the oldest; you have most experience; I will take your
advice.”
“October is sweet as the smile of a gal when she hears that her
man has made fifteen hundred dollars off the purceeds of a half-acre
of onions, to the mines; but these yer fall storms is reg’lar Injuns;
they light down ’thout sendin’ on handbills. We ought to be p’intin’
for home if we can.”
“But Brent’s wound! Can he travel?”
“Now, about that wound, there’s two ways of lookin’ at it. We ken
stop here, or we ken poot for Laramie. I allow that it oughter take
that arm of his’n a month to make itself right. Now in a month ther’ll
be p’r’aps three feet of snow whar we stand.”
“We must go on.”
“Besides, lookerhere! Accordin’ to me the feelin’s mean suthin’,
when a man’s got any. He’ll be all the time worryin’ about the gal till
he gets her to her father. It’s my judgment she’d better never see
the old man agin; but I wouldn’t want my Ellen to quit me, of I was
an unhealthy gonoph like him. Daughters ought to stick closer ’n
twitch-grass to their fathers, and sons to their mothers, and she ain’t
one to knock off lovin’ anybody she’s guv herself to love. No, she’s
one of the stiddy kind,—stiddy as the stars. He knows that, that
there pardener of yourn knows it, and his feelin’s won’t give his arm
no rest until she’s got the old man to take care of and follow off on
his next streak. So we must poot for Laramie, live or die. Thar’ll be a
doctor there. Ef we ken find the way, it shouldn’t take us more ’n ten
days. I’ll poot him on Bill’s sorrel, jest as gentle a horse as Bill was
that rode him, and we’ll see ef we hain’t worked out the bad luck
out of all of us, for one while.”
Armstrong’s opinion was only my own, expressed Oregonly. We
went on preparing breakfast.
“That there A. & A. mule,” says Armstrong, “was Bill’s and mine,
and this stuff in the packs was ours. I don’t know what the fellers
did with the two mean mustangs they was ridin’ when they found us
fust on Bear River,—used ’em up, I reckon.”
Here Brent hailed us cheerily.
“Look alive there, you two cooks! We idlers here want to be
travelling.”
“I told you so,” said Armstrong. “He understands this business
jest as well as we do. He’ll go till he draps. Thar’s grit into him, ef I
know grit.”
Yes; but when I saw him sit still with his back against the spruce-
tree, and remembered his exuberant life of other days, I desponded.
He soon took occasion to speak to me apart.
“Dick,” said he, “you see how it is. I am not good for much. If we
were alone, you and I might settle here for a month or so, and write
‘Bubbles from the Brünnen.’ But there is a lady in the case. It is plain
where she belongs. I know every inch of the way to Laramie. I can
take you through in a week”—he paused and quavered a little, as he
continued—“if I live. But don’t look so anxious. I shall.”
“It would be stupid for you to die now, John Brent the Lover, with
the obstacles cut away and an heroic basis of operations.”
“A wounded man, perhaps a dying man, has no business with
love. I will never present her my services and ask pay. But, Dick, if I
should wear out, you will know what to say to her for me.”
At this she joined us, her face so illumined with resolution and
hope that we both kindled. All doubt skulked away from her
presence. Brent was nerved to rise and walk a few steps to the
camp-fire, supported by her arm and mine.
Armstrong had breakfast ready, such as it was. And really, the
brace of wood grouse he had shot that morning, not a hundred
yards from camp, were not unworthy of a lady’s table, though they
had never made journey in a crowded box, over a slow railroad,
from Chicago to New York, in a January thaw, and then been bought
at half price of a street pedler, a few hours before they dropped to
pieces.
We grouped to depart.
“I shall remember all this for scores of sketches,” said Miss
Clitheroe.
And indeed there was material. The rocks behind threading away
and narrowing into the dim gorge of the Alley; the rushing fountains,
one with its cloud of steam; the two great spruces; the greensward;
the thickets; and above them a far-away glimpse of a world, all run
to top and flinging itself up into heaven, a tumult of crag and
pinnacle. So much for the scenery. And for personages, there was
Armstrong, with his head turbaned, saddling the white machine; the
two mules, packed and taking their last nibbles of verdure; Miss
Clitheroe, in her round hat and with a green blanket rigged as riding-
skirt, mounted upon the sturdy roan; Brent resting on my shoulder,
and stepping on my knee, as he climbed painfully to his seat on the
tall sorrel; Don Fulano waiting, proud and eager. And just as we
were starting, a stone fell from overhead into the water; and looking
up, we saw a bighorn studying us from the crags, wishing, no doubt,
that his monster horns were ears to comprehend our dialect.
