We presume that these are the cases to which Dr. Gooch has referred, when he described them as being “attended by fever, or at least, the most important part of it—a rapid pulse;” and that the majority of them prove fatal: their unfavourable result, however, is not so much from the local affection, as from the puerperal fever under which the patient sinks.
Pure phrenitis, which is a rare disease during labour or the puerperal state, is by no means difficult to control by active antiphlogistic treatment, if taken in sufficient time, before the brain has suffered any serious injury; nor is there much danger of her continuing deranged even after the inflammatory symptoms have been reduced. This appears to be also the case in that form which attends puerperal fever; but here the danger to life is so much greater, that we rarely have an opportunity of ascertaining the duration of the mental disorder after the symptoms of cerebral inflammation have been subdued, since most of these cases terminate fatally.
Gastro-enteric form. In the gastro-enteric form, the cerebral symptoms are of a much milder character: the head is perhaps warmer than natural, and it aches a good deal across the forehead and eyes; the face is seldom flushed, but it is sallow, the eye is yellow, the tongue is foul, the breath offensive, and if any evacuations have been passed, they are excessively unhealthy; the abdomen feels full and loaded, the pulse is irritable, but devoid of strength; the patient is seldom violent, and if so, can usually be restrained by the mildest measures. Her previous history will also assist us in our diagnosis; we shall, probably, find that she has for some time suffered from constipation and deranged bowels, or is known to have greatly neglected them before her confinement.
Puerperal mania from this cause is a result of cerebral irritation, not inflammation, and is a state which will generally cease the moment the cause is removed. As is the case with puerperal convulsions from gastro-enteric irritation, so here the moment we break the chain of morbid sympathies, upon which the disease depends, the symptoms disappear, and are instantly followed by a clearing up of the mental disorder. It usually comes on during the first few days after labour, before the patient has taken the laxative medicine which is customary at this time, and seems to be excited to an outbreak by any little source of mental annoyance or irritation. At first, it appears to be little else than giving way to caprice and temper, but by degrees her manner becomes more changed; and ultimately she grows violent and unmanageable. The state of mind, however, is very different to that of the inflammatory form of puerperal mania; there is no raving delirium, and but a slight degree of incoherence; she understands what is said to her, but reasons erroneously under the influence of a false impression. This state rarely proves dangerous either to her life or her reason, if the proper treatment has been promptly had recourse to; but where it has been allowed to run on for some time, or she has been reduced by antiphlogistic treatment under an erroneous fear of cerebral congestion or inflammation, there may be reason to fear that she will ultimately sink, or at any rate, that the derangement will become permanent.
Treatment. As the pulse scarcely ever betrays a febrile or inflammatory condition of the system, for although quick, it is seldom observed to be full and hard, bleeding is rarely required in this form of puerperal mania, leeches and cold applications being almost sufficient to control any symptoms of determination to the head which may be present: it is upon purgatives that we must place our chief hope in this disease, for until the bowels have been thoroughly and effectively cleared, there will be little chance of the symptoms being alleviated. In some cases it is scarcely credible to what an extent this may be carried; day after day sees the patient relieved of copious, dark, and offensive evacuations, which are evidently not merely the result of enormous accumulations in the bowels, but of excrementitious matters, which are thrown off by the secreting vessels of the liver and alimentary canal. So far from producing debility, the pulse rises with each relief and becomes fuller and slower, the face resumes a healthier aspect, the tongue becomes cleaner, the headach subsides, reason regains its ascendancy, and this favourable change is followed by calm and refreshing sleep. We could quote several cases of our own, in illustration of this form of puerperal mania and its treatment, where the symptoms have quickly yielded, as soon as the source of irritation had been removed from the system; the patient has recovered favourably, although in most instances she has retained a sufficient recollection of what had passed to feel much vexed and even shocked at, what she was aware had been, very strange and unruly conduct; but we prefer selecting Dr. Gooch’s thirteenth case, of which the details are given so graphically, as not a little to enhance the value of it.
