My first duty is to thank you for the honour you have conferred on me in electing me President, and to welcome you all on your visit to East Kent and Folkestone for, I think, the first time in the history of the Association.

I hope it will not be a waste of time to begin by seeing what can be meant by prognosis in this difficult kind of illness. Prognosis is often conceived as the natural history of disease—or the course it will follow if it is not interfered with. Treatment is valued for the good modification it produces in this “natural” course of events; it may hurry up the processes of recovery or it may bring about recovery that would not otherwise occur, or it may lessen the harm the disease does; in other words, the efficacy of treatment is assessed by the changes produced in the time the illness takes and the shape it takes. In the case of such a disease as malaria, this conception of prognosis, and this use of it for assessing treatment, can be demonstrated. In psychiatry, however, one is not as a rule dealing with parasites, bacteria, or other exogenous agents which live and exert their influence in a definite order of time and place. Causes of mental illness have no set sequence or constancy. Those external to the patient are as variable and manifold as the pattern of daily life around us, and those intrinsic in him are seldom capable of forcing their way and becoming manifest as illness, no matter what befalls the patient. They are for the most part dependent on circumstance, and of their particular transmission and manifestation we know little; we infer hereditary and constitutional causes with good grounds, but of the details of heredity in any of the individual forms of mental illness we cannot be sure. Consequently we cannot find now any accuracy of prognosis, in the sense of predictable sequence in an individual, based on comparable experience of many others; the variations will be too many; we may expect such accuracy when we know more of the nature and mode of transmission, and of the influence of external circumstances upon time and form and degree of manifestation of each kind of mental illness. Without accurate knowledge of how the causal and modifying factors act, prognosis must be uncertain to a greater extent than in many other illnesses. In medicine, it is true, prognosis can hardly ever be exact, but here it is more inexact than usual.

The following paper represents an attempt to determine more precise prognostic criteria in the large group of the depressions of later life, to find if possible some other guiding lines than the relatively rule-of-thumb principles which obtain, freed as far as possible from debatable preconceptions as to the existence of an “involutional melancholia” or other specific diagnostic label. Obviously in such a group the influence of the menopause and involution periods might be expected to be prominent.

The observations I wish to make in this paper are based upon some work which my colleagues at Cardiff and I have carried out, and which has a bearing on the question of prognosis in the manic-depressive psychoses.

Originally used to describe any case of dementia with chronic excitement, the term “chronic mania” has been limited in its application to a group of cases described by Schott and others during this century. In the main, they apply it to cases of mania developed after the age of 40, and differing from an acute attack chiefly in their long duration. In the cases I describe I have confined myself to this usage, and have not included constitutional fluctuating hypomanics who have manifested this after their youth onwards, nor do I include prolonged manic phases in circular manic-depressive cases.

The investigations on which is based the form of therapy presented in this paper being partly several years old, and partly published in Scandinavian languages, it will be of advantage to review them briefly.

As there is still considerable hesitancy in the adoption of this valuable form of therapy, I am glad to have an opportunity of stating the case for a more widespread application of prolonged narcosis to the manic-depressive disorders. A legitimate diversity of opinion exists as to the propriety of using any drug with a toxic action over a long period, especially so when it introduces an extraneous, and maybe serious, risk into a disease of itself non-fatal, and with a large recovery-rate. With attention to detail in the treatment, and with the addition of the Cardiff modification of prolonged narcosis, we are satisfied that toxic symptoms arising during the administration of somnifaine—the drug used—can be controlled, and the risk heretofore associated with this form of therapy eliminated.

During 1931, 1932 and 1933 at least 20 female cases of mania were admitted to the Warwick County Mental Hospital, and I propose to review the treatment of these cases, omitting melancholia because of the difficulty of excluding involutional illnesses, because mania is more difficult to treat (1), and finally because the results of treatment are easier to follow.

Dr. Tómasson's interesting remarks on the therapeutic effect of adrenergic and cholinergic drugs lead me to mention some experiments with benzedrine recently carried out at the Maudsley Hospital. These experiments primarily originated from different considerations. They were part of more extensive investigations into the connection between mental phenomena and blood-pressure and its fluctuations. Benzedrine seemed to be suitable for experimental alterations of the blood-pressure because its effect on arterial tension lies between that of adrenaline and ephedrine with regard to rapidity and intensity of action. Experiments on normal persons demonstrated a peculiar stimulating and euphorizing effect of the drug. The experimental subjects were selected as normal in regard to blood-pressure. They included several cases of mild depression. These also showed either a slight elation, or at least a decrease of their depression after the administration of the drug. This result encouraged further experiments on depressives of various kinds. These were always carried out in the following way: Patients whose mental state was well known and who had been constant for a period with regard to their blood-pressure were given at first small, and later slowly increasing doses of the drug. There were intervals without medication in which the subjects received inert tablets of the same appearance and taste as the benzedrine. The blood-pressure was taken several times daily.

In the development of psychiatric genetics progress has been very largely dependent on the progress of clinical psychiatry. In the early days the theory of polymorphism held the field—that is the idea that there is a single hereditary basis for what may be called degeneration, which might show itself in many forms, any form of insanity, psychopathic character, criminality or mental defect. This theory was built up on the unclear psychiatry of the day, when the boundaries between different clinical states were vaguely drawn and largely in dispute. We are now passing out of this stage in clinical psychiatry, but the genetic theory that was built on it, the idea of polymorphism, still lingers on. It has been the stimulus to an immense amount of muddled research of no value. The time has come when this theory should be finally discarded. We are not entitled to think that different clinical conditions have the same genetic basis until such has been proved. From a factual point of view the accumulation of knowledge has shown it in a number of cases to be untenable. From a heuristic point of view it offers no possibilities of advance.

