a patient becoming insane after a subsequent confinement, who has been so in one, are very small, “Although (he adds) as the former attack proves that a predisposition then existed, and may still be operating, that very circumstance would strongly impress us with the possibility of a recurrence, and would induce us sedulously to avoid every exciting cause, and to use the utmost degree of care for its prevention, not only in the next, but all the following labours." Dr. Gooch appears to hold the same opinion; he says "I have attended many patients who came to town to be confined, because they had been deranged after their former lying-in in the country, and, excepting Case No. I., not one of these patients had a return of their disease." Dr. Montgomery relates a case of a lady who became insane after eight successive confinements; and several others in a less marked degree illustrative of the same position. Our opinion is that one attack strongly predisposes to another; and that, if the instances of successive attacks are not so numerous as might be expected, it is because the care and pains alluded to by Dr. Ramsbotham are not without their result in preventing them. In some few cases it has been observed that the sex of the infant acted as a predispos ing cause-women having got over the confinement of a girl with safety, after repeatedly having suffered when the child was a male.

Of the occasional or exciting causes of puerperal insanity we are not well informed. It does not appear that difficult labours exercise much influence in the majority of cases; nor are many of the recorded cases connected with extreme hæmorrhage. We cannot speak definitely as to the relation which it bears to eclampsia; Merriman, Gooch, Esquirol, Frias, Selade, Billod, and Dr. Reid, each relate one instance of such apparent dependence.

In this Journal, for the year 1850, Dr. Webster relates some cases in which he attributes to chloroform the production of the mental disorder; Dr. Simpson relates facts having a very opposed significance. The question is one of very great importance, but one which must be decided by prolonged experience.

Moral emotions will, no doubt, exercise a strong influence upon the development of mental alienation; the cases in which the affection is distinctly traceable to these are certainly not very numerous; but the number would be very much augmented had we full histories of each case. In women who do not nurse, the first menstruation has a strong influence upon the development of this affection: in 60 cases mentioned by M. Marcé eleven became insane exactly at this period. It is worthy of notice also that, amongst those who do nurse, a not inconsiderable number begin to be insane about the same time-i.e., the sixth week. Out of 22 cases six were of this nature. It is scarcely necessary to

point out the practical bearing of this observation; nor how necessary at such a period is the most careful physical and moral hygiene. Errors in diet, exposure to cold,* imprudences of various kinds, inflammation and suppuration of the mamma-all these have been observed to act as exciting causes. We have ourselves observed one case which in the outset was clearly dependent upon a sudden pleurisy. In this, as in other diseases, however, etiology is an obscure science; for the most part the affection will not be due to any one cause, but to the action of many upon a constitution enfeebled or otherwise predisposed.

These general observations apply to the insanity of the newlyconfined, and to that of nurses indiscriminately; it will now be convenient, following the plan of M. Marcé, to separate the two forms, and make some remarks upon each.

The forms of mental unsoundness enumerated by this author as occurring shortly after confinement are mania, melancholy, partial lesions of the intelligence, hallucinations, intellectual and instinctive monomania, and "a special variety of mental enfeeblement, which seems to be caused by excessive losses of blood, and is easily cured by appropriate treatment." These forms of alienation are not equally frequent; amongst M. Esquirol's 92 cases 49 were mania, 35 melancholy, and 8 chronic dementia. In the 44 related by M. Marcé 29 were mania, 10 melancholy, 5 partial lesions, and 2, cases of temporary intellectual enfeeblement. It is worthy of notice that in the insanity of nurses the proportions. between mania and melancholy are much more equal than those here noticed.

