The problem of determining whether or not a particular individual has deteriorated intellectually or with respect to other skills is one which has exercised the ingenuity of clinical psychologists for a long time. Clearly the most satisfactory method from the point of view of reliability and validity is by means of the test-retest method over a given period of time, using tests for which adequate statistical information is available. However, since a direct estimate of the individual's previous level of intelligence is usually not available and since the psychologist often cannot wait six months or longer to obtain a direct retest, some method had to be devised which would overcome this difficulty. Babcock (1930) hit on the method of using the Vocabulary test as an estimate of previous level of intellectual ability and contrasting it with performance on other tests supposedly sensitive to deterioration in order to measure the amount of decline which had taken place.

Some aspects of the use of vocabulary in clinical psychological testing have been reviewed by a number of writers (Cronbach, 1942; Feifel, 1949; Hunt, 1936; Jastak, 1949; Lewinski, 1948; Raven and Walshaw, 1944; Shakow, 1946), and the immense interest shown in vocabulary as a test may be inferred from the 101-page bibliography of vocabulary studies published by Dale (1949). However, previous reviews suffer from two defects in that (a) they do not attempt to cover the ground thoroughly or systematically, being usually introductory to an experiment, or not specifically concerned with the subject matter of this paper; and (b) they naturally give no information about the important research which has taken place in this field within the last few years. The present review has been undertaken for these reasons, and because of the intrinsic importance of the problem.

Relatively little is yet known of the incidence or nature of mental disorder in Africans. The literature on African psychiatry is not extensive and, although a wealth of anthropological and sociological work has given us an idea of the cultural and physical background of the African, we are still much in the dark as to how these factors influence his personality and what bearing they may have upon mental illness. A number of studies of patients in African Mental Hospitals have been made by various writers and diagnostic classifications have been attempted. Most writers agree that it is rare to find any great degree of similarity between the various types of mental disorder in Africa and those found in the higher developed western countries. Most of the work in this field has been summarized by Carothers (1954).

My aim in this paper is to give a rough idea of the African background, to speculate on various aspects of the African personality in the light of present knowledge, and to try and reflect these speculations by description of the various types of insanity that are encountered in a mental hospital in Tanganyika. Some of the differences in the nature and aetiology of these disorders, compared with those most common in the home country, will be discussed. My remarks are, of course, confined to Tanganyika and if I inadvertently use the term “the African” I refer to the native of Tanganyika whom I have studied for the past eight years and who compose the bulk of the patients in hospital.

The handicap of the single as compared with the married state in respect of the first admission rates to mental hospitals has been demonstrated by several workers. Dayton (1939), Malzberg (1940) and 0degaard (1946), to mention but a few, have all shown that the admission rates for single persons are greater than those for married persons of the same age. Hospital first admission rates for mental disorders are more likely to give reliable estimates of the incidence of mental disease than are hospital rates for other types of illness, nevertheless hospital admissions are but a sample of the sick population in the community and, generally speaking, there is no means of knowing whether or not it is a representative sample of the total sick population. For this reason, in this paper it is only the effect of marital status on the hospital care of the mentally sick that it is to be considered. This appears to be a necessary restriction in view of the fact that the data analysed here relate only to hospital admissions, but ⊘degaard (1946) categorically stated, although his data, too, were derived from mental hospitals:

“It is shown beyond doubt that the incidence of mental disease is much higher in the single than in the married, and that this ‘predominance of the single’ among our insane is no statistical figment caused by such factors as differences in age distribution or in the tendency to hospitalize the insane.”

The purpose of this paper is not to discuss differential admission rates between single and married, although some data will be presented to show that the difference exists here as well as in Scandinavia and the United States, for I have dealt with that problem elsewhere.∗ The very great differences between the first admission rates for single and married persons led me to ask the question: “What other differences arise between single and married persons with respect to mental hospital care?” The data of a statistical study of mental hospital admissions which I have already completed provide some information on this point.

