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.

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.

Eighty years ago Gilles de la Tourette (1885) described the syndrome which has become eponymous. It has been usual to consider it as a relatively rare constellation of symptoms, sometimes the concern of the neurologist, sometimes of the psychiatrist; but in recent years three papers (Bockner, 1959; MacDonald, 1963; Polites, Kruger and Stevenson, 1965) discussing the syndrome and its treatment have appeared in British journals alone. All comment on the infrequency of the syndrome, but one does suggest that it may be less infrequent than has been thought in the past.

Ideas of changing sex, and the doubt about sexual identity which these ideas imply, are considered to be “invariable” and “pathognomonic” features of schizophrenia by Macalpine and Hunter (1955). The authors quote, in a footnote, a personal communication from Manfred Bleuler dated 1953 which states that Eugen Bleuler would have agreed that “schizophrenics are almost invariably, if not indeed invariably, in doubt about the sex to which they belong”. Planansky and Johnston (1962), in an uncontrolled study of 150 male schizophrenics, found that only 15 per cent. (22 cases) exhibited “direct expression of confusion of sex identity” and only 4·7 per cent. (7 cases) had clear delusions of having changed into a woman. Jackson (1960), Weckowicz and Sommer (1960), and Skottowe (1964) state merely that these ideas occur, or occur frequently. A check of the standard English language teaching texts reveals that Allen (1962), Bleuler (1911), Mayer-Gross et al. (1960), Noyes and Kolb (1963) and Sim (1963) make only oblique references to ideas of changing sex, whilst Anderson (1964), Arieti (1959), Bellak and Benedict (1958), Curran and Partridge (1963), Fish (1962 and 1964), Freeman et al. (1958), Henderson and Batchelor (1962), Merskey and Tonge (1965), and Stafford-Clark (1964) make no reference at all. In their study of schizophrenic delusions Lucas et al. (1962) similarly do not mention change of sex. They state simply that (in males) 30 per cent. had a sexual content.

Problem

The existence of impairment in abstract ability for certain abnormal groups has been well documented in the clinical literature (Goldstein, 1936, 1943; Goldstein and Sheerer, 1941). The concept of “abstract ability” involves various types of abilities which may or may not be related to each other in specific ways. For example, the ability to solve syllogisms need not necessarily require the same order of skill as elucidating proverbs, although persons gifted in abstract capabilities may excel in both. Nevertheless, groups of abilities variously referred to as “abstract” seem to undergo appreciable modifications in organic and functional pathologies and disorders.

A physiological index of anxiety would be of considerable value if it could evaluate objectively the diminution in anxiety which follows drug treatment, psychotherapy, deconditioning and prefrontal leucotomy. Anxiety is an unpleasant subjective experience of tension, apprehension or anticipation imposed by the expectation of danger or distress or the need for a special effort. The components of the accompanying physiological response lend themselves to objective measurement and are worthy of study since they reflect the emotional changes which defy direct measurement.

In previous studies of somatosensory cerebral evoked responses in psychiatric patients, we found that two characteristics of these responses discriminated between patients with psychotic depressions and healthy or psychoneurotic subjects. The amplitude of the initial negative-positive component was larger and its recovery, as determined by administering paired “conditioning” and “test” stimuli, was retarded (11, 12, 13). Furthermore, after successful therapy, the recovery measure changed in the direction of “normal” (11).

Recent developments in the vexed questions of the relative importance to be attributed to genetic and environmental factors in the aetiology of schizophrenia, and the manner in which they interact to produce a phenotypic psychosis, are highlighted by David Rosenthal's series of critical papers (1959–1962) on twin and family studies and the book edited by him chronicling the lives of a set of monozygotic quadruplets all concordant for schizophrenia (1963). In his thorough and open-minded critique Rosenthal argues that previously reported concordance rates for monozygotic (MZ) twins have been misleadingly high. To this point we shall return in a moment. Rosenthal finally concludes that “the best information we now have with respect to the whole broad question of heredity and environment in schizophrenia, is to be found mainly in the five major studies of twins.” Unlike some who have pointed out weaknesses in the studies, he believes that “our task is to determine their source, extent and implications, not to dismiss them offhandedly because they contain errors” (1962a, p. 132).

The place of genetic factors in the aetiology of schizophrenia remains disputed. Several surveys have demonstrated a significantly higher incidence of the disorder in relatives of schizophrenic persons as compared to the general population. Furthermore, the closer the relationship, the higher the incidence of schizophrenia. The studies of Kallmann (1938) and Slater (1953) are especially significant and the research in this area has been thoroughly reviewed by Alanen (1958).

In recent years there has been a wide interest in the cross-cultural aspects of mental illness. Information concerning incidence, symptomatology and attitudes towards mental illness in the developing countries may contribute to the understanding of psychological processes and psychiatric problems. Kline (1963) reported a number of surveys of psychiatry in non-Western countries. One of these surveys was conducted in Kuwait, which is culturally and geographically intimately related to Iraq. This study aims at adding to Kline's data by providing information about various facets of psychiatry in Iraq. The present data were collected through interviews with a number of practising psychiatrists and through reference to hospital statistics and other relevant literature, in addition to the authors' clinical experience.

During the past ten years much attention has been paid to the question of chronicity in mental hospital patients. At the same time there has been a trend towards establishing units (often attached to general hospitals) for short-stay in-patient and possibly day-patient care. In these units, where the emphasis is on outpatient treatment, it is soon apparent to the psychiatrists staffing them that they, too, have to cope with a population of chronic patients. They tend, however, to be outpatients rather than in-patients, and are probably better described as “long-term”. Heasman (1962) gave a graphic description of this problem in the non-psychiatric outpatient department and compared it to that of the “institutional neurosis” as described by Barton (1959). The purpose of this paper is to describe the situation in a Teaching Hospital Department of Psychiatry attached to a general hospital.

This investigation was done to determine whether marked differences are present among lecturers in a single teaching department. Individual lecturers might vary in their teaching aims and attitudes, but yet resemble some of their colleagues sufficiently for sub-groups to form within the department. Such a university department might set out to provide students with a range of conceptual viewpoints, and for this purpose approve discrepant orientations among the teachers. On the other hand, a department may adopt the contrary view that only a confusing impression can result if—in the course of relatively brief undergraduate psychiatric instruction—contradictory statements are expressed by different teachers. Some departments, as yet unaware of the need to specify objectives, may never give consideration to the amount of consensus prevailing among the lecturers as a body.