left her, nearly succeeded in hanging herself. She had had a good labour, and, though a weak and rather delicate person, was nursing her child bravely and nutritiously. I had seen her in the morning, and the only change in her condition which I had noticed was that she stared at me unusually, and said she had not slept well the previous night. This statement was confirmed by the nurse. As I intended seeing her again in the evening I did not leave any instructions about an opiate, but the bowels being costive I ordered a dose of castor oil. My patient had dined early with the nurse. They were sitting together by the fire afterwards, and the latter had dropped asleep with the baby in her lap. But the sleeper was suddenly roused up by the noise of something falling, and immediately discovered that her mistress had suspended herself to a brass hook by one of her garters and a pocket-handkerchief tied together. The garter had fortunately given way, and the fall had disclosed the tragedy which was all but consummated. For three weeks this lady remained in a state of profound melancholia, and there was the greatest difficulty in getting her to take food. But she ultimately recovered and did well, and passed through two subsequent labours without any untoward symp

toms.

Occasionally the alienation of the puerperal state assumes the form of acute dementia, a sudden shock to the nervous system being the immediate cause.

But, as I before mentioned, many of the maniacal and melancholic cases associated with the puerperal state appear to be on the border-line of suspended faculties. A case was narrated to me some years ago of a poor woman who had been confined about ten days, and was progressing satisfactorily. Her husband was struck by lightning, and she saw him brought into the house dead. She gave a wild shriek, and fell to the ground. To the woman the moral shock was more disastrous than the physical shock to the man, for she remained a lunatic for life.

There is also a form of mental disturbance, of which I have seen one instance, and of which Dr. Gooch gives a very striking example. It appertains to the neurotic temperament, and may be termed cataleptoid dementia. A nervous lady, twenty-nine years of age, had been often pregnant, but had only borne one living child. After delivery, at the seventh month, of a dead fœtus, she was seized with a violent left hemicranial neuralgia, intense flatulence of stomach, and great depression of spirits. She told her husband she had been unfaithful, and tried to cut her throat the next morning. Her violence became intense, and she was put under the care of a regular attendant, and confined with a strait-waistcoat. Drs. Gooch and Sutherland visited her. "A few days," says the former, "after our first visit we were summoned to observe a remarkable change in her symptoms. The attendants said she

was dying or in a trance. She was lying in bed motionless, and apparently senseless. It had been said that the pupils were dilated and motionless, and some apprehension of effusion on the brain had been entertained; but on coming to examine them closely, it was found that they readily contracted when the light fell upon them. Her eyes were open, but no rising of the chest, no movement of the nostrils, no appearance of respiration, could be seen. The only signs of life were her warmth and pulse; the latter was, as we had hitherto observed it, weak, and about 120. Her fæces and urine were voided in bed. The trunk of the body was now lifted so as to form rather an obtuse angle with the limbs (a most uncomfortable posture), and there left with nothing to support it. There she continued sitting while we were asking questions and conversing, so that many minutes must have passed. One arm was now raised, then the other, and where they were left there they remained. It was now a curious sight to see her sitting up in bed, her eyes open, staring lifelessly, her arms outstretched, yet without any visible sign of animation. She was very thin and pallid, and looked like a corpse that had been propped up, and had stiffened in this attitude. We now took her out of bed, placed her upright, and endeavoured to rouse her by calling loudly in her ears, but in vain. She stood up, but as inanimate as a statue; the slightest push put her off her balance; no exertion was made to regain it;

she would have fallen if I had not caught her. She went into this state three several times; the first time it lasted fourteen hours, the second time twelve hours, and the third time nine hours, with waking intervals of two days after the first fit, and one day after the second. After this the disease resumed the ordinary form of melancholia, and three months from the time of her delivery she was well enough to resume her domestic duties." Dr. Sutherland has mentioned several similar but more prolonged

cases.

These, then, are the forms of puerperal insanity which you will meet with in practice. What is their danger to life? What to reason? What is likely to be their probable duration? And what is the treatment indicated? Now, I should tell you that the statistics of public asylums furnish us with but very meagre and unreliable evidence concerning puerperal insanity; for the disease bearing that name is one chiefly of home and private treatment. Moreover, it is one to which, like the gout, the rich are more obnoxious than the poor. The large lying-in hospitals of Dublin and London do not yield many instances of that mental disturbance, which, coming at the season of parturition, or during the progress of nursing, so alarms and terrifies. The cases which are taken to public asylums are not of this class. They consist, rather, of broken-down persons who have been unsuccessfully treated outside, and are at the time of admission in an advanced

stage of debility and disease. Often they are those who have been insane before, and who are weighted with the terrible heritage of an ancestral taint. There is a natural and well-justified indisposition on the part of medical practitioners to send the acute forms of puerperal insanity to asylums; for recovery is sometimes very rapid, and the character of a person is in one sense really injured by confinement in a madhouse. It is a blot upon the family escutcheon. So that you may get into sad trouble with your patient's friends if you subject to asylum restraint and discipline a case which has a quickly successful issue.

It is only when your patient becomes very violent and unmanageable, or has very determined suicidal tendencies, that you are justified in placing her in confinement.

In respect of their danger to life, Dr. Gooch states that in his day there was a very common belief among medical men of great general eminence, but small special experience, that the diseases of this class were never fatal. "Whilst I was attending," he writes, "the near relation of one of the most eminent and experienced of the provincial practitioners of this island, a letter arrived from him, begging the family to have no fears-that he had seen many such cases during his long life, and never saw one die; and even the late Dr. Baillie, when consulted about a case, remarked that 'the question was not whether she was to get well, but when she