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.