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.

While it is usual among psychiatrists to express dissatisfaction with psychiatric classification and its problems it is by no means unusual for their psychological colleagues to advocate factor analysis as an effective technique for resolving such problems. For example, Burt (1954) describes factor analysis as “essentially a statistical device for securing the best available scheme of classification”. Yet the problems and the device tend to remain apart, the former becoming intensified, the latter undergoing continued improvements. Twenty-five years ago T. V. Moore (1930) demonstrated that the application of factor analysis to the study of psychiatric disorders was feasible, and more recent work, especially that of Eysenck (e.g. 1947) has impressively shown its fruitfulness. That some clinicians remain sceptical of the claims made for these techniques is, in part, due to the infrequency with which factorial studies bearing on psychiatry have been pursued far enough for their implications to be tested and the findings integrated with those established by other scientific methods. This deficiency may be attributable to the fact that large scale programme research (Eysenck, 1953) is an almost essential condition, if this is to be achieved.

During the two and a half years from May, 1953, sixty-one cases of schizophrenia, none of whom had been leucotomized, were studied by me at St. Ann's, a 69-bedded subsidiary hospital of Holloway Sanatorium, Virginia Water, which has been available for the treatment of psychoneuroses since the end of 1946 and where at any one time a large majority of the patients are psychoneurotic. Except that patients are normally expected to be in by 10 p.m. it is as open as any hotel, there is no sex distinction in any of the sitting and games rooms, the dining room, the occupational therapy department and so on and where the ‘male side’ and the ‘female side’ meet the rooms may be occupied by men or women, so that men may have to pass women's rooms on the way to the toilets and vice versa. The hospital is mainly an ‘amenity bed’ one with charges of 2 to 4 guineas a week and although no policy of exclusion exists the bulk of patients are from ‘lower middle’ or ‘upper lower’ backgrounds. Treatment is based on careful history-taking and investigations of various kinds, with explanatory and supportive psychotherapy, but E.C.T. always with pentothal and scoline, modified insulin, modified narcosis and other physical treatments are available although they are strictly limited by the small nursing staff. Remembering that there are only three doctors, one of whom is partly taken up with administrative duties, both for in-patients and for a reasonably active out-patient service which includes the use of all the daytime hospital facilities, an exercise in simple arithmetic will make it clear that the forms of psychotherapy used are also strictly limited.

The honour which the R.M.P.A. has bestowed on me fills me with a mixture of pride and apprehension; pride that I occupy the Chair where have sat so many distinguished psychiatrists and apprehension lest I might be unequal to the task of upholding the noble traditions of my predecessors. In offering you my thanks and appreciation I wish to express my most devout hope that I will prove worthy of the mantle you have placed on my shoulders and pass it on to my successors untarnished. It is pleasant to think that the Irish Division of the R.M.P.A. has held such a long and happy relationship with its Royal parent and that in the field of psychological medicine there has been no cleavage between the Sassenach and the Gael. I am proud to be the figurehead which expresses that unity today.

Similarity between certain of the visual effects of mescaline and hypnagogic imagery has been independently noted by several investigators, one of the earliest of these being Weir Mitchell (1896). Our own research group first became interested in hypnagogic experiences when one of the writers, as subject, in seeking to communicate the character of his mescaline visions, likened them to images he had encountered just before sleep. This led to an investigation of hypnagogic imagery as such, the results of which have been published elsewhere (McKellar and Simpson, 1954). Further experiments with mescaline, and consideration of the relevant literature of the two fields, suggest that the mescaline-induced and hypnagogic states are more than superficially alike, and that a comparison may illuminate the processes at work in each.

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.

I value very much the honour of giving the Maudsley Lecture. Henry Maudsley was a pioneer in the study of the physiological basis of mind, and hence of the physiological interpretation of mental disorder. In the preface to his book, The Physiology of Mind (Maudsley, 1876), he said with a blend of optimism and modesty: “The current of psychological thought having set so strongly in physiological channels, it is pretty certain that the reflections which one person has had, however original they may seem to him, some other person has had, has now, or will very soon have.” But half a century was to pass before physiology and psychiatry began to develop techniques which could illuminate the physiological basis of mind, and even now we are only entering the era which Maudsley would have found the fulfilment of his hopes and anticipations. Though intolerant of the idea that metaphysical speculation about mind could take the place of scientific study, he was nevertheless a philosopher, and my aim in this lecture is to try to use a philosophy of perception to interpret the clinical observations of perceptual disorder.

Lesions of the cerebral cortex are generally accepted as a potential source of psychological change, and the difficulties that may arise in distinguishing between one of the psychiatric illnesses at present regarded as idiopathic and one due to a lesion of the prefrontal cortex, the temporal lobe or the posterior parietal region are well recognized. Since there is normally a continual functional interplay between cortex and subcortical structures, lesions in the latter may also be expected at times to produce changes in psychological function.

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 aim of the research of which this study forms part, is to examine the relationship of certain aspects of mental functioning to the psychiatric illnesses of old age.

One of the apparent deficits of function to which psychiatrists commonly attach importance is “memory impairment“. This is considered part of various clinical syndromes, especially of the “organic” disorders of senility. The assessment of memory is, therefore, of considerable practical importance and most psychiatrists working with elderly patients use some kind of “memory tests”. Such tests are usually unstandardized and lack objective scoring criteria.

