Schizophrenia is disputed territory. Thus, the numerous theories put forth to explain it are of all sorts: biochemical, genetic, religious, psychoanalytic, sociological, crosscultural, interactional, legal, moral, and so forth. These theories resemble, in a curious way, the productions of the schizophrenic patients on whose behalf they are constructed; they tend to be self-involved, and while they often display much internal consistency, they lack any comprehensible relation to each other.

Since the definition of subnormality in the Mental Health Act (1959) specifically adds to its other descriptive statements, “… including subnormality of intelligence,” as part of the criteria for delineating this type of patient, it is clearly of great importance to come to some decision about the exact meaning of this phrase. One can either insist on a purely intellectual interpretation where the major emphasis is placed on the individual's estimated problem-solving ability relative to the community at large (Castell and Mittler, 1965); or one can broaden the concept to include much more than sheer intellectual ability (Shapiro, 1965) and argue that it also involves a person's social behaviour and his empirically demonstrated failure to adapt to the social and economic environment. If the purely psychometric view is taken, then reliance is placed wholly upon the use of standardized tests which are capable of arranging the population in order of intelligence, and which supply statistically defined cut-off points, according to the percentage of the whole population likely to fall beneath such limits. Conversely, if the clinical viewpoint is adopted, then intelligence levels assume a relatively minor role, and more emphasis is placed on social maturity, and behavioural control. In the absence of properly standardized, and widely accepted maturity scales, the clinical diagnosis is based mainly on subjective impression, supported by case history factors, and the knowledgeable experience of the examining medical expert.

In choosing the subject for this Lecture commemorating the august personality of Henry Maudsley, I did not intend to be exhaustive and I had in mind two things. I would like to discuss how the study of intellectual defects and their objective measurement may contribute to the knowledge of what Maudsley (1895) called the pathology of mind. Also, I would like to draw attention to the way in which clinical work in mental deficiency may help to explain some of the causes of mental illnesses. The first topic is psychological, the second is biological.

The value of modified leucotomy in the treatment of psychiatric disorders is undergoing constant reappraisal. Ever since 1948 efforts have been made in the Department of Psychological Medicine of St. Thomas's Hospital and at Belmont Hospital to modify operative techniques and to learn more about the proper and discriminative selection of suitable patients within very varied diagnostic categories. A leading article in the British Medical Journal has called for renewed efforts along such lines. (Editorial, 1965). To enable various surgical procedures to be assessed and their merits and disadvantages compared more accurately, better objective methods of evaluating the effects of the operation are certainly required. Although several studies have been directed towards the measurement of intellectual function before and after operation (Mettler, 1949; Mettler and Landis, 1952; Tow, 1955) much less attention has been directed towards the objective assessment of personality changes and measurement of the reduction of key symptoms such as anxiety. Sykes and Tredgold (1964) emphasized what has been repeatedly stressed from this Department (Sargant, 1946, 1962; Sargant and Slater, 1944, 1948, 1954, 1963), that a decision to operate must take careful note of the individual symptoms, especially the degree of tension present. Falconer and Schurr (1959) consider that “the indication for operation should be, not the diagnostic label, but the tension and anxieties which the illness has produced”.

The monoamineoxidase inhibitor drugs are now widely used in the treatment of depression, and complications occurring in patients so treated have been reported with varying frequency. The drugs most frequently implicated have been tranylcypromine (Parnate), tranylcypromine plus trifluoperazine (Parstelin) and phenelzine (Nardil) in decreasing order of frequency. These complications may be divided into three symptom-complexes which may merge one into the other, as they have the common basis of rapid elevation of systemic blood pressure.

