The request from the secretary of this society is a command when he asks me to read a paper, otherwise I should be more profuse in my apology for the modest effort I present to you tonight. For me to present to the gentlemen of achievement before me any of my rare dashes into the field of major procedures in gynecology or obstetrics would be farcical and I was casting about for something of interest for us all to think about together tonight when two post partum patients in the Low Maternity one afternoon developed mental disturbances.

As we must all admire the German attitude of continually interrogating, so we must, when something unusual occurs, say “Why” and “When?” and then become Yankees again and say “What are we going to do about it?” Every few years we must take stock of just such questions and it is perhaps a reasonable duty for some of the younger and less active members of this society like myself to make the inventory.

Definition.

Is it an entity? In Peterson’s “Obstetrics,” Lewis, of Chicago, tells us that the opinion is gaining ground that it is a coincidence and without etiological relation to maternity and that to childbearing can we probably assign only an exciting etiologic relation in the production of an outbreak of insanity. The study of so-called puerperal insanity then resolves itself into the study of the different types of mental disorder as they may occur and reveal themselves in a pregnant, parturient or puerperal woman. (Pp. 825–830.)

Lee, of Manchester, England, in his exhaustive treatise, “Puerperal Infection,” refers very casually to the maniacal symptoms of the infection. (P. 290.)

Williams, in his “Obstetrics,” however, speaks assuredly of puerperal insanity and gives definite etiological factors, two of which are the result of childbearing. (Pp. 915, 916.)

Hirst, in his “Practice of Obstetrics,” feels that it is an entity and more distinctly a disease of this period because of the etiological features he mentions and which will be referred to later. (P. 248.)

Webster, in his “Text Book of Obstetrics,” discussed it as an entity under a separate heading, but not by any etiological factor does he separate it from other psychoses. It is in the frequency of its occurrence that he quotes from Clouston, of Edinburgh, viz., one in 400 labors, in which Hirst concurs that we may infer it is a distinct disease. (P. 613.)

Berry Hart, of Edinburgh, in his “Guide to Midwifery,” says “Insanity may come on in women” while childbearing, and refers to predisposing causes, but gives no well defined picture of the condition. (P. 574.)

Wright, of Toronto, in his “Text Book of Obstetrics,” refers to insanity of pregnancy: symptomatically ordinary insanity, but etiologically speaking, the statement that constipation is frequently marked in the barest allusion. (P. 430.)

De Lee, of Chicago, “During the puerperium and lactation, insanity is a not infrequent disease,” and from his discussion of it he very apparently holds it as an entity. (P. 373.)

Tweedy & Wrench discuss insanity at more length than any of the other authors and must be convinced that it is a definite disease. (P. 401.)

Edgar refers to the “essential puerperal psychoses” and discussed their etiology and time of occurrence very definitely. (P. 800.)

The most comprehensive work on this subject, however, is that in the Journal of Obstetrics and Gynecology of the British Empire, of Robert Jones, Superintendent of London County Asylum, Claybury, England, and to quote him is most convincing. “Of the specially puerperal cases—and it is in this period that I recognize a special form of insanity—more suffered from mania than melancholia.”

Having covered a fair field of literature in this subject of definition we must now seriously consider the question—Have we or have we not a definite disease? Shall we go on to discuss this subject at greater length or shall we put it in the category of a broken wrist or an attack of diphtheria, either of which might occur after the time that any woman had had a baby? If I should say the latter, I should have to conclude this paper and take my seat. So let us go a little farther along and discuss its frequency before the question is answered.

Frequency.

In reference to its frequency, we find among the authorities a great deal of variation and it again shakes our faith in the value of statistics.

In an edition of forty-one years ago of Fordyce Barker’s “Puerperal Diseases,” he gives the ratio of cases of puerperal mania to total labors in Bellevue as 1–80. I have purposely referred to the age of this book because I shall refer to it again in discussing an attributed etiological factor. Not long ago after this work appeared, McLeod took the statistics of births in England and Wales for four years (1878–82) and found the proportion of women committed for puerperal insanity was 1,794–3,500,000 labors, or 1–2000. Baker himself was interested in the variation of statistics and explains part of the difference from the fact that there were many unmarried women at Bellevue; and while there were also among the foreign records, in the old countries, the fact of being a mother and not a wife was felt far less keenly, if at all than in America! (Pp. 160–191.)

