five or six weeks. Nearly all cases develop within a month and many within a few days. In 27 of 68 cases studied, the symptoms are reported to have appeared "immediately' after delivery and in 22 others within one week; in seven of the remainder the symptoms appeared during the second week; in five during the third week, and in the remaining nine during the fourth week.

It more frequently occurs in primipara, and the probability of its recurrence becomes less in each subsequent labor, as the uterus and nervous system become accustomed to these physiological experiences. In 175 cases at the Retreat 125, or 71 per cent., occurred in first labors, twentysix in second labors, seven in third, three in fourth, two in fifth, one in sixth, while eleven have no record in this respect.

According to some authors it is more frequent after the first labors of women who are between thirty and forty years of age, than in the first labors of younger women, especially if the labors are attended with injuries to the soft parts, or the delivery is effected by the use of instruments. This statement, so far as it relates to age, is not corroborated by the statistics of cases at the Retreat. The number of those under 20 years of age is three; between 20 and 30, 89; between 30 and 40, 66; 40 years and over, 14; and in three the age is not stated. There exists, of course, a more or less strong probability of error in reference to the factor of age as reported.

When we take into consideration the large quantity of blood lost at the termination of many labors and the consequent change in the general circulation; also the change which occurs in the quality of the blood by the sudden introduction of fluids which lower the relative quantity of its solid constituents, thus rendering it less fit for its normal

physiological function; the long hours of suffering and straining, with the incident pressure of blood upon the sensitive tissues comprising the cerebrum, and add to these the emotional disturbances which occur from calling into activity the maternal instincts and all that is embraced in these in the way of sudden and profound impulses and states which arise in many delicate women,-we surely may be surprised that more of them do not become insane during the puerperal period, especially when the element of heredity exists. According to Dr. Clouston, in Scotland, only one woman in 400 becomes insane from child-bearing. The statistics of the Retreat and the Connecticut Hospital for the Insane indicate a still smaller per cent. in Connecticut.

The deteriorated condition of the blood which exists in many women during the week next subsequent to labor, from the partial suppression of the lochial discharge, especially when local lesions of the neck of the uterus, the vagina, or the external parts has occurred; imperfect and unequal contractions of the uterus when continuing for several days after labor, the results of retention of portions of the membranes or placenta,-all are of more or less. importance as elements in the etiology of puerperal insanity.

Dr. Bevan Lewis* furnishes the following table of five cases, indicating the character of the blood in puerperal insanity:-

"Text-look of Mental Diseases," p. 370.

AMOUNT OF HEMOGLOBIN IN THE BLOOD OF THE SUBJECTS OF PUERPERAL INSANITY:

REMARKS.

Extreme waxy pallor; blood very pale, watery, and instantly separates
into serum on withdrawal; contains many minute cells like nuclei
and ill-formed corpuscles.

Minute fat globules in blood and many ill-formed corpuscles.

Still many minute nuclear bodies; blood pale, but has more consistence.
Red discs, all contain glistening, nuclear bodies; some tend to form
dumb-bell shapes, and readily split up.
Wild excitement for some
days past.

Profound melancholia; waxy color of face; compulsory feeding re-
quisite. Many minute corpuscles in blood, some dumb-bell form;
large corpuscles measure 6 to 8 m.; smaller measure, 5 m.

76 Considerable torpor of movement; much stupor, but no cataleptic phenomena; pupils dilated; betrays but slight anæmnia.

Medium size corpuscles (5 m.), a few small nuclei (2 m). White corpuscles measure 8 m.

.75

Symptoms. When the disorder arises within a few days after childbirth the symptoms are nearly always of a maniacal type. The contrast in this respect with those which exist in the insanity of pregnancy is very marked. Of the 175 cases in the Retreat 135 were maniacal. Of 36 cases in which the symptoms developed within four weeks 22 were maniacal, 11 had symptoms of melancholia, and 3 had alternating states of excitement and depression.

In the primary stage the patient becomes talkative, changeable, unreasonable, restless, suspicious, and exhibits feelings of aversion toward her husband and other members of the family; demands things which she has not been accustomed to have, and if refused may burst into tears and become much excited. The eyes become over-sensitive to the presence of light and present an unusually bright and excited appearance. The face begins to take on a haggard expression; the skin becomes moist and the tongue dry. Tenderness on pressure over the uterus may or may not be present. And in some cases the bowels become distended and tympanitic. The patient refuses food, both solid and liquid, and declares that she hears voices which forbid her to take it; and at times may be controlled by the delusion that the food is poisoned.

In some cases one of the earliest indications of the approach of disease consists in the exhibition of a morbid character of the maternal feeling toward the newborn child. The mother looks askance at it and desires that it be taken from the bed and out of the room, realizing in some measure that she may do it injury if it is left with her. Horrible impulses come into consciousness which she fears she may be unable to control, and sometimes they end in terrible catastrophies before the friends realize the danger or fully appreciate the fact that disease exists. These unusual

exhibitions of abnormal maternal instinct are sometimes thought little of by friends and may be attributed to irritability or willfulness. They, however, exist in so large a per cent. of cases that it should never be considered as safe to leave the child alone with the mother.

These semi-acute symptoms may continue for a few days or may suddenly become intensified; the patient becomes more talkative, excited, and violent; is unable to sleep and does not, except from the effects of large doses of medicine; indeed, insomnia is one of the most constant of symptoms. The aural and visual hallucinations become more distinct and dominating. Hallucinations of general sensation and of taste and smell are not common, nor are hallucinations usually present except in cases of mania.

Twelve of 22 cases of puerperal mania experienced both aural and visual hallucinations; while they were present in only 33 per cent. of 36 cases affected alternately with mania and melancholia. Hallucinations of sight are generally of an unpleasant or frightful character, and in this respect resemble those existing in delirium tremens. Some patients have visions of impending evil and endeavor to throw themselves from the bed or out of the window to avoid the imaginary danger. They become noisy, extremely talkative, or incoherent; obscene in looks, acts, and language; expose their persons by suddenly throwing off the bedclothes; and exhibit great physical force for a short time during the periods of sudden violence which frequently

occur.

The pulse generally becomes increased in frequency during the first stage of the disorder, and soon gives evidence of diminishing strength. The nervous system becomes highly sensitive, so that the shutting of a door or other sudden sound causes the patient to start with fright,