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weak, and the general physical condition has become greatly reduced before the onset of the disorder. In such cases the hallucinations appear to be more intense and vivid and their effects are quite like those existing in ordinary puerperal insanity. It is impossible to predict what is likely to be the course of conduct at any time, and sometimes patients become highly dangerous.

In those patients whose symptoms do not assume a maniacal type, the conditions of depression and melancholia generally become more pronounced as the disease advances. They believe that they are ruined and are soon to be punished or publicly disgraced, and hence require the most careful and constant observation lest they attempt suicide. Under the effect of delusions of persecution and impending danger they frequently refuse to take food and declare that it has been poisoned.

Manifestations of sexual excitement as evinced in language and behavior are less frequent in cases of lactational insanity than in those of puerperal insanity proper, and feelings of strong aversion toward the husband are common. The wide difference in the physical conditions existing in the two forms of disease doubtless accounts for this.

Hallucinations of both sight and hearing are very common and generally form the basis from which delusions arise. Suicidal tendencies are present in from fifteen to twenty per cent. of all cases, and develop from the fear and dread of some impending calamity. In the more acute cases it has been observed that the symptoms develop during the first four or five months and the patients are more likely to become restless, suddenly irritable, excited, noisy, and talkative, without any preceding period of depression. Thoughts become incoherent and rambling and have little sequence or order. But the history of the larger propor

tion of cases indicates a slow development, and patients. rarely pass suddenly into a maniacal or dangerous condition; the developmental period usually extends over several weeks, during which the patient is more or less restless and depressed and presents indications of physical and mental weakness. Insomnia is often present both during the initial and excited stages of the disorder.

The physical condition is one of debility. The patient is anæmic, weak, and thin in flesh. The pulse is increased in frequency and easily compressed; the face and lips are pale, and complaints of pain of a neuralgic character in the head, flashes of light, lumbago, dragging sensations about the lower portions of the back, noises and ringing in the head and ears, etc., are very commonly made.

The tables on pages 372 and 373 are of interest, as they indicate the symptoms and results in the cases which have been studied as a basis for this lecture:—

The following case presents in a mild form some of the

common symptoms and physical conditions which. are found to exist in lactational insanity. As will be observed, the general health was much below its ordinary state, possibly, in the first instance, from strain and nerve exhaustion incident to teaching, and secondly from the effects of the prolonged labor and instrumental delivery. These causes, together with the drain upon the system, in its effort to nourish the child, proved sufficient to upset the brain, though there does not appear to have been any history of heredity in the family.

C. A. H., age thirty-three, married about fifteen months. Had been for fifteen years previous a school teacher, and on one or two occasions broke down from nerve exhaustion and was unable to teach for several months. Now has a child three months old. The labor was prolonged and the

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delivery instrumental. She has been about as usual and nursed the child, though feeling weak and unable to make any exertion. Finally she was brought to the hospital for the purpose of building up her general health, and after admission there became affected with hallucinations of hearing, and thought persons were calling to her. She made efforts to reply to these voices, and after a few days became so much excited and noisy that she was transferred to the Retreat.

On admission she was despondent and

unable to sleep except with medicine, looked thin and anæmic, but was able to reply to all questions when her attention was secured. She continued to talk to herself or to imaginary persons in a rambling and incoherent manner, and was greatly despondent. She was at once put upon the use of the hypophosphites and an abundance of food, and took hydrobromate of hyoscine for sleeping at night. She continued for some two or three weeks to imagine that some calamity was impending, and that she was fast failing and should never recover; that she was liable to die at any moment. She was suspicious and would not believe what was said to her; but in spite of all her forebodings she slowly gained; the hallucinations became less and her strength improved until she was removed by her friends, and though she was still in a condition of debility and could not be regarded as fully recovered, yet I have no doubt she did recover at her own home.

Prognosis. The prognosis in lactational insanity is generally favorable. By reference to the preceding tables it will be observed that of nine cases in the Retreat, four recovered, and three were so much improved within five months (i. e., were so nearly recovered) that they were removed by friends; as they did not return, they may be considered as recovered. The recoveries, therefore, amount to 77 per cent. One of the remaining two was discharged as improved. She had experienced one previous attack, had borne seven children, and was admitted once afterward. The remaining one is under treatment. Of the 13 in the Connecticut Hospital six recovered; those who were discharged as improved had experienced former attacks, and two more of them had subsequent attacks, while four are under treatment. Of 54 cases reported by Dr. J. Batty Tuke, 39 recovered. Dr. Clouston reports actual

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