Williams refers to more modern statistics of Berkley and of Jones, who noted it in 1 in 616 and in 1,100 labors respectively, but Williams’s own experience has been less frequent.

Hirst states “About one in 400 women confined become insane;” a flat if not grammatical statement, and this proportion agrees with, if not taken from, the experience of Clouston of the Edinburgh asylum. Hanson’s figures are about the same, 1–386.

Let us get at this subject of frequency from the opposite point of view. Among cases of insanity how many are associated with childbearing? Clouston, of Edinburgh, among 1,500 women, found 10 per cent were classified as suffering with puerperal psychoses and most of the earlier figures (and here we have the first real thought) before the antiseptic era give similar percentages—the New York State hospitals from 1888 to 1895 give only 5 per cent as puerperal in origin. Before we draw a too hasty conclusion, let me quote Lane based on observations in the Boston Insane Hospital for ten years, “that insanity associated with childbirth occurs only one-half as frequently as does insanity among women in general of childbearing age. The vast majority of women who become insane are between the ages of twenty and fifty. The task of bearing and nursing children occupies a considerable portion of the time of the average woman during these ages. Therefore, we should expect a large proportion of cases of insanity to begin during such time even without casual connection.” According to Lane’s view the childbearing process gives a certain degree of immunity to insanity instead of predisposition thereto!

On the other hand he points out that there are many more single than married women in asylums—perhaps unmarried on account of their defects. Hirst says of all cases of insanity in women about 8 per cent have their origin in the childbearing process, while Berry Hart gives the lower percentage of five. De Lee, in his textbook—the most recent at my command—gives the high percentage of 10–18 of female inmates affected at this time.

The most reliable figures I have yet obtained came recently to hand through the courtesy of Dr. Ziegelman, one of the resident psychiatrists at Kings County Hospital, and he tells me that of 454 female admissions to the observation ward there, from October 1, 1914, to March 18, 1915, there are twenty-six cases of puerperal insanity, practically 5¾ per cent. These are not very different, except suggestively lower than Jones, of London, who, in 1903, found from 6.4 per cent, private, and 8.1 per cent poor class patients then in the London Asylum.

With so much information, vague and meagre as it is, let us pause a moment and weigh the evidence. As our ideas of pathology change with time, so must our viewpoint as to morbidity and the most recent ideas must settle such questions.

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.”

Tweedy & Wrench, of Dublin, give us nine subsidiary causes—drink, toxemia, post eclampsia, acute pain (the perineal stage), sepsis, severe hemorrhage, prolonged lactation, no marriage and heredity, laying emphasis on sepsis and hemorrhage in the puerperium.

Edgar says that “there is no doubt that the presence of puerperal sepsis in many of the cases is something more than a coincidence.” Alienists assure us that since the introduction of antisepsis into midwifery the frequency of puerperal insanity has been marvelously diminished. Many cases of this type of psychoses are said to exhibit more the nature of delirium—such as is seen, for instance, in typhoid fever—than of actual insanity. Again, the coincidence of severe local infection has often been remarked, and gives color to the toxic theory; while a further coincidence of insanity of the puerperium with puerperal mastitis, phlebitis, and other inflammations remote from the genitals helps the assumption of this point of view. Of other special contributory factors may be mentioned the exhaustion which follows delivery, extreme prostration being a well known cause of certain psychoses or of low delirium. In this connection should be mentioned the influence of post-partum hemorrhage. In women already disposed to insanity the physiological adjustment which follows childbirth is doubtless sufficient to set up mental disorder. Other conditions which excite puerperal psychoses are the painful emotions.

Lewis, of Chicago, who, we must remember, does not call this a medical entity, says: “The inciting factor of insanity arising during the puerperal period are due, in from 70–80 per cent of the cases to either toxemia or infection. In the remainder no exciting cause beyond the general disturbance due to the bodily state can be assigned, * * *. The insanity arising in the lactation period is essentially due to exhaustion and inanition,” occurring in women of the poorer, harder working, more improperly fed classes. “General weakness from other causes, such as may follow severe post-partum hemorrhage or recovery from septic infection, may be the exciting element.”