In the form of puerperal insanity now under notice, the cases almost all begin at one of two periods; either in the first eight or ten days after confinement, or towards the fifth or six week. M. Marcé remarks that in his 44 cases, 33 commenced in the first ten days, and 11 about the sixth week. We do not find in other authors the same precision of classification.†

He says:

*M. Esquirol lays great stress upon cold as an exciting cause. 'Le refroidissement, l'impression du froid, de quelque manière qu'ils aient lieu, sont de tous les écarts les plus à redouter; l'exposition a l'air frais, l'application de l'eau froide, soit que l'accouchée s'expose à des courants d'air froid, ou qu'elle marche en plein air, soit que l'accouchée ou la nourice plonge ses membres dans l'eau froide, la coupe des cheveux, l'abus des medicaments chauds, en supprimant les lochies, provoquent la folie. Chez nos 92 aliénées, quatorze fois l'aliénation mentale a été provoquée par des causes physiques, et dans ces quatorze cas, dix fois l'impression du froid a causé la maladie."

+M. Esquirol's 92 cases commenced as follows:

16 became delirious from the 1st to the 4th day.

21

5th

17 19 19

15th
60th

60th day to the 12th month. after forced or voluntary weaning.

These 92 cases include both forms of puerperal insanity-that of the newly-confined, and that of nurses.

It is not necessary to enter minutely into the phenomena of puerperal mania, so familiar to all of extensive obstetric experience. The outbreak may be quite abrupt, as in the case related by Dr. Reid, where the patient having fallen asleep in good health, awoke suddenly, crying out that her child was dead, and became maniacal from that moment. In the great majority of cases, however, the accession is gradual; the first change noticed is often in the eye, which assumes an expression easily recognisable, but difficult of description. The countenance is restless, anxious, and troubled; sometimes flushed and sometimes unnaturally pale. There is great excitement of the special senses; slight sounds distress the ear, light affects the eyes; there are often hallucinations. The temper changes completely, and family affection is apparently changed into the bitterest hatred; and this is particularly observed as regards the child, which the mother often attempts to destroy. Then succeeds or accompanies these symptoms the outbreak of violent delirium, with the characteristics before mentioned. At the commencement there is not always fever, and if the pulse be accelerated, it is often from the violence of the excitement alone; but after a time it becomes very rapid (especially in those cases which will be fatal); the head is sometimes hotter than usual, although the general temperature is not much raised; there is almost complete insomnia; the tongue is foul, the urine scanty, the bowels often constipated; the breath is offensive, and the skin emits an unpleasant odour. The condition of the milk and the lochiæ has been before noticed. These signs of constitutional disturbance, in the majority of favourable cases, subside long before the mental disorder.

It is of much importance to inquire whether during pregnancy or labour there are any symptoms which may lead us to apprehend insanity afterwards, and so enable us to take every precaution to guard against it. Esquirol states that it is sometimes announced by sinister presentiments even during pregnancy; but such presentiments are so frequent, and are in so small a proportion of cases followed by any evil consequences, that we cannot found much upon them. Dr. Burrows has some important remarks on this point:

“Puerperal delirium consequent on labour is sometimes predicted, though not absolutely developed during gestation. If, while pregnant, there be frequent hysterical affections, preternatural sensibility, unaccountable exuberance or depression of spirits, morbid aptitude to exaggerate every trivial occurrence, and attach to it great importance, suspicion, irritability, or febrile excitation; or, what is still more indicative, a soporous state, with very quick pulse-then the supervention of delirium on labour may be dreaded."

Dr. Ramsbotham adds to this, that "if a great loss of memory be present, such a result is eminently foreboded."

The characteristics of puerperal mania are so well marked, that it is scarcely likely to be confounded with any other disease. From the low muttering delirium of fever, the history will sufficiently distinguish it, as well as its own peculiar characters. From phrenitis it is sometimes not so easy; and cases will occasionally occur where the affection seems to partake of both characters. The delirium of phrenitis is preceded by headache, fever, tinnitus aurium, and flushed cheeks; the pulse is quick and sharp; all these are generally wanting in mania. In the former, the eyes are injected; not usually in the latter. The inflammatory fever of phrenitis has a character almost altogether wanting in mania. It is of the highest importance to distinguish between the two affections; since the active depletory measures required for phrenitis would be ruinous in mania.

