Mentally there is simple depression, without, in the majority of cases, any implication of consciousness. Many patients pass through attack after attack without suffering from hallucinations or delusions, but in rare cases hallucinations of hearing and sight are present. Delusions of unworthiness and unpardonable sin are not uncommon, and if once expressed are liable to recur again during the course of each successive attack. The disease is prolonged and chronic in its course, and the condition of the patient varies but little from day to day. When the depression follows excitement, the patient as a rule becomes fat and flabby. On the other hand, if the illness commences with depression, the chief physical symptoms are mal-nutrition and loss of body weight, and the return to health is always preceded by a return of nutrition and a gain in body weight.
The attacks may last from six months to two or three years. The intervals between attacks may last for only a few weeks or months or may extend over several years. During the interval the patient is not only capable of good mental work but may show capacity of a high order. In other words this form of mental disorder does not tend to produce dementia; the explanation probably being that between the attacks there is no toxaemia.
Treatment.—There is no known curative treatment for the depression of manic-depressive insanity, but the depression, the sleeplessness and the gastric disorder are to some extent mitigated by common sense attention to the general health of the body. If the patient is thin and wasted, then treatment is best conducted in bed. The diet should be bland, consisting largely of milk, eggs and farinaceous food, given in small quantities and frequently. Defecation should be maintained by enemata, and the skin kept clean by daily warm baths. What is of much more importance is the fact that in some instances subsequent attacks can be prevented by impressing upon the patient the necessity for attending to the state of the bowels, and of discontinuing work when the slightest symptoms of an attack present themselves. If these symptoms are at all prominent, rest in bed is a wise precaution, butcher-meat should be discontinued from the dietary and a tonic of arsenic or quinine and acid prescribed.
Mania.—The term mania, meaning pathological elevation or excitement, has, like the term melancholia, been applied to all varieties of morbid mental conditions in which the prevailing mental symptom is excitement or elevation. Mania. As in melancholia so in mania various subdivisions have been invented, such as delusional mania, religious mania, homicidal mania, according to the special mental characteristics of each case, but such varieties are of accidental origin and cannot be held to be subdivisions.
Under the term mania two distinct diseased conditions can be described, viz. acute mania, and the elevated stage of folie circulaire or manic-depressive insanity.
Acute Mania.—Acute mania is a disease which attacks both sexes at all ages, but its onset is most prevalent during adolescence and early adult life. Hereditary predisposition, physical and mental exhaustion, epileptic seizures and childbirth are all predisposing causes. The direct exciting cause or causes are unknown, but the physical symptoms suggest that the condition is one of acute toxaemia or poisoning, and the changes in the blood are such as are consequent on bacterial toxaemia.
The onset is gradual in the large majority of cases. Histories of sudden outbursts of mania can rarely be relied on, as the illness is almost invariably preceded by loss of body weight, sleeplessness, bad dreams, headaches and symptoms of general malaise, sometimes associated with depression. The actual onset of the mental symptoms themselves, however, are frequently sudden. A typical case of the fully developed disease is not easily mistaken. The patient is usually anaemic and thin, the expression of the face is unnatural, the eyes widely opened and bright; and there is great motor restlessness, the muscular movements being purposeless and inco-ordinate. This inco-ordination of movement affects not only the muscles of the limbs and trunk but also those of expression, so that the usual aspect of the face becomes entirely altered. The temperature is generally slightly febrile. The tongue and lips are cracked and dry through excessive shouting or speaking. There is often no desire for food or drink. The heart’s action is rapid and forcible. The skin is soft and moist. The urine is scanty, turbid and loaded with urates. The white blood corpuscles per cubic millimetre of blood are markedly increased, and the blood serum contains agglutinines to certain strains of streptococci which are not present in healthy persons. Sensibility to pain is lost or much impaired. Such patients will swing and jerk a broken limb apparently unaware that it is broken. Sleep is absent or obtained in short snatches, and even when asleep the patient is often restless and talkative as if the disease processes were still active.
Mentally the patient is excited, often wildly so, quite confused and unable to recognize time or place. Answers to questions may sometimes be elicited by repeated efforts to engage the attention of the patient. The speech is incoherent, and for all practical purposes the patient is mentally inaccessible. This state of acute excitement lasts usually for two or three weeks and gradually passes into a condition of chronic restlessness and noise, in which the movements are more coordinate and purposeful. The confusion of the acute stage passes off and the attention can be more readily attracted but cannot be concentrated on any subject for any length of time. The patient will now recognize friends, but the affections are in abeyance and the memory is defective. The appetite becomes insatiable, but the patient does not necessarily gain in weight. This stage of subacute excitement may last for months, but as a rule favourable cases recover within six months from the onset of the disease. A recovering patient gradually gains weight, sleeps soundly at night and has periods of partial quiescence during the day, particularly in the morning after a good night’s sleep. These lucid intervals become more and more prolonged and finally pass into a state of sanity. Some cases on the other hand, after the acute symptoms decline, remain confused, and this state of confusion may last for months; by some alienists it is described as secondary stupor.
The symptoms detailed above are those typical of an attack such as is most frequently met with in adult cases. Acute mania, however, is a disease which presents itself in various forms. Adolescent cases, for instance, very commonly suffer from recurrent attacks, and the recurrent form of the disease is also to be met with in adults. The recurrent form at the onset does not differ in symptoms from that already described, but the course of the attack is shorter and more acute, so that the patient after one or two weeks of acute excitement rapidly improves, the mental symptoms pass off and the patient is apparently perfectly recovered. An examination of the blood, however, reveals the fact that the patient is still suffering from some disorder of the system, inasmuch as the white blood corpuscles remain increased above the average of health. Subsequent attacks of excitement come on without any obvious provocation. The pulse becomes fast and the face flushed. The patient frequently complains of fullness in the head, ringing in the ears and a loss of appetite. Sleeplessness is an invariable symptom. Self-control is generally lost suddenly, and the patient rapidly passes into a state of delirious excitement, to recover again, apparently, in the course of a few weeks. Recurrent mania might therefore be regarded as a prolonged toxaemia, complicated at intervals by outbursts of delirious excitement. Acute mania in the majority of cases ends in recovery. In the continuous attack the recovery is gradual. In the recurrent cases the intervals between attacks become longer and the attacks less severe until they finally cease. In such recovered cases very frequently a persistent increase in the number of the white blood corpuscles is found, persisting for a period of two or three years of apparently sound mental health. A few cases die, exhausted by the acuteness of the excitement and inability to obtain rest by the natural process of sleep. When death does occur in this way the patient almost invariably passes into the typhoid state.
The residue of such cases become chronic, and chronicity almost invariably means subsequent dementia. The chronic stage of acute mania may be represented by a state of continuous subacute excitement in which the patient becomes dirty and destructive in habits and liable from time to time to exacerbations of the mental symptoms. Continuous observation of the blood made in such cases over a period extending for weeks reveals the fact that the leucocytosis, if represented in chart form, shows a regular sequence of events. Just prior to the onset of an exacerbation the leucocytosis is low. As the excitement increases in severity the leucocytosis curve rises, and just before improvement sets in there may be a decided rise in the curve and then a subsequent fall; but this fall rarely reaches the normal line. In other cases, which pass into chronicity, a state of persistent delusion, rather than excitement, is the prevailing mental characteristic, and these cases may at recurrent intervals become noisy and dangerous.