Before we close the subject of its occurrence and cause, let us consider the illegitimacy and the number of the pregnancy, etc. Of 203 strictly puerperal cases collected by Jones, of London, about 10 per cent were single and 33 per cent were primiparal. One patient had an attack of insanity after each of her twelve children and another with each of nine, both becoming subject to chronic incurable insanity at the climateric. In lactation cases the insanity did not commonly follow a first confinement, but appeared to be due to the strain of frequent pregnancies and the exhaustion of long continued nursing. Puerperal insanity is most common between twenty-five and twenty-eight; lactational between thirty and thirty-four.

Jones also gives data pro and con as to the causation of this condition. One of his investigators found always negative blood cultures while others have found, as did Williams, streptococci, staphylococci, and the colon bacilli. It was rare for any of his cases to have fever and some were admitted as early as the second day. He also noted in some cases the signs of endo-toxin development. But he asks, “If these cases be toxic (and he means either chemical or bacterial), how is it that insanity occurs most often after the first confinement?”

Before we proceed to the subject of symptoms and pathology, let me suggest these conclusions: Our disease is decreasing in frequency, as all evidence shows us. We coincidentally are increasing our aseptic technique and obstetric skill and we are continually recognizing the different types of toxemias both bacterial and chemical, more quickly, with resultant more rapid institution of treatment. On the other hand the strong mental shock and emotions that come to women in connection with, or as a coincidence to, childbirth are getting no less in this world of ours and I feel that we must all agree that sepsis and toxemia in the puerperal and anÆmia in the lactational types of insanity are our real causes:—the emotional factors being secondary or only the exciting causes in the majority of cases. The other cases are, however, those of lability of the mental and nervous systems of probable types and with the same exciting causes.

The pathology of many morbid mental states is, I am sure, poorly defined and not well worked out. Jones, in his very exhaustive, though hardly recent article in 1903, gives us, however, very suggestive thoughts on the subject. “Immediately after confinement the morbid and effete material which is taken into the maternal circulation during early uterine involution, must tend to produce in the predisposed a profound irritation of the nervous system, and especially so should secretion and excretion be modified by interference, chemical or bacterial, with the normal functions of the venous, lymphatic and other excretory organs.” It is in the early stage of puerperium, the stage of septic infection, and by that I mean all bacterial disturbances, that the most violent delirium occurs.

The lactational type shows impoverished blood supply, uterine sub-involution, and general cachectic condition.

Symptoms.

Williams has found that the puerperal psychoses are usually characterized by great excitement during the first few days, associated with all sorts of hallucinations. Later, the maniacal symptoms disappear and the patient passes into a condition of depression with frequently suicidal tendencies.

Lewis has found that there are seldom any prodromal, usually of sight and sound, and great motor and mental excitement, appear; later motor agitation, subsultus, expressions of fear and uneasiness. Toxic cases are similar, but not so severe. Progress toward recovery is gradual—hallucinations disappear and lucid intervals occur. Lactational cases come on slowly, hallucinations at first few and later more constant; not a type of melancholia, but a mild, exalted mania, with frequently suicidal tendencies.

Hirst’s cases have been of mania, melancholia or profound lethargy, stupidity and mental confusion, and Webster’s experience has been about the same.

Edgar feels that while most of the cases have been classed as mania, they are in reality hallucinatory insanity.

De Lee has found melancholia with suicidal intent most common, but has also observed mania with infanticidal tendencies, while Vinay holds that the maniacal forms are the most frequent.

Tweedy & Wrench have found that insanity of the puerperium is always associated with either severe anÆmia from hemorrhage or with sepsis. The patient is first irritable and uneasy about unknown dangers. She had a headache, is constipated, she may refuse food or to see her child or husband, and sleeps badly, and finally becomes definitely maniacal and may have suicidal tendencies. During lactation the patient becomes gloomy, sleeps badly, and is constipated. Definite melancholia develops with delusions and suicidal tendencies.

All authorities disagree markedly on this most important aspect. Williams tells that the progress is three to six months and if longer the prospect is very poor, 20–40 per cent fail to regain mental equilibrium and 5–10 per cent die, this high mortality due, he feels, to the underlying infection and not the mental derangement itself, and with these figures Hirst is in practical accord.

