Autointoxication is said to play a prominent rôle in the causation of melancholia. This supposes that there is a manufacture of poisonous materials within the system, whose transference to the nervous tissues causes functional disturbance of these delicate organs. Such poisons are especially liable to be manufactured when digestive disturbances have existed for long periods of time, or when chronic alcoholism is a feature of the case. The ordinary depressed condition so familiar in our dyspeptic friends and that develops so commonly as the result of indigestion, is an example of the depressing effect of toxic substances upon nervous tissues and mental states.
Melancholia does not develop as a rule without some warning of what may be looked for. Nutritive disturbances are nearly always prominent features in the case for some time before any mental peculiarities are noticed. Professor Berkley remarks that a feeling of woe and of uneasiness seems to be the way by which the brain expresses its sense of the lack of proper nourishment. Usually there has been distinct digestive disturbance for some months. There is apt to be loss of appetite. There may be some slight yellowness in the whites of the eyes. Commonly there has been an increasing disregard for the patient's usual habits, especially in the matter of exercise and friendly intercourse. There is a disposition to sit apart and brood by the hour, and a well-marked tendency to avoid friends and even members of the family, with an utter disinclination to meet strangers.
One of the marked features of the disease in women is a tendency to untidiness. Women lose all regard for their personal appearance and fail to arrange their clothes properly. Men who have been specially neat in their personal appearance take on slouchy, careless habits, allow their clothes to become soiled and dirty, and have evidently forgotten all their old customs in this matter.
The symptoms are not always continuous. There is often a rhythmic alteration of intensity of symptoms that corresponds more or less to the physiological rhythm of life. In ordinary circumstances human temperature is highest in the afternoon and vital processes are most active at this time. The lowest temperatures occur in the morning, especially in the early hours; and it is at this time that vital processes are least active and the general condition is most depressed. It is not surprising, then, to find that melancholic patients are liable to suffer from deeper mental depression during the morning hours. In suicidal cases it is especially in the morning hours that patients need the closest surveillance.
In a certain number of cases of melancholia, instead of the quiet, often absolute immobility of the patients, there is a form of the disease characterised by the presence of incessant movement and an agitated state of countenance, [{219}] that disclose their disturbed mental conditions. In melancholia, as a rule, sleep is very much disturbed, and at times patients do not sleep at all. In the agitated form of melancholia, the patient is often quiet only when under the influence of a sleeping-potion. Patients may tear their hair, disarrange their clothing, strike themselves, hit their heads against the wall, sigh and sob, and repeat some phrase that indicates their deep depression. They are apt to reiterate such expressions as "I am lost," "I am damned."
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.
Nearly three-fourths of the patients who suffer from melancholia will recover from a first attack under proper care. Subsequent attacks make the prognosis much more unfavourable. Not more than one-half will recover from a second attack, and, although melancholia is often spoken of as a mild form of intellectual disturbance, recurring attacks give a proportionately worse and worse outlook for the patient.