There are, in relation to memory assessment, some points of conflict between clinical usage and the evidence of objective psychological investigations. For example, the existence of a “memory function” which could be considered as relatively independent of general mental functioning or intelligence, has not been well substantiated when some such clinical tests have been put to critical examination. Eysenck and Halstead (2) after a brief review of the literature and an experimental attack on this problem, conclude that “… the ability involved in the clinical tests of memory studied in this research was identical with that involved in the intelligence test used, and that, therefore, it was misleading to accept scores on these various tests as estimates of a person's ‘memory’ ability.”

With the coming of the National Health Service, there seemed a real chance of establishing fuller psychotherapy in Out Patients. This is not to imply that psychotherapy was not given before; but in most hospitals it was necessarilly limited except in special cases, and there was a tendency to leave it a good deal to junior staff who had the time and wanted the experience.

One has to admit that the treatment of the mentally ill by psychological methods only leaves something to be desired, for even in the neuroses the long term results of psychotherapy are at times disappointing. Shorter methods of treatment, more economical of time and surer of outcome are constantly sought and, of course, there remains the very considerable problem of how to treat the not over-intelligent neurotic who can never hope to achieve profound self knowledge or insight.

It is now several years since acetylcholine was first administered intramuscularly in the symptomatic treatment of anxiety, on the theory that anxiety was sympathicotonic in nature and could be counteracted by the vagotonic action of acetylcholine. Unfortunately decomposition of acetylcholine is so rapid that there is little time for this action to be effective, and the majority of investigators believe that it has no effect, or at least a momentary one, when given either subcutaneously or intramuscularly. Maxwell Jones (1936) used carbachol, a drug with a similar but more prolonged action than acetylcholine to treat six patients with anxiety neurosis. He was able to report relief from the psychic and somatic symptoms of anxiety in all cases but unfortunately, following withdrawal of the drug, they tended to relapse. An entirely different rationale led Tomasson (1936) to claim both alleviation and shortening of the duration of attacks of mania in manic depressive psychotics using a combined ephedrine and acetylcholine treatment.

A geriatric unit containing 200 female and 110 male beds was fully opened at this hospital in March, 1953. There were then resident in hospital 226 females over 70, and 165 males over 65. The aim of this paper is to discuss the mental and physical health of the inmates and assess their medical and nursing requirements. It is hoped that this information will be of value to those intending to open similar units.

This hospital is unique in having a catchment area of over 1,000,000 and only 2,000 mental beds. Three hundred of these are taken by mental defectives, and 500 are over 65 years of age. There is a severe bed shortage with resulting delay in admission of elderly patients from the observation wards. The large initial death rate in the month following notification occurs mainly outside this hospital, and many patients are discharged from the observation wards without reaching the hospital. Admissions are restricted to those with severe conduct disorder. Thus the death rate and discharge rate will be lower than hospitals with a more fortunate bed-population ratio.

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”.

In psychiatry, generalization is a process which requires careful handling. It must be firmly rooted in everyday experience of the practical empiricism which gets results, and must be free, as far as possible, from the numerous fallacies which have brought “armchair” philosophizing into disrepute. These are formidable requirements, but fortunately one way of meeting them lies ready to hand. There are doubtless many others apparent to more fertile minds, but the one with which this paper deals rests on the fact that a patient who has been successfully treated by a psychiatrist behaves, when well again, in a different manner from that which he displayed when ill. He is cheerful, not depressed, relaxed, instead of being tense; realistic and socially enterprising as opposed to being autistic. If the term “Behaviour” is used in a sufficiently wide sense, it can cover the great majority of psychiatric phenomena without losing its cardinal virtue for the present purpose, namely that behaviour can be observed and its manifestations measured with considerable accuracy. The products of observation can be handled statistically, thereby avoiding armchair theorizing. Admittedly the interpretation of statistically derived findings presents some difficulty, but this is not insuperable. It is usually easier than the process of generalizing from observed data without the benefit of statistical pre-digestion.

The speakers for this morning's discussion were asked to be practical, to limit themselves to giving an account of the essential uses of the EEG technique for clinical psychiatry, and to avoid, as far as possible, the theoretical and speculative aspects of the subject. No doubt the time has come for an attempt at re-appraisal. In the last 10 years EEG departments have been developed in most of the larger mental hospitals and nearly every psychiatric centre or group, be it mental hospital, out-patient department or child guidance clinic has access to an EEG department and refers patients for examination in increasing numbers.

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 first recorded attempt to use carbon dioxide inhalation systematically as a form of psychiatric treatment was by Lovenhart et al. (1929). The subjects were catatonic schizophrenics and such modification as occurred was fleeting in nature.

In 1943 Meduna began to use carbon dioxide inhalation in the treatment of the neuroses and his efforts were described in a series of papers and developed in a monograph (1950). This contains a full description of the physiological and pharmacological effects of carbon dioxide upon nervous function and the technique of administration is described as are also the results in 100 patients. These results are taken as giving some support to a neurophysiological theory of the neuroses based on homeostatic and cybernetic considerations. Efforts were made to minimize the effects of “suggestion” and, although the difficulties are acknowledged, the following passage suggests that the author was reasonably satisfied with his precautions.

A number of studies have shown that the incidence of schizophrenic illness (as measured by first admissions to mental hospitals) is high in the central areas of large cities and diminishes progressively towards the suburbs (Fans and Dunham, 1939; Dunham, 1947; Hare, 1956). Two main hypotheses have been advanced to account for this distribution. The first, the “breeder” hypothesis, is that social factors in the central areas are causal for schizophrenia and the particular factor most likely to be responsible is that loosely called “social isolation”. The second, the “attraction” hypothesis, is that the social disorganization or anonymity characteristic of the central areas attracts unstable and schizoid persons, either because such persons are unable to maintain themselves in better areas or because they wish to avoid the intimate personal relations of family life.