“A lady, twenty-two years of age, clever, susceptible, and given to books, was confined with her first child at ——, — miles from town: she was anxious to nurse it; but several days passing with little appearance of milk, doubts began to be entertained whether she would be able: she thought she would, her nurse and surgeon thought she would not: this led to irritating discussions; her manner became sharp, quick, and unnatural; and at the end of a few days she was decidedly maniacal. I and another physician were now sent for; we found her in a straight waistcoat, incessantly talking and reciting poetry; her skin was hot, her pulse full, and much above 100; her tongue covered with a dark thick fur; her bowels were confined, and her stools excessively dark and offensive; she took a dose of calomel and jalap, followed by small doses of sulphate of magnesia; these produced a few evacuations, but they were followed by no relief; she talked almost incessantly, scarcely ever slept, and was so violent that it was impossible to keep her in bed without the straight waistcoat. Thus three days passed from our first consultation. The physician who attended with me, thinking the case would be protracted, withdrew, and I was directed to take Dr. Sutherland down with me. As the purgative had operated very moderately, and the tongue and stools were as unnatural as at first, he proposed a more active purge. The next morning, therefore, she took a strong dose of senna and salts, made still more active by the addition of tincture of jalap; after this had been taken about three hours, it procured a very large evacuation, nearly black, and horribly offensive; this was as usual discharged into the bed without any notice on the part of the patient; it acted again an hour or two afterwards; but now the nurse, who was sitting by her bed-side, was surprised to see her turn round, and in a calm and natural manner request to be taken up, as her medicine was going to operate; her waistcoat was immediately loosened, and she was taken out of bed, when she voided a stool of prodigous size, as dark and offensive as the first, and then walked back to her bed calm and collected. We saw her not many hours afterwards; her waistcoat was off, she was lying on her sofa perfectly tranquil, answered questions correctly, manifested no vestige of her complaint, excepting some strangeness in the expression of her countenance, and a timidity and abstinence from conversation which was not natural to her: she recovered rapidly and uninterruptedly.” (Account of some of the most important Diseases peculiar to Women, by Robert Gooch, M. D. p. 156.)
The chances of recovery in puerperal mania, from, gastro-enteric irritation are as great as they are small in the inflammatory form connected with puerperal fever: the danger is more from erroneous practice on the part of the medical attendant, who either prostrates the powers of life by active depletion, under the supposition that he is treating a case of cerebral congestion, or aggravates the disorder of the mind into wild delirium, by the exhibition of opium, to procure sleep. It is in these cases that we occasionally see so much relief procured by the action of emetics, as at one time to have been considered nearly specific in this disease, by some of the French practitioners. If the powers be good, we cannot agree with Dr. Gooch, in objecting to the use of antimony; when in a sufficient dose, and combined with ipecacuanha, it is too speedy in its operation to depress the patient much by nausea, and has the additional advantage of acting as a rapid and effectual purge: when its action is over, she usually falls into a sound sleep, perspires freely, and wakes greatly refreshed.
The indiscriminate use of emetics in puerperal mania, is not less mischievous than that of bleeding; they are chiefly indicated in those cases, where, in addition to the symptoms above-mentioned, there are signs of a foul and oppressed stomach, and where the patient either complains of nausea, or has already made several attempts to vomit. As soon as the offending cause is removed, the bowels should be kept open by mild alterative and laxative medicine, as equal parts of blue pill, compound extract of colocynth, and extract of henbane, in two pills at night, and a mineral acid in some bitter infusion during the day. The food should be bland but nutritious, the mind quietly but agreeably occupied, and all excitement carefully avoided. In this form of puerperal mania, it is not only a rare occurrence to find that the disordered state of the mind continues, when the cause which had produced it no longer exists, but it is scarcely ever known to return in the patient’s subsequent confinements. In the case which has been so ably recorded by Dr. Gooch, the patient has since had a very large family, her labours have all been perfectly favourable, and without the slightest symptom of her former disease.
The adynamic form of puerperal mania is by far the most common species of the disease, and like the adynamic puerperal convulsions, arises from causes which produce exhaustion and collapse in the general powers of the system. It is to Dr. Gooch that we are indebted for a masterly exposition of this disease, and for having been one of the first to point out its real character.
Causes and symptoms. This form of disordered mind is a disease of true debility, and is closely allied to delirium tremens, and convulsions produced by anæmia. It can scarcely be said to deserve either the terms “puerperal,” or “mania,” for we frequently see a very near approach to it in females who are much weakened by hæmorrhage, either from menorrhagia, malignant disease of the uterus, or abortion; and from being a disease which arises from great exhaustion, it rather deserves the name of melancholia, than of mania. In lying-in women, “there are two periods at which this is chiefly liable to occur; the one soon after delivery, when the body is sustaining the effects of labour, the other several months afterwards, when the body is sustaining the effects of nursing.” (Gooch, op. cit. p. 109.) In the one case, it is usually the result of profuse hæmorrhage, in the other, it is produced by suckling her child when she is not strong enough for this purpose. “I have repeatedly seen the commencement of mental derangement in women who had recovered from their confinement and had been suckling several months. Nearly all these cases were instances, not of mania but of melancholia. They occurred in women who had been debilitated by nursing. The disease at this period has been attributed to weaning; but, in all cases, I have seen, the disease has begun before the weaning, and this measure has been resorted to, because the patient had neither milk nor strength to fit her for a nurse. There was a peculiarity about the commencement of the disease which I have seldom or never noticed at the commencement of mania; there was an incipient stage in which the mind was wrong, yet right enough to recognise that it was wrong.” (Gooch, op. cit. p. 114.)