The Editor of the British Journal of Psychiatry has been kind enough to ask me to write a summary and a critical survey of the objective data bearing on the causation of schizophrenia by environmental factors, especially those of a psychogenic nature. I was also asked to combine with this a general assessment of our knowledge in this field. At first sight the task as defined seems a simple and easy one, namely to collect together all those facts which point to the probability of schizophrenia being caused by the psychogenic influences of the patient's environment. But almost at once, a number of serious doubts arise. What are we to understand by the concept of “Schizophrenia“—should we take it in its widest sense as including all the “schizophrenic reaction types”, as do many American authors, or in the far narrower sense favoured by Scandinavian psychiatrists, who recognize only a central or “nuclear group” as true schizophrenia, and describe all related conditions as “schizophreniform psychoses“? Further, what do we mean here by “causation”, and what do we call “objective data”? We shall see later that if we were to collect as data only such as a “non participant observer” (H. Stierlin) thinks he can perceive in the schizophrenic's environment, we should miss the significance of those very factors which are most relevant to the development of the psychosis. It is indeed a complex question—and one which has been the subject of much philosophical reflection— whether it is at all legitimate to assume the existence of “causes” for psychological processes, and whether a search for “causes” is a meaningful undertaking. This, however, lies outside the scope of the present survey; all we need to do is to bear in mind that the use of a one-sided conception of causality might from the very start greatly restrict our field of enquiry, so that essential processes by which schizophrenia arises might not even come to our notice.

An attempt is made here to present a few concepts of Indian literature, to outline their application in treatment, and to give an impression of the range of conditions in which they may be helpful. These concepts have been prevalent in India for many centuries, and interest in them on the part of doctors has recently revived.

Stupor is an unusual but striking phenomenon, generally recognized but difficult to define in precise clinical terms. A large literature exists on the diverse conditions in which it may occur, but there is little information on differentiating one cause from another, or on the prevalence of these causes. This insufficiency extends to the phenomenology of stupor, where descriptive criteria are not always adequate for separating stupor from allied states. Such difficulties are reflected in a current text book by Merskey and Tonge (1965). The authors only recognize stupor if there is total akinesis, where it is assumed that the diagnosis is schizophrenia. Depressive stupor is not recognized as an entity.

Prolonged facial pain has long been a source of frustration to the medical profession, both from the diagnostic and therapeutic standpoints. The difficulty arises not in the “typical” facial pain syndromes such as trigeminal neuralgia, migrainous neuralgia or post-herpetic neuralgia, nor with pain due to diseases of the teeth, throat, nose, eyes and ears, but in the deep, poorly localized vaguely described pain which does not adhere to a strict anatomical distribution. The latter symptom complex has been given many names, but in spite of this is a remarkably uniform syndrome. It is characterized by pain that is felt deep in the soft tissues or the bone, rather than in the superficial tissues as occurs so often in the typical neuralgias, is poorly localized and vaguely described. The pain may be felt in regions supplied by the fifth and ninth cranial nerves and the second and third cervical nerves. Its distribution does not conform to the peripheral distribution of these nerves, but may involve portions of the sensory supply of two or more of them and may cross the mid-line. In general the pain is constant and endures for long periods of weeks to years. It is unusual to find trigger zones or clear-cut precipitating factors, and the pain is rarely excruciating.

Since Bleuler introduced his concept of schizophrenia in 1911, there has been a steady growth of clinical and experimental data relating to this disease. However, the literature dealing with early diagnosis is sparse and as yet there is no general agreement as to what symptomatology constitutes the early clinical picture. Older texts (Kraepelin, 1919; Bleuler, 1911) do not elaborate early diagnosis, dwelling more on distinguishing schizophrenia from other disease entities. Likewise, more recent texts tend to refer to the early stages very briefly in rather vague terms, signifying the development of the disease over the first few years from its onset. Although practice varies, the diagnosis of schizophrenia is often reserved until Bleuler's primary symptoms of disordered volition, thinking and affect appear overtly, by which time there may be also some evidence of deterioration. It is recognized, however, that these symptoms may take years to appear (Gillies, 1949) so that early diagnosis cannot readily be made by using these criteria.

This article presents the results of a study in which a number of social, familial and demographic aspects of primary depressive illness were examined under carefully-controlled conditions. The following factors are particularly considered:

1. 1. The size of the sibship in the depressive's family of upbringing;

2. 2. the ordinal position of the depressive in that sibship;

3. 3. the depressive's position in the sibship relative to the other sibs;

4. 4. the age of the parents at the time of the depressive individual's birth;

5. 5. the presence of a family history of severe mental illness;

6. 6. celibacy and marriage in depressive individuals;

7. 7. the fertility of depressives;

8. 8. the social class distribution of depressive illness.