The material on which this communication is based was obtained during a survey of all the patients in Severalls Mental Hospital, one of the objects of which was to obtain information about the incidence of the various types of mentally disordered and mentally defective patients. An account of this survey was published in the Journal of Neurology and Psychopathology for January, 1936. For the purpose of the present more detailed analysis of the results relating to manic-depressive insanity and mental deficiency, mental ability has been graded as (1) feeble-mindedness, including all patients certifiably defective, (2) dullness, i.e., subnormal ability without certifiable defect, (3) normal.

The occurrence of irritability has been described in most text-books as a symptom in manic and depressive states. The causation of this symptom and the circumstances in which it is observed, have not received much close attention. Most authors put the states of irritability under the heading of mixed states. They cannot, however, be regarded as such in a strict sense, because the effect of irritability brings into the picture something new which cannot be derived from a mixture of the basal manic-depressive symptoms.

The material for this paper was obtained by using the Rorschach test. Purely as an introduction to this paper it may be said that the test differentiates individuals according to their preference for perceptions of form, colour and movement. This separation into categories is obtained by the exhibition to the patients of ink-blots of different colours and shapes. For details of the technique the best source of reference is Rorschach's Psychodiagnostik, though no English translation of the original German is available in print. For those unfamiliar with the test the articles of P. E. Vernon, McCalman, and the present author may be found useful.

The following tentative theory is to a large extent influenced by Rouart's work. This psychiatrist recognizes two fundamental forms of behaviour—periodic and intermittent.

I am not amongst those who believe that a complete understanding of the manic-depressive states can be reached within the field of psychopathology. On the other hand, it is quite impossible to render intelligible the behaviour, thoughts and feelings of these patients without reviewing the changes which occur at the psychological level. Instead of baffling myself by thinking in those speciously convenient terms “functional” and “organic”, I find it more satisfying to look at the patient from the Meyerian point of view; that is to say, as an integrated series of functional levels—an extension, if you like, of Hughlings Jackson's and Sherrington's well-known conceptions of central nervous function, downwards to the more archaic autonomic level (and all that is implied by that), and upwards into the more recently evolved realm of function, of which we can at present speak only in psychological terms, because we do not know enough to speak of it in any others. The disturbance is of the functioning organism as a whole; and I believe that the clinical picture depends to a large extent upon the levels where the disturbance is greatest. Unless all human values go by the board, however, we shall always require the aid of psychopathology to enable us to reach a complete understanding. Frustration will always produce sorrow, or a state of which sorrow is an important component; and achievement will always produce elation or one of its allied states. The converse of these propositions is not necessarily true; and although there may be strong presumptive evidence for doing so in individual cases, it is not necessarily correct to assume that because a state of joy or sorrow exists, it must have been preceded by some achievement or frustration as the case may be. To me, there are two essential parts of the problem in any given case. The first—and more difficult—is, Why does the emotional swing arise? And the second is, To what extent is the psychosis intelligible by considering the emotional change in relation to the sum total of the events that go to make up the patient's life? This involves a process of empathy—what the Germans call Einfühling—and it is relatively easy for those of cyclothymic disposition to do it. The crux of the situation is therefore the emotional change; and although its origin may not always he at the psychological level—in fact in the extreme sense I suppose it never does—I am much impressed by the psychological principle implied by MacCurdy's explanation of certain manic states. He says, in effect, that they do arise from achievement, from fulfilment—if we must use analytical terms—of an unconscious wish, in respect of which there has been and still is considerable conflict; and that the manifest thought content may be in part a secondary phenomenon, and in part a fragmentary disguise of the wish. It does not matter whether the wish is conscious or not; nor, so far as emotional value goes, does it matter whether it is achieved in fact or in phantasy. A biological urge of some kind has been fulfilled, or what is psychologically very similar, is on the verge of practical fulfilment; and the natural concomitant of that fulfilment is joy or elation. It needs but little introspection and observation to be assured of the naturalness of this reaction; and the benign qualities, which we expect, are present in proportion to its purity. It may be argued that the schizophrenic also secures achievement in phantasy; why then is he not elated? Does not the answer He in this: The manic patient's thinking and behaviour are gross; they are open for all to see; he is frankly and openly erotic or obscene or aggressive, and the more acute the attack the more gross are his thoughts and behaviour. There is no disguise—or perhaps it would be more correct to say the more acute the attack, the less the disguise. Symbols are practically unnecessary for the manic patient; so is projection; he may transfer his affect, but he does not disguise it. He is in fact uninhibited to a degree. As MacCurdy says, where there is no repression, there is no need for disguise. If one likes to put it so, the material with which the manic patient has to deal is not so deeply suppressed, is more ordinary, less archaic, less perverted, less worthy of guilt, or less infantile, according to the shibboleths of one's own psychological beliefs. Needless to say these views are quite incompatible with those of Freud and Abraham, who, although they differ as to the erogenous zone concerned, are agreed that the manic is narcissistically fixated. Anything less narcissistic than a full-blooded acute mania I have never seen. The whole keynote of the manic is that he is ordinary. He is concerned with real things, the most clamant of which is his own real emotion, with which he cannot deal if, at the same time, he is to keep his thought and behaviour directed towards ordinary everyday external goals.