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.