INSANITY OF LACTATION. 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 time. 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. removed by a breast pump. Warm fomentations and rubbing may also be used to prevent the formation of abscesses. Simple and nourishing food should be given often, and, if necessary, should be administered with a tube. Sleep is of special importance in the treatment of this form of insanity. It may usually be secured more surely by a 15- or 20-grain dose of chloral than by any other hypnotic. When this is contraindicated for any reason sulfonal or chloramid may be used with advantage. In some cases the bromide of sodium with cannabis indica has proved to be efficient in securing several hours of sleep each night. In those cases in which the blood is much impoverished cod-liver oil and cream or rich milk, with wine, may be given after the more active symptoms have passed away. Iron in some form, either alone or combined with strychnia, may be used with good results. In fact, iron is more often beneficial during the latter stage of puerperal insanity than in many other forms. Care should be taken from the first to secure movements from the bowels by the administration of the most simple laxatives or by the use of suppositories. It is very important to secure frequent changes in the air of the rooms occupied by the patient and also to have several hours of sunshine in the room. As soon as practicable the patient should be taken from the house and into the open air every pleasant day, where she should pass several hours with her attendant if the temperature is such as to warrant it. Improvement in the physical condition is, in the large majority of cases, attended with improvement in the mental states. INSANITY OF LACTATION. 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 time. 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 not 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 |