If we examine his appearance and bodily condition, what do we find? His aspect is dejected, dull, and heavy, or woebegone to an extreme degree. He sits or stands in one place for hours, or constantly tries to wander away. He is, in all probability, much thinner than usual. He sleeps badly, and eats little; the tongue is foul, coated, and creamy, the bowels obstinately constipated, the breath offensive, the pulse slow and weak.

Climacteric

Now, among which of our pathological varieties are we to look for these melancholic patients? Chiefly we melancholia. find them among those who are passing into the decline of life, whose insanity has been termed "climacteric." We do indeed see melancholia in patients of all ages, and see it accompanying all causes and conditions; but it is the exception to find it in the young, the rule to find it in those whose vigour is beginning to fail, whether at forty, fifty, or sixty years of age. Of 338 cases of melancholia admitted into St Luke's Hospital, only 9 patients were below the age of twenty. Occasionally it occurs after parturition in women. who have been much weakened by their confinements. The insanity which appears some weeks after confinement generally takes this form, and often rises to a very acute state, with sleeplessness and obstinate refusal of food. The weaker the patient the more urgent are the symptoms, and the greater the need for active and immediate treatment. There is nothing of the sthenic character which marks the wild excitement of mania. It is not usually found in phthisical patients, who are commonly excited and maniacal, but we sometimes see it thus associated. It is an old belief that it is connected with the abdominal organs, as the liver; or, according to Schroeder van der Kolk, the colon; but there seems reason to doubt this. The disorder of the liver and the loaded state of the colon are as likely to depend on the general derangement of the nervous system as to be the

cause of the mental disorder. The question is not set at rest

by their vanishing together. The propter hoc in such cases is very hard to come at.

Whatever be the cause of the insanity, whether we call it idiopathic or sympathetic, phthisical or sexual, or even paralytic, the melancholia is the effect and indication of the condition of the sufferer at a particular time. He is generally depressed, his slow and feeble circulation imparts little force to his brain-centres, and the supply there is always in defect. Not only is it in defect-for this appears to be the condition of almost every phase of insanity-but there is little action going on. The metamorphosis is not rapid; there is no immediate danger to life, emaciation does not occur rapidly as in acute mania. The patient is not absolutely sleepless, though he may sleep little. This depressed state may last for years and then pass away; and, so soon as the feeling is gone, all the delusions and fancies bred of it vanish too. We are far from understanding the exact pathology of that state which gives rise to melancholic feeling. I have known it to exist in a gentleman who ate heartily, who was stout in body and florid in face, who was free from all bodily disease. In him it appeared without assignable cause, and in process of time it vanished; and all that we can say of such a case is, that by some concurrence of conditions beyond onr recognition, the nerve-power of this man's brain was insufficiently produced.

We find patients whose melancholic delusions are attended with so much excitement that they may rather be called maniacal. This only indicates that their condition, though one of depression and defect, is at the same time one of greater disturbance of the brain and more rapid metamorphosis; and, as we shall see, when it attains a certain height, it becomes as formidable and dangerous a disorder as any other acute form of insanity.

Treatment of

But here I wish to point out the treatment of an ordinary case of melancholia, attended with melancholia.

great depression and melancholic delusions, disinclination to take food, little sleep, and obstinate constipation.

Suicide to be

The first thing you are to remember is, that every patient of this kind is to be looked upon as suicidal. apprehended. Never mind whether he has, or has not as yet, made attempts, or shown signs of such a disposition. He may have had no opportunity, or he may have never yet felt the particular idea or impulse. But this is the description of patient who jumps out of window, or into the river. Nay, he may commit suicide in even an earlier stage, before his friends have noticed anything like delusion, when "they only thought him a little low," and were afraid to take any measures for his safety, "for fear of worrying him.” Hundreds and hundreds of inquests are held upon patients of this kind, who, by the commonest care, might have been successfully treated and cured.

