This is a much more serious form of melancholia than the quiet kind. The mental faculties are much more completely unbalanced, and the prognosis of the case is more unfavourable. There may be recovery within a very short time, and this recovery may be more or less complete. Usually, however, the condition becomes chronic and runs for many years. Such patients may sometimes be distracted sufficiently from their state of depression to smile and manifest pleasure in other ways. Usually, however, this diversion is only temporary and they recur to their darker moods until some new and specially striking notion distracts their thoughts once more.
With regard to melancholia the most important feature is the tendency to suicide. This is apt to be present in any case, however mild, and may assert itself unexpectedly at any moment. Where there is suspicion of the existence of melancholia, patients must be under constant surveillance; and, as a rule, they should be under the supervision of some one accustomed to the difficulties that such cases may present. Patients are often extremely ingenious in the methods by which they obtain the opportunities necessary for the commission of suicide. For instance, a man who has been calm in his depression and has shown no special suicidal tendencies may make his preparations apparently to shave and then use his razor with fatal success. In a recent case in New York City, a woman under the surveillance of a new, though trained nurse, asked the nurse to step from the room for a moment. When the nurse came back three minutes later, the woman was crushed to death on the sidewalk seven stories below. A male patient asks an attendant { 220} to step from the room for a moment for reasons of delicacy, and takes the opportunity to possess himself of some sharp instrument or of some poison. At times, during the night, patients rise up while attendants doze for a few minutes, and find the means to hang themselves without the production of the slightest noise.
These unfortunate suicides are happening every day. They are the saddest possible blow to a family. Only the most careful watchfulness will prevent their occurrence. Clergymen should add the weight of their authority to that of the medical attendant in insisting, when such patients are kept at home, that they shall be guarded every moment. As a rule melancholic patients should be treated in an institution. Their chances of ultimate complete recovery, and, more important still, of speedier recovery than at home are much better under the routine of institution life and the care of trained attendants.