PUERPERAL insanity is commonly divided into three varieties:.
1. Insanity of pregnancy, appearing during the term of gestation.
2. Puerperal insanity proper, occurring soon after delivery; and. 3. Insanity of lactation, occurring during or after the continuance of prolonged lactation.
In my belief, the first and last of these varieties should not be classed as puerperal, as they are usually due to some cause other than the puerperal state, which latter stands in the relation of precipitating cause only. There is an inherited predisposition, neurotic or hysterical foundation, syphilitic taint, or and exhausted devitalized state, and the puerperal state is no more an aetiological factor than any non-puerperic cause of exhaustion, mental or physical.
The second variety, or puerperal insanity proper, occurs more or less suddenly after a recent accouchement, and is a septic condition. It is almost always maniacal in type, especially if accompanied with much elevation of temperature and the other symptoms of septic intoxication, while those cases (decidedly in the minority) which take on the melancholic type are the outgrowth of a less active involvement of the system with the septic poison and accompanied by the usual symptoms of asthenia.
In the cases of pure puerperal insanity that have come under my personal observation there has been no doubt of the septic origin of the disease, as evidenced by the condition of the sexual organs, the veins, the breasts, the development and course of the symptoms, the reading of the thermometer and the other evidence of septic absorption.
The two following cases will illustrate the two types:.
Mrs. N.; aet. 30; multipara; nervo-sanguine temperament; delivered with forceps after a tedious labor; did well the fifth day, the night following which she was restless and did not sleep; temperature on sixth day, 101 degree. Became possessed with the delusion that another child had been substituted for her own by the nurse, with collusion on the part of the attending physician, upon the entrance of whom into her room she would develop paroxysm of intense excitement, although toward the nurse she maintained a tone of imploring entreaty, as though she might in this way induce her to restore, through pity, her own babe. Examination showed a diphtheritic inflammation of the vagina; the womb was enlarged somewhat and not particularly tender, but much pain along the course of the saphena veins in the thigh was complained of.
Her temperature for a period of four weeks was often up to 103.5 degree and was rarely below 100 degree, at which times of depression there was distinct sweating, once or twice profuse. She made good recovery, at the end of three months, under antiseptic treatment and the indicated remedy.
CASE II.-Mrs. K: aet. 35; multipara; was seen by me, with a brother practitioner. On the sixth day, after an easy and natural labor, she complained of chilliness, aching in the back of head, limbs and lumbar region; temperature 100.5 degree; milk rather scanty, and patient much depressed there at, fearing that she could not sufficiently nourish her child. This fear became so fixed that in a few days she talked of it to any one ho would listen to her. She became dejected, lachrymose and despondent, declaring that God was punishing her by depriving her of her milk for her babe, because she had not desired it, and had striven in the early months of her pregnancy to procure miscarriage.
During a period of three weeks her temperature ranged from 97.5 degree to 101 degree, no regularity in the remissions. She perspired much, and there was an unwholesome and sickly odor about her person. Examination showed slight laceration of the cervix and perinaeum, a single stitch having been taken in the latter at the time of delivery. There was an offensive lochia, not profuse in quantity. She became very morose refused food, expressed a desire to die, and needed to be watched constantly that she did not execute the threats of suicide which she constantly made. She made recovery after persistent treatment, consisting of antiseptic measures at first, the indicated remedy, enforced feeling, with careful nursing.
Both of these cases were clearly septic in their origin. There was no albumin in the urine of either; there was a history of insanity in the family of the first patient. In fifteen years’ experience I have seen eight cases in the acute, either my own or in the practice of friends, that, in my estimation, were septic. I have seen a number of others brought to Atlantic City for the benefit of climate, most of them, of course, several weeks or months after delivery, and many of them, in my belief, not puerperal at all, but in whom the puerperal state had been precipitating cause.
It follows from this:.
1. That true puerperal insanity is septic or ptomanic in its origin.
2. That the prognosis based upon this belief and the following out antiseptic measures is much more favorable than ordinarily laid down; and.
3. That prophylaxis is of the utmost importance.
As treatment, I advise quiet, rest and freedom from care, absolute cleanliness of the person of the patient, the intra- vaginal use of.
R. Hydrogen peroxide, f. oz.j.
Aqua. therm., O.j. or stronger.
The use of Creolin, Hydrarg, bi-chlor, 1-10,000, Permanganate of potash solution, or simple hot boiled water, etc.
if undoubted indications existed of uterine involvement I would not hesitate to make use of the intra-uterine douche, with any of these, particularly the peroxide of Hydrogen, and as a last resort, but not hopelessly late, the inter-uterine curette.
