THE most fearful calamity which can possibly befall the puerperal chamber, not excepting death itself, is insanity. The term puerperal insanity, likes many expressions in medical nomenclature, has been used in a most careless and elastic manner, and has been made to do service in describing every variety of mental alienation connected in any way with child- bearing, from the mental disturbance sometimes seen in neurotic subjects during the early stage of pregnancy to that which follows the exhaustion of prolonged lactation, two years after delivery.
This evening we propose being more exact our use of this term, and to confine the meaning of puerperal insanity to its most contracted sense. We shall limit the use of the phrase to describing a condition of departure from mental health coming within two weeks after labor.
The basis of this paper will be thirty-nine cases of puerperal insanity, which came under the writer’s care while first assistant physician at the hospital for insane at Middletown, N.Y.
The disease is fairly prevalent, and about 4 per cent, of all cases of insanity are of this variety. It is said to follow once in every four hundred deliveries.
It is also claimed to be more frequent in obstetric hospital service than in private practice, and it seems to vary, too, in hospitals. In Bellevue, one of the largest of the general hospitals in this country, the proportion of such cases to the number of deliveries reaches the appalling figures of 1 to 80. In Westminister, London, the proportion is 1 to 382, and in the celebrated Dublin Obstetric Hospital the proportion in only 1 to 528. I have no statistic at hand to show the proportion in private practice, but it is asserted that fewer cases occur than in hospital work. All forms of insanity are seen among these patients-melancholia, mania, dementia, and general paresis.
Mania is said to be the form in 75 per cent. of the cases, melancholia in about 20 per cent., and the other two varieties much less frequently.
Before discussing a typical case, we will describe a mild form which is occasionally seen in young women who inherit strongly a neurotic tendency, and in whose unmarried life they displayed indications of hysteria. In such cases, a few days after labor, when everything is apparently doing well, there suddenly develops an intolerance of husband or child, a willful disregard of the doctor’s directions, a peevish irritability of temper toward everybody, accompanied by restlessness, sleeplessness, and constipation. There is no especial rise of temperature or diminution of the discharges.
These symptoms characterize the mildest form of puerperal mania.
The treatment consists of the removal of any discoverable cause, absolute rest of body and mind, freedom from the exhausting influences of talkative friends, weaning the baby and its removal form its mother’s sight and hearing, which is most frequently Aconite.
As a rule, these changes in the care of the case are sufficient to remove the symptoms within a few days. In a few cases, unfortunately, the symptoms just described are the forerunners of a more serious illness.
In the typical form of puerperal insanity the disease may be sudden in its outset, but, as a rule, it is gradual, and is preceded for some days by the symptoms we have already given you, or else by suppression of the lochia and milk, high temperature, rapid pulse, dilated pupils, flushed face or pallor of the face with quick flushing, great physical restlessness, and constant talking. There is also an irascibility and great mental unrest. Soon she begins to place every one’s motives under suspicion; she talks very rapidly and sometimes incoherently; she mistakes the identity of her nurse, doctor, husband, or parents; takes strong and unaccountable dislikes to those nearest and dearest to her; charges them with unkindness and neglect.
She is sarcastic in her statements and imperious in her demands. All these symptoms within a week or ten days increase in violence, and others are added, until finally there in an outburst of uncontrol-lable frenzy. After the appearance of violence, delusions and hallucinations follow. She carries on conversations with imaginary persons, or she imagines herself poisoned, or she entertains the delusion that she is some royal person. At this stage, an impulse to kill her husband, child, or herself may appear. It is likely that among the prominent symptoms at this time is nymphomania, displayed by a desire to expose her person and by the use of the most obscene language. Unless she is now too incoherent to be understood, she is quite likely to charge her husband with marital infidelity.
In a small proportion of cases the earliest symptoms which appear are the opposite to those described, and consist of a disposition to be unnaturally quiet and taciturn, with an inclination to be alone and to gloomy conversation. She may entertain delusions of a depressed character, and imagine she is unworthy of her husband, or that she has been very wicked, with a strong desire to commit suicide. The physical symptoms in the melancholic type are asthenic. The temperature is usually slightly subnormal, the skin is dry and harsh, the extremities are cold, the tongue is coated a brown or dirty-white, and there is persistent constipation. Sleeplessness is a prominent symptom in al forms of this disease.
