Suicidal tendencies are often present, and depend largely upon the misery associated with the condition. Melancholics often conceal this tendency, or may exhibit it in varied ways so as to hide the method which has been definitely decided upon. Thus a person so afflicted may be found in possession of poison at one time, a pistol at another, a knife at another, when the real intention is that of drowning. Thus it is necessary to keep an extremely careful watch on melancholics. Homicidal tendencies are not common. In some cases the melancholia is combined with marked agitation. The face depicts misery, the eyebrows raised, and the person moves about incessantly, picking up objects and replacing them, moaning and uttering the same phrases expressive of misery and hopelessness, wringing the hands, and rocking the body to and fro.
In other cases stupor is predominant, and the person sits in silence and in the same attitude. Some resent interference, others are easily persuaded by their attendants to do certain acts, but when done relapse again into stupor. They manifest extreme apathy. Suicidal tendencies are a pronounced feature of such cases.
Melancholia and mania may alternate periodically, with lucid intervals intervening. The term circular insanity has been applied to this alternate character of the disease.
DEMENTIA OR FATUITY
Dementia consists in a failure of the mental faculties, not congenital, but coming on during life. “A man,” says Esquirol, “in a state of dementia is deprived of advantages which he formerly enjoyed. He was a rich man who has become poor. The idiot, on the contrary, has always been in a state of want and misery.” In this state there is always more or less coherence, and maniacal paroxysms are not infrequent. In mania, incoherence may be present, but then it is characterised by sustained and violent excitement. In dementia, on the other hand, there is apparent torpor and exhaustion of the mental faculties. Closely allied to this form of mental unsoundness is that interesting disease known as “general paralysis of the insane,” or perhaps a better term, progressive paralysis of the insane. It is considered by some to precede the psychical derangement, a contrary opinion being held by others. General paralysis may accompany any of the forms of mental derangement, but it is generally preceded by a stage of melancholy. As the paralytic affection becomes more marked, there is a concurrent loss of memory and incapability of mental association, and all sense of duty is lost; the patient becomes careless as to his person, and dirty in his habits. He expresses himself as possessed of great property, and boasts of the wonderful deeds that he can or has accomplished. Gradually he sinks into a state of complete mental and physical decay. He cannot give expression to his thoughts, and has to be fed, the food being pushed into his mouth. The symptom which first attracts the attention, and which is perhaps the first order of sequence, is a modification in the articulation. “This is neither stammering nor hesitation of speech. It more closely resembles the thickness of speech observable in a drunken man. It depends upon loss of power over the co-ordinate action of the muscles of vocal articulation.” If the tongue be now examined, it will be found that when it is protruded it is not inclined to one side, but that it is tremulous, and is protruded and withdrawn in a convulsive manner. Griesinger was the first to call attention to the fact, and his statement has since been confirmed, “that this motory disorder is at the commencement not so much paralytic as convulsive in its nature.” The gait becomes unsteady, the patient walks stiffly, and stumbles over the slightest unevenness in the floor. Step by step the paralysis progresses, till at last the unfortunate sufferer takes to his bed, on which he may lie for months. Sometimes, especially during the earlier stages, he may suffer from terrible delusions, from maniacal paroxysms, or from epileptic fits, the latter possessing certain peculiarities. The tongue during the fit is seldom bitten, which is so commonly the case in epilepsy; and the convulsions are not so general, being limited more to one side than to the other. It is also remarkable that each fit is in most cases followed by an increase of the mental derangement.
Pritchard recognises four stages of dementia or fatuity:—
First Stage.—Forgetfulness and impaired memory. This is common to old age. In most cases passing events produce little, if any, impression, whilst the past is remembered with tolerable freshness.
Second Stage.—Incoherence and unreason, characterised by a total loss of the reasoning faculty.
Third Stage.—Incomprehension. The person so affected is quite incapable of comprehending the meaning of the simplest question; and should he attempt to reply, his answer is generally remote from the subject.
Fourth Stage.—Inappetency. The animal instincts are lost. The unfortunate sufferer lives, and that is all, being scarcely conscious of life. Organic life is all that is left.