I advised careful and persistent feeling, forced feeding, and not of liquids, which in this condition as in other states of insanity is of little avail, a half pound of solid food being of more value than many quarts of liquid each case will require careful study, comparison and selection, I may be pardoned for calling attention to a few of those perhaps not so well known, that I have found of value.
Hyoscyamine.-Hyoscine hydrobromate. These have been of much value in the maniacal form, in substance and in potency, and of particular value in many cases in procuring sleep, working admirably in a case where Morphia and Chloral had failed utterly in the hands of an Old-School friend.
Valeriana.-Mother-tincture in water. This is particularly indicated in excitable, hysterical cases.
Scutellaria.-This drug is indicated in the melancholic variety with marked depression, nervous exhaustion, apathy, and characterized by frequent changing of the phase of the symptoms.
Monotropia uniflor.-This remedy is of essential value in cases exhibiting great erethism accompanied by disturbances of the sympathetic nervous system, as dyspnoea, rapid, vacillating pulse-rate, vaso-motor disturbance, etc.
Ammon. c. -One of the best remedies in the maniacal type, to be thought of also if the case should present any albuminuric complications, or uraemic phenomena.
Of course, it is of little use of me to speak here of the value and indications of such well-known remedial agents as Bell., Stram., Lachesis, Arsenic, Aurum, Phosphorus, Ignatia, Stannum, Zinc, Sulphur, etc. Very few cases could be successfully treated without their use.
To summarize then, the treatment that I would recommend, would be:.
The indicated remedy.
L.C. GROSVENOR, M.D.: I want to say a word to this last paper. I want to say just a word in regard to feeding. A few years ago, one of our professional brothers sent for me and I went there to assist. The patient believed everybody was trying to poison her. We gave her oyster broth, milk, soups-in fact we gave her good square meals every day, but the third morning she looked up when we were making preparation for her meal and she said: “Well, I believe I will take my breakfast in the old way this morning.” I speak of this to emphasize what the doctor said in this paper.
DR. YEOMANS: In reference to puerperal insanity I cannot quite agree with the doctor that it is the result of sepsis always. It brings one case to my mind where one patient for four successive times, became insane about the third month. She came under my care during the third time. I think I was able to ameliorate her condition very materially, but she had little confidence in woman doctors, and especially in Homoeopathic woman doctors, and through a combination of influences, my patient was wrested from my hands. Her child was neglected as all of her children were.
For the want of a mother’s care they had died in early infancy, and she was moved to an asylum, and what became of the woman I don’t know, but there was no septic influence so far as I was able to detect. I could detect no uterine lesions. There seemed to be some influence affecting the nerve centres that I couldn’t really explain.
DR. CUSTIS: I don’t know that I have anything further to say except to mention that during the past winter I had a very peculiar experience. I had a case where traumatism was the cause of fever, and the first thing I knew I was in the case without knowing it until I got in the room, and the case was so urgent that my attention was demanded. Then there was another case that I referred to in the paper, of diphtheria.
Accidentally, without anybody’s fault at all, that infected room was used for a confinement case before the first patient had been out of it five days. So I came to the conclusion that in this disease we have one that is contagious in the highest degree; that the disease can be contracted through the larynx, stomach or any other organ, and that it is almost impossible for a physician in attendance upon such a case to rid himself of the poison while thus coming from other cases.
DR. DINSMORE: Dr. Grosvenor did not mention-at least I did not hear him mention-Veratrum viride. Some regard this drug as the remedy to control the high degree of fever. I will just say, in regard to puerperal fever, that I was unfortunate enough, as a few years ago, to have five such cases inside of ten days, and that after that siege was over I did not attend any more for a long time. After that I did not see a case that I thought was carried directly by the physician.
DR. YEOMANS: I have had quite a number of cases of puerperal eclampsia, and I just want to say that I have had excellent results with Hyoscyamine, and when I hear this subject spoken of, that remedy always comes to my mind, and I find it an almost invaluable medicine.
DR. GROSVENOR: In a Homoeopathic convention from all the United States and Canada and the West, it seems like a work of supererogation to speak of remedies, and I only alluded to the prophylactic management.
DR. YOUNGMAN: Mr. Chairman, in closing the paper, I can only answer Dr. Yeomans, of Iowa. I think the case she refers to as occurring three or four times, was one of those that I speak of. I don’t believe much in puerperal insanity. I think it is insanity incurred form some other cause, or some excitement, or from a predisposing cause.