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.