Puerperal insanity is peculiarly liable to attack primiparae and those who have borne few children. The exhaustion which follows too frequent maternity has very little, if any, influence in its production. In our thirty-nine cases, twenty were primiparae, seven had two children, five had three, four had four, one had seven, and two had eight. Thus, 51 per cent. had but one child, 41 per cent. had between two and five children; that is, 92 per cent. had given birth to less than five children, and only 7 per cent. had more than five children.
On studying our cases we find the most frequent remote cause to have been an inherited predisposition to disease of the nervous system. Thus, twenty-one, or 52 per cent., displayed a history of insanity in their immediate progenitors-ten from the mother’s side, eight from the father’s side, and three from both sides; and in every case which the disease attacked those who had borne more than one child, this inheritance was very strong, and in three such instances the insanity was inherited from both paternal and maternal sides. In only six instances was this inheritance denied by the friends. In twelve cases the histories were incomplete, and it was unknown whether these persons received a neurotic inheritance or not. It is probable that many of those last-mentioned patients did possess a neurotic taint, and consequently such a family tendency probably existed in our cases more frequently than shown by our figures.
In three cases a previous attack as the remote cause. Anaemia was asserted to have been the cause in three cases. Getting up too soon after labor was assigned in three instances. Illegitimacy was alleged to have produced two cases, and in nine cases no remote cause could be assigned by the friends. The exciting or producing cause in five cases was overwork; five others were caused by excitement too soon after labor; worry is chargeable with seven cases; procidentia, too rapid maternity, exhaustion, and puerperal fever are each held accountable for one case. The cause in thirteen cases is, unfortunately, unknown.
Late maternity has been said to be a factor in the causation of this disease. While a fair proportion displayed an age beyond that at which most women bear their first child, yet none were very far advanced in the child-bearing period. One was less than twenty years old; fourteen were between twenty-one and twenty- five; tan were between twenty-six and thirty, and fourteen were between thirty-one and forty. Of the primiparae one was less than twenty, twelve were between twenty-one and twenty-five, two were between twenty-six and thirty, and five between thirty-one and forty. We find, among the multiparae, only two patients were under twenty-five, eight were between twenty-six and thirty, and nine were between thirty-one and forty.
It is claimed by Dr. Duncan that the height of fecundity is reached at twenty-five. Measured by this standard, eighteen of our thirty-nine cases had passed the zenith of the child-bearing period before they had their first attack of insanity.
Scotch authorities lay especial stress upon illegitimacy as a cause. In our experience this is one of the most infrequent causes. Only two of our patients appear as having fatherless children. These women both belonged to the lower stratum of society and were not worried particularly by this evidence of their lapse from virtue, and both of them possessed a neurotic inheritance.
In seventeen cases, or 43 per cent., the disease developed on or before the fifth day after labor, as follows: five on the first day, two on the second day, three on the third day, one on the fourth day, and five on then fifth day. One patient showed the first symptoms on the sixth day, and ten on the seventh day. It will thus be observed that twenty-eight cases, or more than 71 per cent., developed the disease during the first week after labor. Eight cases displayed the symptoms first on the tenth day, one on the eleventh day, and two on the fourteenth day.
The most dangerous days, therefore, seen to be the first, third, fifth, and seventh. In regard to sex of child our experience is in accord with the accepted impression-that the disease more frequently follows the birth of male children than female. The thirty-nine mothers bore forty children. Of this number twenty- seven, or 69 per cent, are recorded as male, and thirteen, or over 30 per cent, were female children.
In fifteen cases, 38 per cent., of the thirty-nine, the labor was said to be either severe, protracted, or instrumental. In seven cases the labors were natural. In the large number of seventeen patients, on 41 per cent. of the cases, the character of the labor was unascertainable. The proportion displaying some complication in the labor is larger than usually obtained in labors not followed by insanity. It is, therefore, a fair assumption that the character of the labor exerts some influence in the causation of the disease.