The Concept of the Body Image and the Perception of the Human Body

The consideration of our awareness of our own bodies ceased to be wholly a philosophical problem when Pick (1908) and Head and Holmes (1911), having observed neurological disturbances of body awareness, first suggested the concept of a Body Image or Body Schema. The concept, has in its slow growth, become at times confused and has always resisted satisfactory definition. Pick himself made no attempt to define it, while for Head and Holmes it was a “postural model of the body” being constantly built up and changed by every new posture and movement and forming a “plastic schema” which was “the fundamental standard against which all postural changes are measured“. Schilder (1935) greatly enriched the concept by emphasizing not only its physiological and neuropathological basis but its psychological aspect. He defined it thus: “The image of the human body means the picture of our own body which we form in our mind, that is to say the way in which the body appears to ourselves.” This was a comprehensive “body image”; more than a perception or mere representation and including even Head and Holmes's “Body Schema“. The Body Schema concept has been more recently defined by Clifford Scott (1948) as “that conscious or unconscious integration of sensations, perceptions, conceptions, affects, memories or images of the body from the surface to its depths and from its surfaces to the limits of space and time”.

Two observations made on the post-leucotomy patient inspired the investigation to be reported in this paper. They are, first, that the post-leucotomy patient seems unable to deal with two things at once. Both Ackerly (1935) and Brickner (1939) have referred to this deficit. The second observation was that there was apparently lesser vitality of imagery after operation. A photographer in Pippard's study (1955) who had had, as he said, a “photographic memory”, could no longer connect people's faces with photographs of them he had taken in the past. A 35 year old schoolteacher in the same study completely lost her visual imagery after operation, and Brain (1954) has reported a similar deficit in two cases. Zangwill and Humphrey's report (1951) of cessation of dreaming in some patients after brain injury is possibly related to this deficit. Petrie (1952) found an increase in reversals, especially willed reversals on the Necker Cube after operation, and Gordon (1950) has presented findings showing that the control of fluctuation was significantly related to less vivid and controlled imagery.

The investigation reported here was designed to examine further these two post-leucotomy deficits, and to see if they were related in any way.

The problem we are concerned with is the relationship between neurosis and psychosis. It is well known psychiatrically that many patients tend to be what are called “mixed” states, meaning that the diagnostic classification is doubtful. Patients complaining of physical symptoms, such as sleeplessness, heart palpitations, and other signs of autonomic imbalance, accompanied by anxiety or phobias, and who seem well reality-oriented, are not hallucinated or deluded and do not show any cognitive deterioration, are classed as neurotics. Psychotics, on the other hand, are generally deluded and hallucinated, are poorly reality-oriented, tend to show signs of cognitive deterioration, but have an absence of the physical symptoms so characteristic of neurotic disorders.

Reserpine is one of the active alkaloids extracted from the root of the plant Rauwolfia Serpentina. The physiological changes resulting from the use of the drug in animals—such as hypotension, bradycardia, sedation, increased peristalsis, meiosis, etc.—are probably the result of a central action. The precise sites are not known although it seems likely that one of them is the midbrain reticular formation. There is no evidence of any peripheral action, nor of any direct effect on the cortex. The reason for the long latent period, before the drug begins to show an action is still obscure (Lancet Leader, 1955; Mover, 1955; Plummer et al., 1954). The recent work on the pharmacological relationships between Reserpine, Serotonin and the hallucinogens suggests interesting possibilities (Pletscher et al., 1955; Shore et al., 1955).

There is already a considerable literature on the toxic effects of Reserpine, the most serious of which are Parkinsonism, of a post-encephalitic type, and severe depression (Achor et al., 1955; Barsa and Kline, in press; Locket, 1955; Schroeder and Perry, 1955; Stead and Wing, 1955).

The therapeutic problems confronting those of us engaged in mental deficiency practice are manifold. This is due to the varied and mixed population inhabiting our hospitals.

There is the group known as “high grade” with intelligence quotients of 75 per cent. upwards who are admitted on account of their social inadequacy due to emotional maladjustment, sexual deviations and other psychopathic behaviour problems. The “low” and “medium grade” with intelligence quotients of 25 to 60 per cent., in addition to their deviant behaviour are intellectually so low that they could not cope outside an institution.

