Treatment. —This should be, above all, hygienic, and, with Marc6, we absolutely reject the induction of premature labor and of abortion. What is, then, the influence of insanity upon pregnancy and of pregnancy upon insanity ? The effect of insanity upon pregnancy is nil, and women affected by puerperal insanity carry their children to full term. Burrows, however, has cited the two cases of abortion alluded to before. Does the same statement hold true regarding the influence of pregnancy upon insanity ? What are the consequences of pregnancy occurring in an in sane person ? It is a popular notion that pregnancy cures insanity, but this view has no actual basis in fact, and if, in exceptional cases, pregnancy and labor happily modify insanity, there are innumerable cases in which there is no such modification. One cannot too strongly condemn the practice of some physicians in recommending pregnancy for insane women, not amenable to the ordinary therapeutic agents. In some rare cases, however, pregnancy has had the singular effect of checking the advance of mental alienation, but, labor being once completed and the patient re stored to her ordinary condition of health, the nervous troubles reappear with equal intensity. There are still other cases in which parturition has had a plainly beneficent influence in aiding the cure of a paroxysm of insanity. Mara! has collected five such cases. Generally, the course of pregnancy is not interrupted by distressing incidents. A remarkable fea ture, observed in our two patients, was the slight intensity of the labor pains. In certain cases, several of which Mard. mentions, the patients are not aware of their delivery. There seems to be a difference between the children whose mothers were insane at the time of conception, and those whose mothers became insane during pregnancy. In the former case, the children are born healthy, but in the second case, they are often still-born or die soon after birth. In our two cases the children wero born in perfect health. In these cases, the children are certainly subjected to that hereditary influence which plays so important a role in the etiology of mental diseases, but it is not true that their intellectual condition need, necessarily, be affected by that of their parent.
Even in 1826 Bouchet noted, in twenty-two cases, this absence of ame lioration in the mental state from pregnancy and labor, while See and Montgomery reported a, temporary aggravation during cervical dilatation.
Temporary Insanity at the Time of Delivery.
Sometimes labor does not limit itself to the production of the agitation, anxiety and irritability which all accoucheurs have observed, but attacks the intelligence or even leads to the development of maniacal delirium. These cases, which are rare, may be classed in two categories, as Marce has done. " In one variety, the actions and words are of constant inco herence, while in the other, the delirious actions instigated by the severe pains of labor are logically related to their point of origin. Thus, some women, in real frenzy, seek to inflict violence upon themselves or the child, to abridge their sufferings. In many cases, the intellectual trouble assumes the characters of acute mania. There is complete incoherence; patients have no appreciation of their condition, and nothing in the symp toms betrays the physical and moral causes which occasioned the deli rium." It is, therefore, a sympathetic phenomenon, encountered most frequently in difficult labors, but also, sometimes, in natural ones, when it coincides with the expulsion either of the fcetus or of the placenta. In
spite of its apparent gravity, this delirium has no serious consequences. It ceases spontaneously when labor ends, and in the cases where it is pro longed after delivery, it rarely lasts more than a few days and hardly ever ends in mania. The most rational treatment consists in terminating labor as rapidly as possible, and in then adopting expectant measures.
Insanity ofWamen just delivered and of nursing nmen.
The types of insanity observed in these cases are: Mania, melancholia, lypomania, partial involvement of the intellect, hallucinations, intellec tual or instinctive monomania, alternate insanity or duplex insanity, and simple dementia. These forms are far from being equally frequent. ..A.mong forty-four cases Marce found twenty-nine of mania, ten of melan cholia, five of partial insanity, and only two cases of temporary intellec tual enfeeblement. In nursing women melancholia is, at least, as com mon as mania. The number of monomanias is hardly equal to one-fifth of the cases of mania.
Among forty-four cases, the insanity appeared within the first ten days in thirty-three cases. Sometimes the delirium appeared on the first or second day, but most often did not develop or attain its maximum until the fourth or fifth day. The inception of insanity on the tenth day is quite rare. In eleven cases insanity developed at about the sixth week, i.e., at the return of the menses. (Mame.) I. Mania.
The attack is sometimes sudden, but generally gradual, and accom panied by precursory symptoms, lasting from some hours to several days. The women are sad, morose, but more often excited. Their manners and behavior become modified, the senses grow more acute, the slightest noise or too bright a light causing suffering; the agitation is aggravated day by day, and violent mania developes. Insomnia becomes complete, the tongue is coat,ed, the mouth slimy, the head more painful and the pulse, accelerated during the moments of agitation, beats more quietly so soon as the woman grows calmer. Hallucinations of sight and hearing are now developed, and put the patients into a state of violent agitation, during which they become dangerous to themselves, to those around them, and particularly to their child. Some of the most important symptoms are the fancies of the patients, the odor which they exhale, and the pres ence of albumin in their urine. Some observers, as Mard, attach im portance to the presence of erotic ideas. Puerperal mania, thus, has nothing peculiar to itself, either in the delirium or in the physical symp toms.
Mania terminates in recovery, incurability or death. Recovery is much the most frequent, and occurs more or less rapidly, within a few days or several months. Among the complications which may prove fatal, we should accord the first place to acute delirium, which sometimes begins. with the attack, but sometimes is not developed until after several weeks, or after a paroxysm of duplex insanity. Instead of ceasing in a few days, acute delirium may be prolonged, entering a new stage. Then typhoid symptoms develop, syncope occurs and the patients succumb, either sud denly from syncope, or slowly with all the symptoms of profound nervous exhaustion. To recapitulate: Patients who die during acute puerperal mania, succumb either to an intercurrent disease or to violent agitation and acute delirium.