Unexpected death frequently occurs in mania because of the failure to recognise the existence of serious pathological conditions. Pneumonia may develop, for instance, without the slightest complaint on the part of the patient and go rapidly on to a fatal termination during the exhaustion incident to the constant movement, it being utterly impossible to confine the patient to bed. Meningitis may develop in the same way and proceed to a fatal issue without the patient's making any complaint or any sign that will call attention to its existence. In the meantime, the patient may be constantly in the wildest motion and so add to the exhausting effect of the organic disease.
The prognosis of acute mania is not unfavourable. Patients suffering from a first attack will recover completely in eight cases out of ten. Notwithstanding complete recovery, relapses are prone to occur whenever the patient undergoes a severe emotional strain. As a rule not nearly so much mental disturbance is required to produce a second attack { 228} as the first one, so that patients require great care. In a certain number of cases recovery is incomplete; persistent delusions remain, and there may even be some weakness of intelligence. Paranoia, as it is called, mild delusional insanity, may assert itself and then may persist for the rest of life. Notwithstanding this, patients may get along in life reasonably well, though their mental condition is decidedly below the normal.
In a certain number of cases, after the period of excitement disappears, a certain amount of dementia is noticed. This consists of a distinct lowering of the intelligence, though without the presence of any special delusion. This dementia progresses until finally there is a state of almost complete obliteration of the mental faculties. The prognosis as to life in cases of mania is very good. Very few patients die during an attack of acute mania. At times there is a development of tuberculosis that proves fatal, because of the restlessness of the individual. Pneumonia or typhoid fever may also prove fatal.
Besides mania or melancholia, there is a third form of functional mental disease, which is a combination of these two forms. It is usually spoken of as circular insanity. The patient has usually first an attack of melancholia, then an attack of mania, and then after an interval melancholia and mania once more. We have said that most cases of mania develop after a distinct stage of depression of spirits, so that successive attacks of mania take partly the character of circular insanity. This latter disease, however, is an index of a much more degenerated mental state of the individual than is either mania or melancholia alone. When it occurs, the prognosis as to future sanity for any lengthy interval is unfavourable. A series of attacks alternately of depression and excitement finally make it necessary to confine the patient to an institution.