It is the aim of the psychiatrist to rehabilitate the former group and here in our hospital we have a very active programme to accomplish this end. The latter group are, however, an ever-pressing therapeutic problem on account of the frequency of psychomotor excitement, noisiness and destructiveness.

The present study was designed to assess the effectiveness of the new drug Reserpine in controlling deviant behaviour in such mentally defective patients.

When we commenced using reserpine in our disturbed male ward we were impressed by the calming effect which this produced in many of the patients and by the fact that the ward as a whole became quieter. In order to confirm these impressions we created a method which enabled us to express the behaviour of the patients in a graph. We thus had a simple means of comparing one clinical state with another and of assessing the influence of the therapeutic measures used.

Behaviour disorders resulting from localized lesions of the brain have attracted increasing attention recently. With the rapid progress being made in neurosurgical treatment there is a prospect that their accurate diagnosis may become more than an academic exercise. In the present paper a description will be presented of characteristic overactive behaviour which appears, in the majority of cases, to be due to cortical damage, frequently involving the temporal lobe, and sustained either at the time of birth or in later childhood.

The behaviour symptoms exhibited were remarkably constant throughout the series of twenty-five children studied. There was marked restlessness, distractibility and an inability to concentrate for more than a few seconds at a time. The affected children showed an apparent compulsive need to touch every object which they saw, and to suck or chew them. Outbursts of aggressive and irresponsible behaviour occurred frequently, and the patients seemed to be incapable of responding to reprimand or chastisement for longer than a few minutes. The majority suffered from epilepsy or showed other evidence suggesting the presence of cerebral damage on examination.

Historical Background

Asthma is an illness which has puzzled our profession since earliest times. Each generation has based its concept of aetiology on current concepts of disease, so that delving into its history shows a colourful pattern of widely conflicting views.

Early in this century Osler (1910) is in favour of a nervous cause, though he pays little attention to treatment on psychological lines. After that date there is a procession of changing viewpoints.

In the second decade, anaphylactics, according to Conner (1917), have cracked the hard core of the aetiological riddle, but Eppinger and Hess (1917), writing of vagotonia, correlate this with the asthmatic attack.

Freeman (1921) writes of precipitating nervous reflexes. Bray (1934) is convinced that the allergist holds the key to solution. There is emphasis on allergic diathesis and an hereditary asthmatic constitution.

Wittkower (1935) showed that asthma might have a purely psychological conditioning. Since that time, belief in the importance of the psychological factor is still gaining ground.

The theme of the present communication arose from research of Bostock and Shackleton (1951, 1952) on the aetiology of enuresis. There emerged the concept of premature toilet training interfering with later development of urinary control. It suggested that a study of asthma in its early stages might show an interference in the normal process of respiratory and speech maturation.

As will be shown, there is a similarity, although the mechanism is more complicated.

Sakel (1938a) drew attention to the difficulty of establishing satisfactory comas in a minority of patients attending for Deep Insulin therapy. This phenomenon has since been confirmed by other workers including Tillim (1938) whose patient received 500 units of insulin without the production of deep coma, by Hall (1940) who reported an instance in which 1,000 units of insulin was equally unsuccessful, by Reznikoff and Scott (1942) who described how neither 120 nor 1,000 units of insulin when injected intravenously produced any significant difference in hypoglycaemia in insulin resistant patients, and more recently by Fogarty (1953) whose case required 5,000 units of insulin for the production even of sopor. Other recorded examples of resistance to massive doses of insulin include those of Banting et al. (1938) and Tennent (1944).

Various explanations of this perverse response to insulin have been formulated, including that of Jones (1939) who proposed that resistance to insulin was both a problem of true insulin insensitivity and also of an anomalous response of the central nervous system to hypoglycaemia. Meduna et al. (1942) preferred to ascribe it to anti-insulin factors in the blood, but a more interesting interpretation derived from Freudenberg (1952) who suggested that if the effects of high insulin dosage employed in insulin coma treatment were regarded as a special instance of a stress response, then the fluctuations and differences in response could be equated in terms of the General Adaptation Syndrome of Selye. High doses were thus an index of an effective “alarm stage” characterized by a discharge from plentiful adrenocortical reserves.

