Nor do authors agree as to the significance of the term puerperal state, or as to the limits which should be assigned to the term puerperal tnania. While Griesinger reserves this title for intellectual derangements mani fested during and after labor, Monneret and Marco consider all derange ments occurring from conception to weaning as puerperal insanity. We think that the puerperal state includes, at once, both narrower and broader limits, and while admitting Raymond's classification of minor puerperal state, (pregnancy) and major puerperal state (post-partum state) we be lieve that the true puerperal state begins with pregnancy and terminates with the post-partum state. It is unnecessary to include lactation, but since some authors compare the mania of women just delivered with those of nursing women, we think that the insanity of pregnant women should be included in the same category, and that the phenomena of mental alienation occurring in pregnancy, labor, the puerperium, and lactation are all intimately connected. Sympathy, if one will, but the puerperal state and the exhaustion due to lactation, impress peculiar characters upon this alienation. We might, perhaps, make three special chapters of the subject, as Marc6 does, but to our mind, 'lecher went too far when he said: " It is well enough to treat of the mania of women who are preg nant, but it must not be called puerperal mania." True puerperal mania, we admit, will manifest itself three or four weeks after labor, but it seems impossible to us to separate it entirely from .the insanity of pregnant or of nursing women. We therefore include these forms in our study.
Prequency.—It is difficult to collect trustworthy statistics regarding puerperal mania, for it often does not appear until after the patients have left the hospital. The following figures have, therefore, only a relative value. Thus: Among the fourteen cases occurring in the puerperal state, Leidesdorff saw eight develop from the sixth to the tenth day, five from the third to the eighth week, one at the twelfth week.
On the other hand, the proportion of cages of puerperal mania compared with the total number of the insane, furnishes much more positive data. Thus: The following table shows the relative frequency of the cases in preg nancy, in the puerperium, and in lactation.
Insanity during pregnancy is, therefore, much the most rare. Causes.—In the first plate: 1. Heredity, i.e., a predisposition which Griesinger calls a psychopathic diathesis, transmitted by ancestors affected by insanity, diverse neuroses, hysteria, epilepsy, etc., in brief, by phreno and neuro-pathies. Thus: 2. Altered blood Anemia, which may ante date pregnancy or be its result. Its causes may be repeated pregnancies, hemorrhages either during pregnancy or during and after parturition; exhaustion from lactation, and, in the poorer classes, bad or inadequate food, fatiguing work, unhealthful dwellings, lack of sleep—in brief, all the causes of debility. b. Hyperferrila; active or passive congestions; Laserre's serous congestions.
3. Repe,ated Thus, among 287 patients, 70 were primiparte and 217 multiparte.
4. among 55 cases, found: At 18 years, 1 case; from 30 to 35 years, 13 cases; from 20 to 25 years, 13 e,ases; from 35 to 4) years, 5 cases; from 25 to 30 years, 17 cases; at 40 years and upward, 6 cases.
Reid, among 1771 cases, found: Under 20 years, 69 cases; from 40 t,o 45 years, 54 cases; from 20 to 30 years, 1,100 cases; from 45 to 50 years, 6 cases; from 30 to 40 years, 542 cases.
5. c,ause has no effect, according to Brierre de Boismont, Lagneau, Peter and others, unless the related parents are them selves insane or suffering from the psychopathic diathesis. In this case, they transmit to their progeny a double predisposition.
6. certain influence is attribut,ed to the generally fuller devel opment of boys, but this is not proven.
7. Moral Causes.—These are beyond question, and act both as predis posing and as exciting causes, particularly the latter. Rocher, although he attributes to them an important part, yet makes this reservation, that one ought always to assign to the temperament its share of the responsibility. The emotional nature of the pregnant women justifies the fear that her extreme nervous excitability may, under the existing special physiological circumstances, be the avenue for the entrance of intellectual disorders. He, however, willingly admits that this nervous state is not the indispen sable auxiliary of moral shocks, and that a sudden, violent emotion, may immediately precipitate an attack of mania.
Berard, Esquirol and others, have noticed that moral causes exercise their pernicious influence, particularly among the higher classes of society. The lower classes are more affected by physical causes. Nevertheless, the part played by moral causes in the evolution of puerperal insanity, is per ceptibly greater than that of the physical c,auses. Esquirol estimated the relation as 4 to 1; Weil as 12 to 6. Marce alone reverses the proportions.
8. Physical Causes.—Writers have mentioned dystocia, obstacles to delivery and obstetrical operations. Marce, however, remarks that insan ity shows itself as frequently after prompt and easy labors as after long and painful ones.
Return of Menstruation.—The mania may appear before or during the first menstruation, or hemorrhages. There is another cause, the influ ence of which cannot be disputed, in view of the frequency with which puerperal mania succeeds it, viz., eclampsia. All authors agree in con sidering puerperal mania as a relatively frequent termination. of eclampsia. Chloroform has been accused, but authors do not agree about it. Webster admits this cause, basing his views upon five of his cases, while Simpson opposes to these cases three of his own, where the women, being predis posed by heredity, had most happy deliveries after the use of chloroform, but were attacked by mania in their next confinements when chloroform was put aside. Waters not only does not regard chloroform as a cause of puerperal insanity, but proposes it as the best means of preventing and curing mania,. Finally, we should mention prolonged lactation, forced weaning and abscesses of the breast, and will recall; as matters of histori cal interest, the old theories of the suppression of lochia and of milk metastases, besides Esquirol's view regarding the etiological effects of cold, which, in ten of his cases, is said to have been the cause of insanity.