Lewis tells us 25 per cent of the infection cases die, but the progress of toxic cases is not so bad. Death occurs usually from sepsis or the exhaustion on account of the motor excitement. Lactational cases recover in 50 per cent, and they take eight to nine months.

Webster quotes from Clouston of Edinburgh that 75 per cent of his cases have recovered; one-half of those in three months and 90 per cent in six months, and occasionally recovery takes place after years of impaired mentality and, surprisingly, he states that there is probably a larger number of recoveries in acute and severe cases than in mild ones. Dr. Lee states that the prognosis is fair—recovery in the majority of cases in from six weeks to six months.

Edgar tells us that exhaustion is the usual cause of death but recovery is the rule even from the insanity; if not, it goes on to a terminal dementia or paranoia. A high pulse-rate is a bad sign.

Berry Hart says the prognosis is good under proper treatment and the return of menstruation is such a good sign that emmenagogues should be employed.

Tweedy & Wrench say some 60 per cent of all cases recover, but if, as the patient gets fatter and stronger the mind does not improve, the prognosis is bad.

In the subject of treatment our authorities again differ, but not in the usual way. Webster briefly dismisses it with advising an asylum, as does Hirst, except in cases of refusal of families or friends to commit the patient, when general symptomatic treatment is necessary. Edgar and De Lee both are no more explicit. Berry Hart with his regard for the return of menstruation, says when the patient gains weight to use hot sitz baths, aloes and iron pills and binoxide of manganese two grains in pills thrice daily should be administered. In lactational insanity immediate weaning of the baby is indicated. Williams feels that it is a good deal of an obstetric problem because of its presumably infective causes and we must search for the underlying etiologic factor for the cause. The symptomatic treatment he refers to only generally and suggests, if immediate improvement is not seen, to refer to a psychiatrist.

Tweedy & Wrench logically prescribe rest, food, excretion, and exercise as the key notes of prevention and cure. When the attack is established, use forty grains of bromide and ten of chloral every two hours. With acute mania, hyoscine is the best stand-by.

Lewis of Chicago gives many practical suggestions.

The deduction and conclusions that we may draw from this summary of the literature and from our own experience are these:

First: We have a definite clinical entity.

Second: Its etiology is in a great number of cases toxic, either bacterial or chemical, except in the lactational type which is one of general impoverishment of the body from prolonged nursing.

Third: It occurs in about one in 2,000 labors at present and it causes about 6 per cent of all insanity in the female.

Fourth: Its types, which I am poorly equipped to discuss technically, I will group briefly as manias and melancholias. At first thought we would expect the former to be the strictly puerperal type, and the latter the lactational and in general this classification is correct.

Fifth: Symptoms of the former have a more or less sudden onset frequently preceded by a febrile disturbance and a pulse that either fails to fall as the temperature does or even climbs higher. There may or may not have been foul lochia previously. The onset is characterized by hallucinations, sexual and religious excitement, suicidal and infanticidal promptings, the latter more common in the lactational type.

Sixth: The prognosis is fairly good and as time goes on is improving, especially for the class of cases due to infections or intoxications.

Seventh: Treatment will tax all our ingenuity. General bodily health must be closely watched. The cause of infections must be met on surgical principles, as in any other infection, and the emunctories must be carefully looked after in this class, and, in those of chemical origin, its particular cause must be run down and met, whether in liver, intestine or kidney.

Rest must be obtained in the proper way. Restraint without resistance must be used, a constant attendant rather than a straight jacket. Pleasant surroundings make for mental rest as well.

Food must be nutritious and easily assimilated and its elimination must be watched and the kidneys stimulated with all the means at our command.

Exercise to the point of stimulation, but not fatigue, is as necessary as in any disease.

Medication must be studied very thoroughly. Of the hypnotics, hyoscine is the best. The suggestion of Berry Hart as to the emmenagogues is well worth a trial.

In the lactational type, we have profound exhaustion to deal with, and rest, more than exercise, will be indicated, but the most important indication is immediate weaning for the mother’s sake; while in the early puerperal type, weaning is indicated to remove from the mother all thoughts of the labor and also to avoid infanticide. If early improvement is not observed, a psychiatrist should be consulted and personally, I feel that a joint conduct of the case, particularly the early ones, of obstetrician and psychiatrist will give the most happy results to these unfortunates.—Long Island Medical Journal.