According to which table, of every 100 insane women, nearly 9 became so in consequence of the puerperal condition in some of its stages. On the other hand, the records of lying-in hospitals show that a very small proportion of the whole number of women confined become insane. In the Westminster Lying-in Hospital, according to Dr. Reed, only 9 out of 3500 delivered there were attacked. In Queen Charlotte's Lying-in Hospital, in 2000 cases there were eleven who became insane. Other institutions of a similar nature furnish like results. It must be recollected, however, that the time spent in a lying-in hospital after delivery is usually very short, and does not include the period of lactation most productive of mental disease.

Analysis of Fifty-six Cases.-Age.-The age at which insanity first appeared in these cases, was as follows:

It will be seen that from 20 to 25, and from 30 to 35, the proportion is much larger than at any other period; but this might have been expected, so far as the first period is concerned; for the proportion of females living at that age in the United States greatly exceeds that of any other period, excepting less than 20 years of age. So far as any conclusion can be drawn from such limited data, it points to the period of life between 30 and 35 as the time most prolific of puerperal insanity. Many of the cases in our survey did not come under observation during the first attack. We must therefore inquire the age at which the attack (herein alluded to) was developed :

And in this connection we must also take into account the number of attacks suffered. Thus, it was

We shall more full understand the influence of age by ascertaining the periods at which each of these attacks occurred :—

The history of the 55 persons, therefore, embraces 85 different attacks of insanity, of which more than one-half occurred between 25 and 30 years of age; while taking those only who had one attack, the period from 30 to 40 furnishes more than one-half. Whether the inference to be drawn from this, that those attacked more early are more liable to a recurrence of the disease, is warranted by the other circumstances of the cases, will afterwards be adverted to. One case of the 56 not included in the above analysis had suffered from several attacks (the exact number not being known to me), of which the first took place before 25 years, and the last at 32 years of age; from all of which she perfectly recovered.

Occupation. The influence of occupation receives but feeble illustration from this series of cases. All classes seem equally liable. Neither riches, with the luxury that attends, nor poverty, with its supposed exemption from enervation, can claim any exemption.

Civil Condition.-As to their civil condition very little can be said. 54 patients were married, and 2 single women. Esquirol remarked that the number of single persons becoming mothers, who are afflicted with puerperal insanity, bears a large proportion to the married. Of 92 cases reported by him, 63 were married and 29 single. We might expect, à priori, that if moral causes exerted so preponderating an influence in the production of insanity as many

writers assert, a larger number of those unfortunate women who have borne illegitimate offspring would be found subjects of this disease than the statistics of insanity in any country exhibit.

Hereditary Transmission. How far does hereditary tendency display itself in cases of this description? This is a difficult question to answer correctly, for no point is more assiduously concealed by the friends of parties than the existence of any hereditary taint. Where collateral relatives have been insane, I have included them in my estimate, as leading to the surmise of a taint in the common ancestry, in the absence of precise information; though such evidence is by no means conclusive :

Twenty-two out of fifty-six, or two in every five, are suspected or known to have been predisposed to mental disorders by the existence of hereditary taint. This corresponds with the proportion observed by Esquirol, while Dr. Burrows found, in 80 women who became insane after delivery, more than half hereditarily predisposed. Dr. Gooch remarks: "A very large proportion occurred in patients in whose families disordered minds had already appeared;" and in 217 cases collected by Helfft, Weill, and Marcè, 89, or 41 per cent., belonged to this class.

Unusual Circumstances. Any unusual circumstances affecting the patient about the time of the attack must be taken into consideration, as exercising more or less influence in its causation. Of such several have been ascertained in this series of cases. These can be arranged as follows :—

Primipare and Multiparæ.-Are primiparæ more liable to become affected than multiparæ? Among 53 persons (3 being unknown), it was observed there were attacked in connection with the

Only 18, or 1 in 2.94 of the number were primiparæ ; while of these 7 had a repetition of the attack in connection with every child born to them. When insanity has once established itself as one of the incidents of the puerperal condition, it seems to have a great tendency to appear at every successive period of that kind. This periodicity was noticed in 10 women, and was established in the 1st, the 2nd, the 3rd, and even the 5th puerperal state. In only one case did it skip over one child after it had once appeared, and then re-appeared with the next. M. Marcè found in 57 patients only 14 primiparæ ; and amongst the 43 remaining cases, 13 had been confined 5, 6, and even 9 times.

Circumstances attending the Labour.-How far the nature and history of the labour influenced the production of insanity which may have ensued, is open to much discussion. Difficult and tedious labours seem as innoxious as regular and easy labours. Nor are those who have flooded profusely more certainly liable to an attack than any others. Drs. Merriman, Gooch, Esquirol, Frias, Selade, Billod, and Reid, mention one instance each of insanity in connexion with labour, complicated with puerperal convulsions, and apparently dependent on that cause. Yet the proportion of patients with eclampsia becoming deranged is exceedingly small; too trifling to furnish evidence of any relation existing between them, as cause and effect. Dr. Webster has charged upon the use of chloroform in labour some few cases of puerperal insanity, and Dr. Skae, of the Edinburgh Asylum, reports one case attributed to this, the only one out of 44 cases of puerperal insanity admitted into that institution since the discovery of chloroform. On the other hand, Dr. Simpson relates two cases where the use of chloroform in labour prevented the expected usual attack of mania after it. Period of Invasion :

Immediately after weaning (about 12 months after delivery)
Unknown, but during lactation

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7

5

244

20

264224

To complete the history of this stage of the disease, it may be necessary to ascertain at what period the previous attacks already alluded to occurred. Four attacks were non-puerperal; four attacks were during pregnancy; fourteen attacks were during the second epoch; two attacks were during lactation; and the circumstances of six* attacks are unknown. So that of 76 known puerperal attacks, 11 began during pregnancy; 43 during the two months following delivery; 22 during lactation, or immediately after weaning.

Compare with these the results of others. Esquirol thus classifies

A summary of the cases reported by Dr. McDonald, Dr. Burrows, M. Marcè, and at Hanwell, in 1848, and those collected by M. Marcè, and by Dr. Wyman, of Boston, in Report of 1834, may also be useful for comparison:

The second period is, therefore, the most important in the causation of disease. Some have regarded that as embracing only six weeks after delivery instead of two months, the limit I have adopted; so that were the figures corrected to that period, the numbers of the second epoch would be still slightly increased.

Access of Disease.-The access of the disease was marked by symptoms in this series, which were, in many instances, doubtless but imperfectly recorded. Often the alterations of manner, of feeling, the emotional and instinctive changes which ushered in the attack, were either unobserved, or their value unappreciated. Something startling, out of the usual routine of life, must occur to be remembered as the starting point in the history of mental disease in such cases. I have estimated the first symptoms as closely as possible, in the following table::

*These six attacks, marked as unknown, occurred either during the second or third epoch,-in which is unknown.