The attack was said to have been the first in thirty-two cases, or 82 per cent., the second in six cases, and the third in one case. From this one would judge that one attack does not predispose to others. Only four cases had puerperal mania previously, and the other there women had attacks of insanity previous to their marriage. In recent years there has been a disposition to scribe sepsis as a cause of nearly all forms of disease, and puerperal insanity has not escaped the charge.
In the thirty-nine cares referred to, only two were preceded by any symptoms of septic poisoning, and there is a doubt in the writer’s mind whether in either of these cases there existed the relation of cause and effect. One patient had, according to the history, a mild run of puerperal fever, and the other had eclampsia during labor. A few years ago it was the writer’s privilege to see over forty cases of puerperal fever, in an obstetric hospital, and, as far as his knowledge goes, nor more one of these cases subsequently became insane.
The prognosis in this disease is, as a rule, favorable. The general physical state of the patient at the time the disease comes on has a marked influence over the result. Twenty-seven of our cases recovered, about 70 per cent. of the number treated. One patient came in moribund, and died a few days afterward. Three patients were discharged improved. Two were discharged unimproved, and six were still under treatment when the statistics were gathered.
The treatment of puerperal mania or melancholia consists of isolating the patient from relatives and solicitous friends, whose presence, as a rule, has the undesirable effect of increasing the patient’s excitement, and thus aggravating the case, carefully selected diet and the proper remedy.
If the case must be treated at home, two thoroughly efficient, trained nurses are necessary; one for day duty, and the other for night. Whenever restraint can be dispensed with, it should be done of course; but in the majority of the maniacal cases, some kind of restraint is absolutely necessary. Never permit a patient to be tied down tote bed by sheets, but obtain from an instrument maker a good, strong apparatus, which will hold the patient, and in which she will be entirely comfortable. The writer does not wish to e understood as advocating mechanical restraint to the insane; on the contrary, he is a strong partisan, favoring the non-restraint system, and has frequently employed his pen and voice in upholding the abolition of restraint.
In insane hospitals there are very few cases in which restraint is excusable, but in private practice we do have recourse to the protection-sheet to prevent the patient from hurting herself or some one else. Diet is of the utmost importance in the treatment of those cases. Hot milk is our sheet anchor; it should be given often, and it is well to add a teaspoonful of bovinine or Murdock’s food to every cupful. Other prepared foods, such as Mellen’s and Horlick’s are of value.
In some cases, Cibil’s and Armour’s beef are needed. Some food should be given every three hours, and during the violent stages it may be necessary to give it at two hours intervals. It must be borne in mind that one of the principal symptoms to combat is exhaustion.
The patient’s chance of recovery largely depends upon whether she has the strength to weather the maniacal cyclone, so that food must be pushed as far as her stomach will stand it.
The drug treatment is largely confined to those remedies which are most useful to combat feverish conditions and the opposite state of exhaustion. As especial remedies, we find Acon., Ars., Bapt., Bell., Cimicif., Canth., Gels., Hyos., Stram., and Verat. vir. Sometimes, Ign., Nux vom., Platina. and Verat. alb., are useful.
When there is great incoherency, restlessness, flushed face, a tendency toward violence with an evident strong desire to strike and bite those standing near from anger, accompanied by hallucinations of sight, we have found Bell. especially useful. When the patient is noisy, singing, laughing, and very talkative, using obscene and profane language, violent towards everybody, but good-natured, or a condition of mental confusion, with suspiciousness and changeable conduct, Hyos, has been used with good effect.
When hallucinations of hearing are the particularly marked symptoms, with a desire for company, and a fairly good-natured condition, but quite changeable, the temperature about normal, Stram. is a most excellent remedy.
Verat. vir. has helped very many cases when the patients are very suspicious and imagine they are to be poisoned, with great restlessness, flushed face, high temperature and rapid pulse.
I will not take up your time by mentioning the indications for any more remedies.
In our experience we have rarely been obliged to go beyond Bell., Hyos., Stram., or Verat. vir., in maniacal cases, and Acon., Cimicif., Gels., Ign., or Verat alb. in cases of melancholia.
The earlier the treatment is begun the better. The chance for speedy recovery is better in a hospital than at home. Select your remedy with great care, and stick to it. Give easily- digested food, and give it often. Avoid hypnotics and narcotics as you would death, and a large proportion of your puerperal insanity cases will recover.