This paper reports part of a research into the relationship of certain aspects of mental functioning and the psychiatric illnesses of old age. One of the apparent deficits of function to which much importance has been attached is “memory impairment”. This is commonly considered part of various clinical syndromes, especially of the “organic” mental disorder of the senium. The measurement or estimation of memory function is, therefore, thought to be of considerable importance and most clinicians working with elderly patients use some kinds of tests which purport to measure it. There are, however, some points of conflict between clinical usage and the evidence of objective investigations in this area. It has never, for example, been demonstrated in relation to memory assessment that “memory” as such, can usefully be considered as even relatively independent of intelligence in young normal adult subjects (Eysenck and Halstead (1)).

While to no one can the present state of child psychiatry afford grounds for complacency, there is at this time an awareness of shortcomings, a lively sense of self-criticism and an urgency for advance in one direction or another that does give some grounds for optimism. I have thought it profitable at the present time to attempt to survey the scene.

It is often said that the Disorders of Affect are the most commonly encountered psychoses and it is, of course, depressive illness which accounts for the large majority of such disorders; nevertheless Mania and Hypomania present as great a problem. As great because from the medical point of view treatment is less certain and less satisfactory, and socially because the manic, and even more the hypomanic, patient seems capable of doing more harm to his family and home by his ill-judged actions and schemes than almost any other person. He seems, too, to have a singular affinity and attraction for wasters, ne'er-do-wells and psychopaths who assist all too readily in the disposal of goods and money and encourage him in his grandiose and extravagant schemes.

For depressive illness we have, in Electro-Convulsant Therapy, a ready, useful and comparatively reliable, safe and effective therapeutic measure. The majority of patients accept such treatment quite readily and respond well to it. Where there is a history of chronic or recurrent illness, leucotomy (often in one of its modified forms) seems to offer a good hope with an excellent prognosis. Depressed patients, moreover, from the very nature of their illness, tend to accept treatment, even if they dislike it, often maybe from poorly concealed masochistic urges and as punishment for what they believe to be their guilt and unworthiness.

Manic and hypomanic patients, on the other hand, present a totally different problem. Firstly they rarely, if ever, complain themselves and consequently they resent being referred to the doctor. When they do come it is often unwillingly or merely to demonstrate their well-being; or maybe to show some invention, gadget or discovery they believe they have made. Secondly, such patients, even when they have been seen, are notoriously unreliable over treatment and will rarely accept it. In the majority of patients it is only when under some form of control (which for all practical purposes means certification) that treatment can be carried out satisfactorily.

In Mania (and Hypomania) as in depression, convulsion therapy—usually E.C.T.—proves satisfactory in many instances, but the problem of long-term prognosis is not affected and in the case of recurrent manic attacks leucotomy seems to have no benefits to offer and is in fact often liable to make things worse. Any effective method of treatment is therefore to be welcomed, and more especially so if there is any suggestion that it can be continued after the patient leaves hospital, on a maintenance or prophylactic basis.

The Wechsler Adult Intelligence Scale is now rapidly replacing the Wechsler-Bellevue as the major battery used by British clinical psychologists to test intelligence or intellectual deterioration. The following investigation was conducted to ascertain divergences in British mental patients from the American order of difficulty of items in the Information, Vocabulary and Picture Completion Tests, where both obvious and subtle cultural factors are present. The equivalence of certain possible substitute items was also explored.

Disorientation is not a uniform phenomenon and does not always follow the same pattern. Its pattern varies with its causes. Three varieties may be recognized. (1) The disorientation of toxic delirium. This is the best known variety. (2) The disorientation seen in some cases of schizophrenia. (3) That seen in some cases of brain tumour and other organic brain disease. The three varieties are all different, and the object of this paper is to consider why.