Puerperal mania terminates by recovery, by incurability, or by death; the first appears to be much the most frequent; the last is rare. "It used to be the prevalent opinion (says Dr. Ramsbotham) that puerperal mania never resulted in a fatal termination. Even the late Dr. Baillie, observant as he was of disease, and well-informed upon the morbid conditions of the body in all their forms, when consulted about a case of this kind, remarked, 'that the question was not whether the patient was to recover, because of that he had no doubt, but how long the disease was to last!'-she died within a week after this opinion was uttered. Of Esquirol's 92 cases, 6 died, I after six months, 1 after a year, 2 after eighteen months, 1 after three years, and 1 after five years after delivery. These statistics, however, as well as those of Dr. Webster and Dr. Burrows, include not mania only, but all the forms of puerperal insanity.* In 24 cases of mania, M. Marcé enumerates 16 recoveries, 2 incurables, 2 in which after one year there was no amendment, and 4 cases of death; 1 in twentysix days, 1 in nineteen, 1 in sixteen, and 1 in seven days. Almost all deaths in this disease result from a complication with, or transition into, acute delirium, the délire aigu of French writers. Where the insanity has been developed during the first fifteen days after confinement, it may be thus complicated from the first, but it may also occur after the mental affection has lasted many weeks. M. Marcé's sketch of this affection is graphic:

"The agitation augments from day to day, the tongue becomes dry, the digestive functions are impeded; the pulse becomes rapid, more than 120 per minute; the face is flushed, the head hot, and the eye haggard; the skin is covered with a viscous sweat; the patient is a prey to incessant hallucinations, and exhausts herself by violent agitation and

As this is the case with all the statistics yet published on the subject, we shall recur to the various terminations of puerperal insanity, after reviewing the different varieties.

an unceasing loquacity; she is no longer conscious of anything that is present; under the influence of her delirious ideas, or even of a veritable hydrophobia, she rejects all aliments, especially drink, and spits almost perpetually. M. Baillarger has remarked the expectoration of large yellowish crachats, which are unaccompanied by cough, or by any pulmonary symptoms."

Then follows a quasi-typhoid state, with fœtid breath, and still incessant spitting; the urine and fæces are passed involuntarily; insomnia is constant, and the powers are speedily exhausted-the termination being often accelerated by diarrhoea. The signs of amendment are, that the pulse becomes somewhat slower, and has more volume; the tongue moistens, the agitation is a little calmed, and the patient returns either to reason, or to the normal condition of the previous insanity. But when once the condition above described is fully developed, there is but very slight hope of any amendment; the prognosis is most grave. With regard to the prognosis of puerperal mania in general, the quickness of the pulse is the most serious sign-not that quickness which is brought on merely by agitation, and is transitory, but a continuous permanent acceleration, which does not subside even during moments of calm. The acute delirium would seem to be merely the maniacal agitation, carried to its extreme limits; and the constitutional disturbance is merely a consequence. is of importance to recognise the beginning of this acute delirium; and fever is the distinctive sign between it and the ordinary maniacal agitation. Meningitis offers striking relations occasionally to this acute delirium; but in this we meet early with partial paralyses, contractions, or strabismus; the head is thrown backward, there is subsultus, coma, and resolution of the muscular fibres. Those patients who do not die of this affection are generally carried off either by diarrhoea, or by some pulmonary disease, if the insanity terminates fatally.

The pathology of puerperal insanity is as obscure as that of mental affections generally; morbid changes are found occasionally after death, of various kinds, but none that are constant or special; and it must always be remembered that death has taken place, for which some physical cause must exist, which is not necessarily connected with the psychical disorder. Esquirol has examined the bodies of patients who have died of puerperal insanity, in which there was no morbid change to be detected. Others have found thickening, or eburnation of the skull, induration, or softening of the brain, opacity and adhesions of the membranes, purulent or serous deposits, &c. &c. In one of our own patients the most careful examination failed to detect any morbid condition. Dr. Gooch relates a case which was exactly similar. As a general rule, in those cases which are fatal,