I gave the party their stirrup-cup from the Champagne Spring.
The waters gurgled adieu. Rich sunrise was upon the purple gates of
the pass. We struck a trail through the thicket.
Good bye to the Luggernel Springs and Luggernel Alley! to that
scene of tragedy and tragedy escaped!
 CHAPTER XXIII.

AN IDYL OF THE ROCKYS.

I shall make short work of our journey to Laramie.
We bent northeastwardly by ways known to our leader,—alas!
leader no more. He could guide, but no more gallop in front and
beckon on the cavalcade.
It was a grand journey. A wild one, and rough for a lady. But this
lady was made of other stuff than the mistresses of lapdogs.
We crossed the backbone of the continent, climbing up the clefts
between the ragged vertebræ, and over the top of that meandering
spine, fleshed with great grassy mounds; then plunging down again
among the rifts and glens.
A brilliant quartette ours would have been, but for my friend’s
wound. Four people, all with fresh souls and large and peculiar
experience.
Except for my friend’s wound!
My friend, closer than a brother, how I felt for him every mile of
that stern journey! He never complained. Only once he said to me,
“Bodily agony has something to teach, I find, as well as mental.”
Never one word of his suffering, except that. He wore slowly
away. Every day he grew a little weaker in body; but every day the
strong spirit lifted the body to its work. He must live to be our guide,
that he felt. He must be cheerful, gay even, lest the lady he had
saved should too bitterly feel that her safety was daily paid for by his
increasing agony. Every day that ichor of love baptized him with new
life. He breathed love and was strong. But it was love confined to his
own consciousness. Wounded, and dying perhaps, unless his life
could beat time by a day or an hour, he would not throw any share
of his suffering on another, on her, by calling for the sympathy which
a woman gives to her lover.
Did she love him? Ah! that is the ancient riddle. Only the Sphinx
herself can answer. Those fair faces of women, with their tender
smiles, their quick blushes, their starting tears, still wear a mask
until the moment comes for unmasking. If she did not love him,—
this man of all men most lovable, this feminine soul in the body of a
hero, this man who had spilled his blood for her, whose whole
history had trained him for those crowning hours of a chivalric life
when the lover led our Gallop of Three; if she did not love him, she
must be, I thought, some bloodless creature of a type other than
human, an angel and no woman, a creature not yet truly embodied
into the body of love we seemed to behold.
She was sweetly tender to him; but that the wound, received for
her sake, merited; that was hardly more than the gracious
thankfulness she lavished upon us all. What an exquisite woman!
How calmly she took her place, lofty and serene, above all the
cloudy atmosphere of such a bewildering life as hers had been! How
large and deep and mature the charity she had drawn, even so
young, from the strange contrasts of her history! How her keen
observation of a woman of genius had grasped and stored away the
diamond, or the dust of diamond, in every drift across her life!
She grew more beautiful daily. Those weary days when, mile after
dreary mile, the listless march of the Mormon caravan bore her
farther and farther away into hopeless exile, were gone forever. She
breathed ruddy hope now. Before, she had filtered hope from every
breath and only taken the thin diet of pale endurance. All future
possibility of trial, after her great escape, seemed nothing. She was
confident of Brent’s instant recovery, with repose, and a surgeon
more skilful than she, at Fort Laramie. She was sure that now her
father’s wandering life was over, and that he would let her find him a
home and win him a living in some quiet region of America, where
all his sickly fancies would pass away, and his old age would glide
serenely.
It would be long, too long, for the movement of this history,
should I attempt to detail the talks and minor adventures of that trip
by which the character of all my companions became better known
to me.
For the wounded man’s sake we made lengthened rests at
noonday, and camped with the earliest coming of twilight. Those
were the moonlight nights of brilliant October. How strange and
solemn and shadowy the mountains rose about our bivouacs! It was
the poetry of camp life, and to every scene by a fountain, by a
torrent, in a wild dell, on a mountain meadow with a vision of a
snow-peak watching us all the starry night and passing through
rosiness into splendor at sunrise,—to every scene, stern or fair, our
comrade gave the poetry of a woman’s presence and a woman’s fine
perception of the minuter charm of nature.