Since in most cultures it is normal practice for children to be reared by their parents, there is a general consensus of opinion that it is undesirable to be deprived of one's parents in childhood. This can scarcely be disputed, but to assert, as many authorities do, that a variety of severe psychological abnormalities may arise in the child as a result of such deprivation is to make an assumption of some magnitude. It requires an even greater assumption to postulate a causal connection between a long-past occurrence like childhood bereavement and a psychiatric illness which develops in adult life. It will be contended here that, with some exceptions, the evidence for such a connection is meagre. In particular, it will be shown that there is no apparent justification for regarding parental deprivation as an aetiological factor in depressive illness.

Since the time of Esquirol (1838) a discrimination has been made between illusions and hallucinations. The latter are generally taken to be perceptions that spring into being in a primary way and not transpositions or distortions of any genuine perception (Jaspers, 1962). There are, however, various phenomena comparable to hallucinations proper (as defined above), such as various forms of imagery and pseudohallucinations, which may be part of normal experience. This paper is concerned with a comparison of various types of hallucinatory phenomena differentiated on phenomenological grounds.

This enquiry was prompted by a discussion on training in psychotherapy which took place at the Troon Conference on the Teaching of Psychiatry (Ingram, 1963). We felt that more precise information was required about what is meant by the term psychotherapy, which methods are in use and what opinions are held by psychotherapists in training. This information could be of value in assessing the workload of psychiatrists and in deciding what training might be given to psychiatrists and medical students. It was therefore decided to seek the opinions of Scottish psychiatrists on some aspects of their current practice in psychotherapy.

In recent years, the Maudsley Personality Inventory (M.P.I.) has been widely used in experimental, psychiatric, social and applied research (Eysenck, 1959a, 1959b). Its use in a university setting has been described by Furneaux (1962) and Lynn and Gordon (1961).

There is still little agreement on the value of frontal leucotomy in the treatment of chronic psychiatric illness (Pippard, 1962). A familiar feature of this uncertainty is the contrast between the enthusiasm of the authors of uncontrolled studies (Pippard, 1955; Scoville, 1960; Sargent and Slater, 1963; Birley, 1964; Sykes and Tredgold, 1964) and the scepticism of those who have included a matched untreated group (Robin, 1958; McKenzie and Kaczanowski, 1964; Brit. Med. J., 1965). These controlled series were only concerned with “standard” leucotomies, which are now generally abandoned. All studies, including those of modified leucotomy, examined heterogeneous psychiatric disorders and concentrated on their final state rather than their progress towards it. This approach may obscure important differences both in type of disorder and stage of follow-up.

Concern is now general (College of General Practitioners, 1958; Hill, 1960; School of Medicine and Human Biology, 1963) that doctors are inadequately trained for a number of the demands made on them in practice. Many doctors are not equipped to treat emotional disorders and to collaborate with psychiatrists in the treatment of psychologically ill patients. Under present conditions many young doctors graduate with a distinct antipathy to the social and emotional aspects of illness (Walton et al., 1963; Walton et al., 1964). Experienced general practitioners sometimes express strong dislike for the psychological component of their practice and disinclination to get any further training in psychological medicine (Rawnsley and Loudon, 1962). Even those doctors who do seek instruction in psychiatry differ widely in the type of teaching they want and in their attitudes to patients (Walton, 1965). Many of those selecting themselves for training are unsuitable (Balint et al., 1966).

“The non-mathematician is seized by a mysterious shuddering when he hears of ‘four-dimensional’ things, by a feeling not unlike that awakened by thoughts of the occult. And yet there is no more commonplace statement than that the world in which we live is a four-dimensional space-time continuum. By this we mean that it is possible to describe the position of a point at rest by means of three numbers (co-ordinates) x, y, z, and that there is an indefinite number of points in the neighbourhood of this one, the position of which can be described by co-ordinates such as x1, y1, z1, which may be as near as we choose to the respective values of the co-ordinates x, y, z of the first point. In virtue of the latter property we speak of a ‘continuum’, and owing to the fact that there are three co-ordinates we speak of it as being ‘three-dimensional’.

Since Kraepelin's classical description of cryptogenic or functional psychoses—manic-depressive, schizophrenia and paranoia—the possible influence of culture on the frequency of these clinical reactions has been considered. Although it is recognized that there are other types of mental disorders peculiar to certain cultural groups (8, 12), it is acknowledged that the kinds of psychoses mentioned above are repeated in the various cultures (5).