— The mental symptoms of melancholia are depression, hallucinations and illusions, delusions, fear of death, and tendency to suicide. The last-named is potentially present in all cases, but is active in many.
In simple melancholia there is pro found depression, with a fear of never recovering either physical or mental health. In these cases the memory and judgment are usually preserved, but the patient is so entirely under the control of the depressive emotion that he cannot think normally.
In melancholia with delusions, the latter are usually those of self-accusa tion, self-abasement, or of justifiable persecution. The melancholiac feels that he is justly punished by God for some transgression, real or imagined. Indeed, he fancies usually that his pun ishment is entirely inadequate to the transgression.
The melancholiac seeks death either because he thinks he merits it, or—and this is perhaps more frequently the case —to escape from mental distress, which becomes unbearable.
[A patient of mine, who had set fire to her clothing and thus attempted to destroy herself, gave as an excuse that "the devil w as after her and she tried to escape him." GEORGE H. Rona] One of the most persistent delusions of melancholia is that there is destruc tion of the abdominal viscera and that no food can pass; that, if taken it will not pass and that it will cause the patient's death if forced upon him. The com plaints of being "rotten inside" are fre quent among melancholiacs. The phys ical demonstration of eating a meal, of living through it and maintaining the strength, and of the regular continuance of defecation has no effect upon the de lusion. It persists in spite of the con stant contradictions which the patient himself furnishes. On the other hand, it must be borne in mind that the sensa tions of obstruction may be real, and that an actual stenosis of the bowel may be present. Such cases have been re ported by Clouston and by me.
The delusion that the patient has com mitted "the unpardonable sin" or "the sin against the Holy Ghost" is an ex tremely obstinate one. Savage regards
this delusion as an unfavorable one, as patients manifesting it—"the unpardon able sinners," as he calls them—rarely recover. The nature of the unpardonable sin varies with different persons. Most of them cannot or will not define it.
In some cases the fear of impending death colors all thoughts and actions of the patient. Food and medicine are re fused, because the patient will presently die. Nothing can be done to prevent it. In other cases all friends have deserted the patient, and there is nothing left hut to die.
Most melanch.oliacs are more or less passive and quiet; beyond making ver bal complaints of their sufferings they sit and brood over their troubles, which are always real to them. In other cases, however, there is great restlessness. The patients are constantly in motion, crying and lamenting, sometimes under the stress of their delusions there are out breaks of violence, although these are rare.
The suicidal tendency is present in a large proportion of melancholiacs. Life is usually taken by violent means. Hang ing, shooting, jumping from a height, cutting the throat, and drowning, are the most frequent methods. Even such pain ful methods as burning, and swallowing broken glass are resorted to. The at tempts are sometimes very persistent.
Sometimes melancholia is combined with a stuporose condition,—"melan cholia with stupor." In these cases the patient sits or stands all day long, mute, apparently taking no note of anything going on around him. There is some times also resistance to everything done for the patient. Some authors class the affection described by Kahlbaum under the name catatonia with stuporose melan cholia, but in my opinion, catatonia be longs to the group of which general paresis is the type.
Causation. — Anything that depresses the general nutrition in one predisposed to insanity may cause melancholia. The essential physical substratum of the dis ease is probably cerebral anremia, al though at present the morbid anatomical condition of the brain in melancholia is not known.