And then—think of it!—she had a genius for cookery. I have
known this same power in other fine poetic and artistic beings. She
had a genius for imaginative cookery,—a rich inheritance from her
father’s days of poverty and coal-mining. She insisted upon her
share of camp-duty; and her great gray eyes were often to be seen
gravely fixed upon a frying-pan, or watching a roasting bird, as it
twirled slowly before the fire, with a strip of pork featly disposed
overhead to baste that succulent revolver; while Brent, poor fellow,
lay upon the grass, wrapped in blankets, slowly accumulating force
for the next day’s journey, and watched her with wonderment and
delight that she could condescend to be a household goddess.
“Ther ain’t her ikwill to be scared up,” would Armstrong say on
these occasions. “I’m gittin’ idees to make my Ellen the head woman
on all the Umpqua. I wish I had her along; for she’s a doughcyle gal,
and takes nat’ral to pooty notions in thinkin’ and behavior and fixin’
up things ginerally.”
 Armstrong became more and more the paternal element in our
party. Memory of the Ellen on the Umpqua made him fatherly
thoughtful for the Ellen here, a wanderer across the Rocky
Mountains. And she returned more than he gave, in the sweet
civilizing despotism of a lady. That grizzly turban presently
disappeared from his head. Decorous bandages replaced it. With
that token went from him the sternness. He was a frank, honest,
kindly fellow, shrewd and unflinching, but one who would never
have lifted his hand against a human being except for that great,
solemn duty of an exterminating vengeance. That done, he was his
genial self again. We never tired of his tales of plains and Oregon
life, told in his own vivid dialect. He was the patriarchal pioneer, a
man with the personal freedom of a nomad, and the unschooled
wisdom of a founder of states in the wilderness. A mighty hunter,
too, was Armstrong. No day passed that we did not bag an antelope,
a deer, or a big-horn. It was the very land of Cocaigne for game. The
creatures were so hospitable that it hardly seemed proper gratitude
to kill them; even that great brown she-bear, who one night “popped
her head into the shop,” and, muttering something which in the
Bruin lingo may have been, “What! no soap!” smote Armstrong with
a paw which years of sucking had not made tender.
Except for Brent’s wound, we four might have had a joyous
journey, full of the true savor of brave travel. But that ghastly,
murderous hurt of his needed most skilful surgery, and needed most
of all repose with a mind at peace. He did not mend; but all the
while
“The breath
Of her sweet tendance hovering over him
Filled all the genial courses of his blood
With deeper and with ever deeper love.”
But he did not mend. He wasted daily. His sleeps became deathly
trances. We could not wear him out with haste. Brave heart! he bore
up like a brave.
 And at last one noon we drew out of the Black Hills, and saw
before us, across the spurs of Laramie Peak, the broad plain of Fort
Laramie.
Brent revived. We rode steadily. Just before sunset, we pulled up
at our goal.
 CHAPTER XXIV.

DRAPETOMANIA.
For the last hour I had ridden close to Brent. I saw that it was
almost up with him. He swayed in his saddle. His eye was glazed
and dull. But he kept his look fixed on the little group of Laramie
Barracks, and let his horse carry him.
I lifted up my heart in prayer that this noble life might not be
quenched. He must not die now that he was enlarged and sanctified
by truest love.
At last we struck open country. Bill Armstrong’s sorrel took a
cradling lope; we rode through a camp of Sioux “tepees,” like so
many great white foolscaps; we turned the angle of a great white
wooden building, and halted. I sprang from Fulano, Brent quietly
drooped down into my arms.
“Just in time,” said a cheerful, manly voice at my ear.
“I hope so,” said I. “Is it Captain Ruby?”
“Yes. We’ll take him into my bed. Dr. Pathie, here’s a patient for
you.”
We carried Brent in. As we crossed the veranda, I saw Miss
Clitheroe’s meeting with her father. He received her almost peevishly.
We laid the wounded man in Ruby’s hospital bed. Evidently a fine
fellow, Ruby; and, what was to the point, fond of John Brent.
Dr. Pathie shook his head.
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