Where is the treatment of such a patient to be carried out? An asylum is not absolutely indispensable, if the patient's means will afford him what he requires elsewhere. If a poor man, there is nothing for it but to send him to an asylum. For he must not be left for a moment where he can do himself harm, or make his escape. He requires the companionship of some person his equal in education, as well as of attendants; must be removed from home to a house, airy, light, and quiet; and should have facilities for taking exercise without going into crowded thoroughfares. All this implies some considerable expense. If, as I say, his means suffice, such a plan often works a cure more rapidly, in my opinion, than the asylum, with its depressing influences, and lack of sane companions; but if funds are scanty, the latter is a necessity, for the other plan is impracticable unless carried out completely in all its details. Having removed your patient into a suitable abode, and having arranged that he shall never be left alone Medicines. for a moment, what are you to do by way of treat

ment? Your object is to restore the defect of brain by means of food and sleep, and you will find that in many cases a most satisfactory result follows the treatment, and this in no long time. I have seen some very bad cases recover perfectly in two months, and recover in a manner which was clearly due to the medical treatment, and not to mere change of scene and surroundings; for this had been already tried, and tried in vain.

Besides the mental symptoms, there are three things specially to be attended to-the want of sleep, the tendency to refuse food, and the constipation.

Chloral will produce sleep in these cases, as in others; but is better suited to the excited than the depressed forms of insanity. It is a sleep-compelling agent; beyond that its effect seems of little import. It does not appear to have such a healing influence as opium where the latter is beneficial. In violent and excited cases of acute melancholia, chloral can be given with benefit; but in sub-acute melancholia, the preparations of opium are of great service, whether given by the mouth or by subcutaneous injection. I have very rarely been obliged to discontinue them, and have almost invariably found the patient mend after their administration. The preparation which has, according to my experience, succeeded best is the liquor morphia bimeconatis, for it does not cause sickness or constipation, which too frequently follow the administration of the acetate or hydrochlorate of morphia. As the patient is already inclined to refuse food, often on the plea of nausea or loss of appetite, and as his bowels already are obstinately constipated, it is important that we do not increase this state of things by our remedies. Dover's powder, in some cases, or solid opium, or Battley's solution, we may give, and give freely, in full doses at night, and in smaller doses two or three times a day. It is of little use to give at night by the mouth less than the equivalent of half a grain of morphia.

Food.

We now come to the food question. We read that patients refuse their food because of dyspepsia, and that the latter is indicated by the foul, coated tongue, fetid breath, and loaded bowels. I am obliged to say that I think all the symptoms of dyspepsia are the result, and not the cause, of the depressed nervous condition; that the tongue is covered with old dead epithelium, which, for the same reason, is not thrown off; that the fetid breath is caused by this, or is due to actual starvation; and that the loaded bowels must also be ascribed to the want of general power. And I say this with some confidence, having treated a very considerable number of these cases, and having removed all the symptoms by means which were in no degree directed to cure dyspepsia. This is the kind of diet which I have frequently given for the purpose. Before getting out of bed in the morning, rum and milk, or egg and sherry; breakfast of meat, eggs, and café au lait, or cocoa; beeftea, with a glass of port, at eleven o'clock; and a good dinner or lunch at two, with a couple of glasses of sherry; at four, some more beef-tea, or an equivalent; at seven, dinner or supper, with stout and port wine; and at bed-time, stout or ale, with the chloral or morphia. This allowance I have given to patients who were said to be suffering from aggravated dyspepsia; who, I was told, had suffered from it all their lives; who had never been able to take malt liquor, or eat more than the smallest quantity at a time; who, in fact, had constantly been living on about half the quantity requisite for their support, and, through chronic starvation, had come to this depressed condition. I need hardly tell you that the patients and their friends were aghast at the quantity ordered to be taken; but improvement has taken place immediately, the tongue cleaned, the constipation given way, and the depression diminished; and I have known patients themselves become so convinced of the necessity of this augmented diet, that after recovery they have continued