dren, because they had neither milk nor strength to enable them to nurse." (Op. cit. p. 130.)

A similar state of mind may be induced at an earlier period and more suddenly, by the effects of a profuse hæmorrhage, by serous discharges, which occasionally take place shortly after labour, or even by mental depression; in fact, by whatever lowers the vital powers to a considerable extent. In these cases, the very history and appearance of the patient are sufficient to explain the nature of the disease; her hollow eyes, pale face, and blanched lip, show distinctly how her strength has been reduced. The source and extent of her debilitated state will in great measure determine the degree of danger, and the chances of her recovery. In ordinary cases of this form there is not much to fear, as far as the life of the patient is concerned; and the cases which have come under our own notice confirm the excellent remark of Dr. Gooch, that "mania is a less durable disease than melancholia; it is more dangerous to life, but less dangerous to reason." But if the disordered mind has come on shortly after labour, in consequence of profuse flooding; if the powers of the system have rallied but imperfectly, and, from the tinnitus aurium, strabismus, half vision, &c., it is evident that the cerebral functions are greatly impaired; if the nights are passed without sleep, and the days in continued and exhausting excitement; if the pulse be feeble and rapid, the skin cold and clammy, the face covered with perspiration, and there is a disposition to colliquative diarrhoea, we shall have but too much reason to fear an unfavourable issue; every symptom denotes that the powers of the system have received a fatal blow, and she either sinks exhausted, or dies in a state of coma, probably from serous effusion upon the brain. On the contrary, if, in addition to a general improvement, she has enjoyed some hours of refreshing sleep, there is every prospect, not only of returning health, but also of reason. A mere gleam of returning reason without a corresponding improvement of health, will afford but little satisfaction to the mind of a discerning practitioner, for it gives no assurance that the danger of fatal sinking is at all diminished.

Disordered mind coming on some weeks after delivery from the effects of over-nursing, when the patient has been unable to afford the necessary supply to her child, is seldom attended with so much danger to life, as where suddenly induced immediately after labour by hæmorrhage: the intermediate stage between reason and derangement is more distinctly marked, and is of considerable duration; and the gradually increasing affection of the mind frequently warns even the patient herself to seek medical advice before the symptoms become more serious.

We believe that the proportion of patients in whom the mind continues deranged after their health has been restored, is very small, and feel convinced that the results afforded by the practice of lunatic hospitals are far from giving a correct estimate. A large majority of the cases of derangement in lying-in women are of such short duration that they never come even under the notice of those members of the profession whose attention is particularly devoted to this branch of medical practice, still less do they require to be removed into asylums for lunatics. "The records of hospitals contain an account of cases which have been admitted only because they were unusually permanent; they are the picked obstinate

cases, and can afford no notion of the average duration of the cases of all kinds; the cases of short duration, which last only a few days or a few weeks, which form a large proportion, are totally lost in the estimate of a lunatic hospital." (Gooch, op. cit. p. 125.) The result of Dr. Gooch's practice, which is known to have been very extensive, and especially in consultation, shows that out of a considerable number of cases only two of his patients remained disordered in mind, "and of these, one had already been so before her marriage." There are two classes of patients in whom disordered mind is not only much to be apprehended during their lying-in, but in whom there will be some reason to fear that it may become permanent; first, in those who have already been deranged, independent of the puerperal state, or who inherit a strong predisposition to mental disease; and secondly, in those where hysteria has existed in an unusual degree during the latter part of pregnancy. These circumstances justify us in using every precaution in their lying-in to avoid any thing which may excite the disease; but, as already stated, not only is the disorder of the mind rarely of any duration, but it is seldom known to recur on any subsequent occasion.

Treatment. Our indications of treatment are two-fold, viz., to rouse and support the powers of the patient, and to allay as far as possible the irritability of the brain and nervous system.

If the patient has been prostrated by hæmorrhage, not only a nutritious, but even a cordial and stimulant diet will be necessary: the emulsion of egg and brandy, which we have before recommended in anæmic puerperal convulsions, will here prove very useful; and it must be given in small but frequently repeated doses, until an improvement is observed in the pulse and in her general appearance. Under all circumstances, it will scarcely ever be proper or even safe to confine her to low diet; beeftea, veal-broth, &c. should be given in considerable quantities during the twenty-four hours; and it is surprising what improvement will even take place merely from the administration of this bland nutriment. If the face be pale and the pulse low, wine may be given according to the circumstances of the case.

To calm the cerebral excitement and procure sleep, sedatives will prove of the greatest value, and require to be repeated until the nervous system is fairly under their influence. The intense pain at the vertex, which of itself is sometimes quite sufficient to produce delirium, the tinnitus aurium, &c., all cease; the pulse becomes softer, fuller, and slower; and, even if sleep be not immediately induced, a state of calm tranquillity follows, in which the mind becomes more composed. The Liquor Opii Sedativus may be given in a dose of twenty-five minims, and repeated in an hour or so according to circumstances. The combination of camphor with morphia, or extract of henbane, is an excellent form, and may be given with perfect safety to a considerable extent.

The bowels should be opened by the mildest laxatives, such as castor oil, rhubarb and manna, &c., medicines which will neither act violently, nor weaken by producing watery evacuations; and, once in every few days, it will be desirable to rouse the action of the liver by Hydrarg. c. Cretâ, with extract of hop or gentian. To assist still farther in restoring her health and strength, she should take an infusion of a vegetable bitter

with a mineral acid. As soon as her strength will permit, a change of residence may be recommended, and she should remove to some quiet watering-place, where invigorating air and agreeable scenery and occupations will assist in completing her recovery.

"The constant attendants on the patient ought to be those who will control her effectually but mildly, who will not irritate her, and will protect her from self-injury. These tasks are seldom well performed by her own servants and relatives.

"If the disease lasts more than a few days, and threatens to be of considerable duration, her monthly nurse and own servants ought to be removed, and a nurse accustomed to the care of deranged persons placed in their stead. Such an attendant will have more control over the patient, and be more likely to protect her from self-injury." "With regard to the removal of her husband and relations, this also will be a question; if the disease threatens to be lasting, it is generally right. Interviews with relations and friends are commonly passed in increased emotion, remonstrance, altercation, and obviously do harm: large experience also is decidedly favourable to separation as a general rule; yet there may be exceptions, which the intelligent practitioner will detect by observing the effect of intercourse." (Gooch, op. cit. p. 158.)

INDEX.

Abdomen of the foetus, labour obstructed | Anatomy of the pelvis, 17.

Anamic puerperal convulsions, 333.

Period at which it is most common, 126. Anchylosis of the foetal joints, obstructing

Contraction, hour-glass, of the uterus, 305. Diameters of the pelvis, 20.