The purpose of this book is to influence public and legal opinion in the United States, following some high-profile cases in which women patently suffering from mental illness have been convicted of murder and jailed for long periods. To a European, it offers an insight into a culture completely foreign—a nation thirsting for vengeance against mothers who, when severely ill, killed (and lost) their children; a nation that can afford psychoanalysis but not inpatient mother-and-baby units; a nation that still relies on the M’Naghten rules to define exemption from homicidal responsibility; a nation encapsulated within its own literature, insulated against the accumulated wisdom of the world.

Professor Oberman’s analysis of the purposes of punishment and Judith MacFarlane’s explanation of American defense options are illuminating, but I have reservations about the psychiatric contribution. The starting point must be classification, because there are many forms of infanticide, each with different causes and manifestations; this has been delegated to a lawyer, and not surprisingly her classification is incomplete. Five psychiatrists summarize postpartum disorders. They seem to recognize three entities—depression, psychosis, and obsessional disorders. The psychiatry of childbirth is much more complex than that (1). Conspicuously absent is any mention of severe mother-infant relationship disorders (hatred and rejection of the infant), which are crucial to fatal abuse and neglect; even the chapter on the mother-infant relationship deals only with minor forms of these disorders. These psychiatrists believe that "cognitive disorganization" sets puerperal psychosis apart as a distinct "organic" disease. This is a feature of acute polymorphic or cycloid psychoses, long known to be linked to childbirth, and (although not recognized by DSM) occurring in greater than 10% of nonpuerperal psychotic patients (2).

Dr. Spinelli interviewed 17 women accused of neonaticide and identified dissociative states as a key factor. Interviews with defendants facing the death penalty are not clinical or research interviews. As in all medicolegal inquiries, truthfulness is an issue. Likewise, Dr. Miller equates "denial" of pregnancy with dissociative unawareness. What about deliberate concealment of pregnancy? It is astonishing that a book on infanticide omits to mention the other psychopathological syndromes occurring around parturition (1). When Judith MacFarlane turns her legal mind to psychiatry, she believes that depersonalization would be an effective defense. But people overpowered by aggressive impulses sometimes feel "taken over" by something outside themselves and distanced from what is happening. Should this be a defense against homicide?

Any attempt to overturn entrenched and time-honored jurisprudential principles must start with comprehensive knowledge. This book cites most of the recent American publications on infanticide, a fraction of the English-language literature on postpartum mental disorders, and only three foreign works (by Marcé, Esquirol, and Gerchow). The world literature on puerperal psychosis and infanticide extends to more than 2,000 articles each, of which about a third are in English.

Dr. Spinelli disparages "early and outdated literature." The study of infanticide, however, has not benefited from modern medicine. There have been no major advances since the application of histopathology to the proofs of live birth 80 years ago. We have everything to learn from the "legal doctors" of the 19th century—men who not only examined the cadaver but visited the scene of the crime, conducted gynecological examinations, and interviewed the mothers. Tardieu (3) and Brouardel (4) amassed 783 cases between them, and the German experience is more extensive. No one can brush this evidence aside without studying it.

In a resourceful final chapter, Dr. Spinelli urges the reader to "take heart" because the goal of preventing infanticide is attainable. Of course it is. Anomic neonaticide, once a public health problem, has dwindled to an occasional scandal. This was achieved partly, no doubt, by contraception and the relaxation of the abortion laws but largely by a change in attitudes toward single mothers. I suspect that persuading APA to accept doubtful propositions or persuading 50 states to change archaic laws is not the way forward. Rather, the United States needs a medical philanthropist to change public attitudes. Perhaps Dr. Spinelli can do for the United States in the 21st what Hunter did for Britain in the 18th and Jörg for the German-speaking world in the 19th centuries (5)—persuade Americans to show mercy and compassion to mothers in extremis.