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374                                              MEDICAL JTJEISPRUDENCE

normal in frequency. The temperature is usually sub-normal, but is often
slightly raised in the evenings. The urine is diminished in quantity, and is
passed at long intervals. It may even be passed only once in twenty-four
hours. In males impotence is usually observed. In females menstruation
is generally absent, but reappears when recovery occurs, or when the
disease becomes chronic.

The superficial and deep reflexes are often found exaggerated. Mus-
cular movements are slow and weak, the larger proximal joints are rigid
and the powers of fine inco-ordination are impaired. Sensation is, as a rule,
normal, though sensitiveness to noise is a marked feature.

The mental symptoms generally appear along with the physical
symptoms. Perception is normal, orientation is usually quite correct, and
the memory and the intellectual faculties are well preserved, but volitional
attention is generally poor and defective. There is paralysis of emotional
reaction. Good or bad news or even a joke does not affect the patient, who
feels gloomy and miserable, and experiences psychic pain. He has lost the
social instinct. He sits apart, refuses to mix with his neighbours, or to take
part in outdoor games or social festivities.

Hallucinations and delusions are usually present. Hallucinations are
often of an auditory type, in which the patient imagines that he hears voices
accusing him of various misdeeds or threatening him of punishment.
Delusions are generally of a hypochondriacal nature. The patient believes
that he suffers from some incurable disease, e.g. closure of the oesophagus,
gangrene of the intestines or wasting of the brain, and that he will die a
miserable death. Delusions may also be of the religious or persecuting
character. The patient believes that he has committed the unpardonable sin
against God, or that his food is being poisoned by some persons conspiring
to kill him.

Suicidal tendencies are common, though the patient may develop
homicidal tendency, and may kill his wife and children to save them from
the supposed utter ruin, or may kill some person, whom he believes to be
giving him and his family all the imaginable trouble of the world.

Sometimes, the patient is afraid of some impending disaster, and he is
so much agitated or excited in his anxiety, that he keeps on moving inces-
santly, wringing his hands, rocking to and fro and bemoaning his piteous
plight. Such a patient often resists being fed, dressed or washed. He is
unmindful of personal cleanliness, and passes urine and faeces in his

On other occasions the patient passes, as it were, into a stuporous
condition. He is pathetic, and sits silent and motionless in the same fixed
attitude for a long time. He has to be spoon or tube fed, and his bladder
and bowels have to be attended to.

Acute melancholia may alternate with an attack of mania with a lucid
interval intervening between the two. This alternating form of the disease
is known as circular insanity or folie circulaire.

An attack of acute melancholia, on an average, lasts from six to eight
months and ends in recovery. If the attack is not followed by recovery
within a year, it usually passes into a chronic condition. Death may occur
in the acute stage, when the patient passes into a typhoid state.

Chronic Melancholia.—This form results from the acute form, and is
characterized by some improvement in the physical signs but not in the
mental symptoms. The patient becomes fat and increases in weight. His
digestive powers also improve, and the bowels open regularly. The patient,
however,.remains persistently depressed, and suffers from hallucinations
and delusions.