Williams, Hirst, Edgar, Webster, De Lee, Jones and Tweedy & Wrench, refer to it absolutely as a disease. Wright of Toronto and the Englishmen Berry Hart and Let are more vague, and only Lewis, of Chicago, calls its occurrence a coincidence. When we consider its frequency, if only we accept the very conservative estimate of Williams and the definite figures from McLeod, of England, of 1–2000 births and are not so radical as Hirst the obstetrician and Clouston the Edinburgh alienist, who state 1–400, to say nothing of Fordyce Barker’s 1–80, we must feel that there is more than a coincidence, and if we consider the large percentage who are confined to asylums suffering from it, I feel we have all the evidence needed.

Causes must be studied before we can put pathology on a sound basis, to say nothing of diagnosis and treatment. Here again we find many authorities in disagreement and at times extremely vague.

Williams, of the school that, I think we all feel has, through the laboratory, magnified the science of medicine perhaps sometimes to the detriment of its art, says:

“Puerperal psychoses may be due to one of three causes: Infection, auto-intoxication, or direct liability of the nervous system. Of these, infection is by far the most important. This fact has long been recognized, but it is only of late that the bacteria concerned have been identified, and then only in a small proportion of cases. In two of the three instances which have come under my observation, the infection was due to the streptococcus, and in the third to the streptococcus and colon bacillus.”

Berkeley likewise reports a case due to the organism first mentioned. Auto-intoxication is also a frequent etiological factor, and it is probable that the vast majority of mental disarrangements following eclampsia are due to this condition. Ordinarily, insanity is regarded as a rare complication of eclampsia, though Olshauser observed it in 6 per cent of his 515 cases. According to Hansen and Picque infection and auto-intoxication are responsible for more than 80 per cent of all cases, while the remainder are to be attributed to other causes, occurring particularly in women afflicted with hereditary tendencies, “the exciting cause of the insanity being shock, extreme mental depression or the rapid loss of a large quantity of blood.”

The general trend of investigation of etiology and pathology has been of course to ascribe definite tangible factors as the cause of definite organic changes, and we hear less and less of idiopathic diseases and functional conditions, and while the view of Williams may seem to be almost too definite, please contrast it with the causes ascribed by Hirst, which he divides into “predisposing—the nervous excitement of gestation in women predisposed by hereditary influence to mental breakdown, great reduction in physical strength and prolonged mental strain or worry * * *; the exciting causes may be exaggerated anæmia, as from prolonged lactation, septicæmia; albuminuria; profound emotion or exaggerated fear of impending danger; remorse and shame of illegitimate pregnancy; the grief of a deserted woman; accident or hemorrhage; great physical or mental exhaustion. In my experience insanity in the childbearing woman has almost always resulted from some profound emotion.”

Webster, of Chicago, says: “Frequently there is a predisposing cause—e.g., bad heredity and prolonged mental or physical strain. Anæmia, sepsis, albuminuria, marked emotional disturbance and the pain and excitement of labor.”

Berry Hart only mentions the predisposing causes of a neurotic constitution, too frequent pregnancies, too prolonged lactation, and in some cases the shock of a seduction ending in conception.

Wright, of Toronto, as I have stated before, says: “Constipation is frequently very marked,”—whether he means as a cause or a symptom is problematic.

De Lee, of Chicago, says: “Puerperal infection, mastitis, eclampsia and allied toxemias, post-partum and other hemorrhages, especially if grafted on a bad heredity, exhausting labor and the drain of lactation are the most common causes. The attack may be developed by a violent psychic shock, such as the death of husband or child.”