has passed fifty-five or sixty years of age, there exists a rapidly diminishing capacity for overcoming the conditions of disease, especially if the experiences of past life have been of an unfavorable character or the patient has indulged in the abuse of alcohol in any of its forms.

Treatment in a large number of these cases must be of a stimulant and tonic character; a large amount of time spent in the open air; gentle exercise; an abundance of nourishing food in the form of soups, beef-tea, eggs, and milk (in some cases with brandy); patients should never be allowed to go long without food, and if necessary it must be administered; opium, cod-liver oil, iron, strychnia, quinine, and phosphorus. In my experience opium is remarkably well borne in this form of insanity, and is certainly of great value in alleviating the suffering and diminishing mental activity. It should be used in the form suggested when recommending it in melancholia. It should be given in doses of from twenty to sixty minims three times a day. I have never known the opium habit to become established from its use after this method and for this purpose, even during several weeks, and as the patient becomes stronger, it can be gradually reduced in quantity until it is entirely omitted with little or no inconvenience. Its use is sometimes followed by the most favorable results, though I am unable to predict beforehand in what cases it would be likely to do so. Sleep may be secured by exercise in the open air, and, if necessary, the use of sulfonal, chloralamid or chloral, combined with the bromide of sodium or ammonium.

LECTURE XVIII.

INSANITY OF THE PUERPERAL PERIOD.

I. INSANITY OF PREGNANCY.

Importance of-Insanity of Pregnancy-Ætiology-Intimate Relation between the Brain, the Stomach, and Sexual Organs-Craving for Particular Articles of Food while in the Pregnant State-Heredity-Tables of Cases in the Connecticut Hospital and the Retreat - First Pregnancies-Symptoms-Puerperal Insanity Proper-More Frequent in First Labors between Thirty and Forty Years of Age-Frequency of in ScotlandCharacter of Blood in Puerperal Insanity-Symptoms, Primary and Secondary-Hallucinations-Homicidal and Suicidal Tendencies-Convalescence-Age-Table of Thirty-nine Cases in Reference to Recoveries, Ages, and Time under Treatment-Cases.

The general practitioner has professional care of women during periods of pregnancy, childbirth, and lactation. He assumes the responsibility of ministering to the discomforts which are incident to the first period, the perils that attend the second, and such derangements of the system as may arise during the third. It may not be too much to claim that, while in the majority of women these periods pass without serious results to either mother or child, yet certainly two of them are attended by such conditions of discomfort and suffering, with many mothers, as to render the care and skill of the physician even more acceptable than do many other ailments for which he is called to prescribe. But no one of these many disordered conditions, whether surgical or medical, is more serious and important than that of

insanity. In most cases its advent is unlooked for; in many its symptoms appear unannounced beforehand, and suddenly in the majority of cases. They are acute, positive, and unmistakable, and move forward in the development of their character so rapidly as to arouse the most apathetic husband, brother, or sister into intense anxiety and alarm.

The prodromous stage of most other forms of insanity is more prolonged. The symptoms develop slowly. The relations and friends are slow to perceive the initial and early changes in the mental states, and generally still more so to acknowledge them when suspected. The physician, therefore, is not early consulted and rarely sees his patient until weeks or months have passed and he is far on in the perilous journey. Not so in the puerperal case; time is rarely lost by delay, and his resources, both medical and moral, receive a loud and early summons. The general practitioner, therefore, comes into more intimate relations to the early period of puerperal insanity than with that of any other, and in consequence is regarded by his friends ast having a larger measure of responsibility.

While the term puerperal is applied to the state incident to parturition, yet as this latter is necessarily connected with and presupposes both gestation and subsequent lactation, it will be for our advantage to study together the mental disorders which may exist in connection with the three periods. While the symptoms of these periods tend to merge gradually into each other, and it is doubtless true. that no sharply defined line can be drawn between them, yet they have some differences in both character and ætiology which it is worth while to observe.

INSANITY OF PREGNANCY.

Etiology. Physicians are often reminded by professional experiences of the intimate sympathy which exists between the brain and the viscera and of their interdependence in the discharge of their ordinary functions. One of the most common examples of this sympathy relates to the stomach. Continued acute pain in either the brain or the stomach very soon modifies the functional activity of the other organ. This intimate sympathy, however, exists between the different viscera themselves, and the physician is often called to give counsel and, so far as he may be able, relief to pregnant women suffering from this cause. Nausea. when arising from simple and direct causes produces a most profoundly depressing effect, and this is much increased when it arises from the irritation of a growing pregnant uterus and from the changed currents of blood which it requires in consequence of its increase of volume. And when these functional changes are in operation not only for a few hours, but during days and weeks, it is readily perceived how great the depression may become in some sensitively organized women.

There are, however, many women who, though not seriously affected with nausea and vomiting, yet, as the gravid uterus becomes larger from month to month, and begins to rise out of the pelvis, affecting the neighboring organs, suffer much mentally from these reflex influences. According to the observation of Dr. Savage more mental disturbance is likely to occur when the offspring is male than when it is female; and he says that this coincides with the popular idea on this matter. Many women rarely or never feel in their normal condition, and often have a craving for some particular article of diet, and unless they can have it

the general impression, which has no foundation in either reason or fact, is that there will result some unfavorable effect upon the child in utero. This craving appears to be similar to that of the dipsomaniac at times, and becomes about as uncontrollable. It is certainly impossible to satisfy its extraordinary demands.

In other cases the nerve centres become somewhat irritable and sensitive, doubtless from these same changed currents of blood supply, and the subjects are fretful and unable to view their surroundings and experiences in a hopeful way. They are depressed and spend hours in anticipating some form of trouble which will arise at the time of the coming confinement, or before then. The experience is altogether unknown, and in the depressed state of the nervous system the mind conjures up and pictures all forms of danger as the time for confinement approaches.

The sexual antipathy toward the husband which not unfrequently exists during pregnancy in many women may lead them to imagine that their husbands do not love and sympathize with them as they should. Some careless word or sentence spoken in merriment may be interpreted as an evidence that their friends do not longer care for them, especially if they have failed to visit them as often as formerly. They are confident that other women have never suffered as they are doing, and experience many imperfectly defined apprehensions of impending danger. These abnormal changes may become so great as to implicate the judgment and cause most remarkable likes and dislikes and violent caprices. They especially dislike their husbands. and will have little or nothing to do with them, and can rarely speak civilly to them. I was invited to visit such a case several years since. The woman had actually left her