If the general condition of the patient, that is, the physical health, is very much run down when the mental disturbance commences, then the outlook is much better than if the mental disturbance should occur when the patient is enjoying ordinarily good health. Thin, anaemic patients, contrary to what might be expected, usually recover and often their recovery is permanent. The first favourable sign in the case is an improvement in physical health. This is very shortly followed by an almost corresponding improvement in the mental condition. When the patient has reached the normal physical condition, the mental disturbance has usually disappeared.
It is an extremely unfavourable sign, however, to have run-down patients gradually improve in physical health [{221}] without commensurate improvement in their mental condition. This is nearly always a positive index that the mental disturbance will continue for a long while, may not be recovered from completely, or may degenerate into a condition of dementia with more or less complete loss of mental faculties.
The severe forms of melancholia are apt to be associated with delusions. Fear becomes a prominent factor, and the patient is afraid of every one who approaches, or concentrates his timidity with regard to certain persons or things. Delusions of persecution are not unusual, and this sometimes leads to homicidal tendencies. After enduring supposed persecution for as long as he considers it possible, the melancholic turns on his persecutors and inflicts bodily harm. The simplest actions, even efforts to benefit the patient by enforcement of the regulations of the physician, may be misconstrued into serious attempts at personal injury, for which the patient may execute summary vengeance. At times the hallucinations take on the character of the supposition that attempts to poison them are being made. The patient may conceal his supposed knowledge of these attempts until a favourable opportunity presents itself for revenging them. On the other hand, it is not an unusual thing to have melancholic patients commit homicide with the idea of putting friends out of a wicked world. The stories so common in the newspapers of husbands who kill wives and children, of mothers who murder their children, are often founded on some such delusion as this. A mother argues with herself, that her own unworthiness is to be visited on her children, and that they are to be still more unhappy than she is. Out of maternal solicitude, then, but in an acute excess of melancholia, she puts them out of existence and ends her own life at the same time.
When the melancholia is founded on supposed incurable ills in the body, patients are sometimes known to mutilate themselves, or to have recourse to alcohol, or some narcotic drug, in order to relieve them of their pain, which is mostly imaginary, and make life somewhat more livable during its continuance. Alcoholic excesses are especially common in [{222}] cases of recurrent or periodical melancholia. Many of the cases of so-called periodical dipsomania are really due to recurring attacks of severe depression of spirits, in which men take to alcohol as some relief for their intense feelings of inward pain and discouragement.
One of the most characteristic symptoms of melancholia is the refusal to take food. Sometimes this refusal is the consequence of an expressed or concealed desire to commit suicide. In many cases the refusal of food is associated with the patient's melancholic delusions. If the patient is hypochondriac, food is not taken because the stomach is supposed not to be able to digest it, or because it would never pass through the system. At times the delusions are in the moral sphere and the patient is too wicked to eat, or must fast for a long period or perhaps for the rest of life, with the idea of doing penance. As a matter of fact the refusal to eat is associated with the lowered state of function all through the system, which is the basis of the melancholic condition. This causes loss of appetite and lowering of the digestive function with a certain amount of nausea even at the thought of food, so that it is scarcely any wonder that patients refuse to take food. Needless to say, they must be made to eat. This often requires the insertion of a stomach tube and forced feeding. And as it must be done regularly, it is accomplished much more easily at an institution than at home.
The other most common type of functional mental disease is mania. This is a form of insanity characterised by exaltation of spirits with a rapid flow of ideas and a distinct tendency to muscular agitation. It is almost exactly the opposite of melancholia in every symptom. Originally, of course, mania meant any form of madness. Then it became gradually limited to those forms of insanity which differed from melancholia. Now it has come to have a meaning as an acute attack of mental exaltation. It is necessary to remember this development of signification in reading the older literature on the subject of mental disturbance.
Professor Berkley calls attention to the fact that Shakespeare's statement, "Melancholy is the nurse of frenzy," may have been founded upon the observation that there are [{223}] few cases of mental exaltation without a forerunning stage of depression. It is characteristic of the acuity of observation of the poet whose works have created so much discussion as to his early training, that this association of mental states, which became an accepted scientific truth only during the last century, should have been anticipated in a passing remark in the development of a dramatic character. Melancholia precedes mania so constantly that it is not an unusual mistake in diagnosis to consider a patient melancholic when an outbreak of mania is really preparing.
Mania is sometimes said to break out suddenly. As a matter of fact there are always preliminary symptoms; though these are of such a general nature that they may have escaped observation. The patient's history generally shows that there has been loss of appetite and consequent loss in weight, commonly accompanied by constipation and headache with increasing inability to sleep. Usually these symptoms have been present at least for some weeks or a month or more. Then the patient brightens up. Instead of the brooding so common before, there is a tendency to talkativeness; the eye is bright; the expression lively; in the midst of his loquacity the patient becomes facetious and jocular. The backward before become enterprising. Undertakings are attempted that are evidently far beyond the power, pecuniary or mental, of the individual. Active employment is sought, and, where this fails, restless to and fro movement becomes the habit.
Friends notice this change in disposition, and also note a certain lack of connection in the ideas. There is apt to be a distinct change of disposition. A man who has been very loath to make friends before, now becomes easy in his manner toward strangers and takes many people into his confidence. In the severer forms motion becomes constant; the arms are thrown around; to and fro movement at least is kept up; the voice becomes loud and is constantly used. Patients can not be kept quiet, and, as a consequence of their constant movement, their temperature rises and loss of sleep makes them weaker and weaker until perhaps physical exhaustion ensues.