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Etiology. The third and remaining form of insanity connected with and arising from child-bearing is that of Lactation. It is nearly always of an anæmic type, and its symptoms resemble those existing in cases which arise from other causes producing this state in the system. This form, like that of puerperal insanity proper, is more likely to occur in females above 30 years of age; but unlike that, is rarely found except in women who have borne and nursed several children, or when there has occurred a large hemorrhage or other complication at the period of labor. In some cases the division between the two forms is a rather arbitrary one. We have already stated that puerperal insanity proper may not arise until several weeks after the labor, and consequently long after the function of lactation. has become fully established. Such cases, however, should be confined to that group in which the etiology exists in the abnormal conditions of the uterus itself, and has little. or no relation to lactation. Such a distinction can generally be recognized, for, though both may act as causes of depression and greatly reduce the systemic nerve energy, yet lactation rarely acts in this way during the first three months. Indeed, it is a function so closely allied to the deepest maternal instincts, that nearly always the mother experiences greater disturbances from its suppression than from almost any other incident that can occur at this Whereas, the disturbances which are engendered in connection with the imperfect involution of the uterus and lesions of its neck, attended with the strain upon the brain incident to protracted labors, act as a powerful factor of irritation and exhaustion of the nerve centres, and always during the few weeks next subsequent to the termination of labor.

The period requisite for the occurrence of normal involution of the uterus will vary somewhat in different cases and in the same cases in different confinements, it being in some measure dependent upon the physiological condition of the system at the time. It may, under favorable conditions and in healthy subjects, occur after the first two or three labors within four or six weeks; but is likely to be longer delayed in subsequent ones, especially if the labor has been complicated or the pregnancies have occurred with short intervals. In some women it is rarely complete in less than three months.

The period during which nursing may, with safety to the mother, be continued; must depend very greatly upon the physical conditions existing. Many women nurse much longer than is advisable for their health, with the object of avoiding another pregnancy; and when the advice of the physician is asked in reference to the length of time it can be continued with safety, I think one of the most important points of inquiry should relate to the hereditary tendency. If this exists in even a small degree in the family, or the mother has formerly experienced conditions. of nerve exhaustion, anæmia, or an attack of insanity, the child should be weaned before, or at the earliest indication of, any debility which appears to arise from the continuance of the function. Some mothers may with impunity nurse their children twelve months, while others should never pass beyond three or six.

The influence of prolonged lactation is an important factor which is not usually sufficiently recognized by the physician. A large difference in the capacity for nursing and in its effects upon the system exists even in healthy women. While in some the materials essential to the formation of milk of good quality may be taken from the blood with little or no

unfavorable effect upon the system, yet with some others who are obliged to make much muscular exertion in labor it tends rapidly to diminish the fatty matters essential to health and vigor.

Again the modes of living, the quality of food, and the habits of life exercise a considerable influence upon lactation. Those women who enjoy a sufficient and moderate amount of exercise in the open air, and take an abundance of nitrogenous and fatty elements in their food, are likely to become and remain better nurses than the more sensitive, who live in heated rooms with vitiated air and take but little exercise except indoors, especially if overworked and burdened with care. In such cases the drain upon the system, from the frequent suckling a large infant six or eight months old, tends rapidly to develop a state of anæmia; and if continued beyond the first indications of this condition is likely to be followed by serious mental disorder. Again, not only should the heredity and the normal temperament be taken into consideration in giving counsel as to the continuance of lactation, but also the history of the confinement and the present environment of the individual.

Allusion has already been made to the influence of accidents and complications at the time of labor, such as unusual floodings from imperfect contractions of the uterus, retained portions of the membranes retarding the normal course of uterine involution, profound impressions upon the brain and nervous system from the long continuance of pain in highly sensitive women-as being directly or indirectly a factor of causation in puerperal insanity. But this influence does not end with the involution of the uterus; and while, in any given number of cases, it may not prove to be sufficient to cause the development of insanity during the first few weeks succeeding labor, yet

in connection with other agencies at a later period it may prove to be very important. The effect is always from the first of a lowering character. The store of nerve energy becomes lessened and the inhibitory centres weakened. The system, therefore, is in a much less favorable state to bear the experience of a protracted period of lactation than it would be if no such complications had occurred. The nerve centres have experienced a profound shock and strain, or the blood has been so greatly diminished that it cannot fully regain its normal constituents of red corpuscles and fibrin while lactation is carried on, and the patient tends rapidly toward an anæmic state.

Among the poor, too (and it should be borne in mind that lactational insanity is much more common with them than with those who are favorably conditioned), the hygienic environment is often most unfavorable. The food is generally of poor quality and improperly cooked; the child may be ill and restless at night, so as to prevent the sleep of the mother. She generally has the care of several other small children and also of the whole household, and all the while is living in the sexual relations of a wife. In short, the whole physical and mental system experiences such exposures and hardships as must test the most robust, and only such are able to pass through them with impunity. The more delicate and sensitive, and especially those having an hereditary tendency, are those who succumb. In reviewing, therefore, the aetiological elements as above presented, it will be observed that while lactation, to which has been assigned the first position, has determined the nomenclature of the disease and should properly be made prominent, yet it has associated with it in the larger proportion of all cases other elements of causation the relative importance of which will vary very much in different cases.

Symptoms. The symptoms may be of an excited or depressed type, but in either case they are generally of a more transitory character than in other forms of insanity. Sometimes, though rarely, they partake of the character of dementia. The record of eleven cases which have been in the Connecticut Hospital shows that in seven of them the symptoms of mania were present; in three, those of melancholia; and in one, those of dementia; these figures indicate that 63 per cent, were cases of mania and only 27 per cent. were cases of melancholia. This corresponds very closely with the experience of Dr. Bevan Lewis in his statistics, comprising 66 cases. But in Dr. Clouston's experience with 50 cases, the states of excitement and depression were quite evenly divided-21 being somewhat excited and 19 being mildly depressed. The degree of excitement or depression is generally less than pertains to other acute insanities and yields more quickly to the effects of remedies.

The first mental indications are those of doubt and suspicion, especially of the husband and those that sustain the nearest family relation. Whatever may be said or done is very likely to be misjudged and wrongly interpreted by the patient. These mental states, with a mild form of depression, may continue for three or four weeks and frequently longer before the patient becomes excited, somewhat noisy, and incoherent. The degree of excitement varies considerably in different patients. Some become very noisy, aggressive, abusive in language, violent, and destructive, and largely dominated by imperative concepts of fear and delusions of impending danger. They imagine that their most intimate friends are conspiring against them, and endeavor to protect themselves by attacking them.

Morbid impulses are not infrequently present in maniacal cases, especially when the patient is anæmic, feeble,

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