Not infrequently the hallucinations and delusions of the patient are of a sexual character. The most refined women will surpass the imagination of the veriest rake and gutter-snipe in their obscenity and vulgarity of language and action.
Motor excitement is common. There is frequently a tendency to remove the clothing. In some this appears to be a desire to expose the body to view; in others it probably is due to an halluci nation of common sensation, rendering the weight or pressure of the clothing unbearable.
A second stage following this excite ment is often one of depression. The distinction from true melancholia is, however, easy. The patient gets apa thetic, there may be depressive delusions, suicidal tendencies may develop, and there may be alternations of excitement and depression, with incoherence as a dominant symptom, lasting for years. While cases end not infrequently in secondary dementia, this is not frequent. The writer has seen an apparently com plete recovery from puerperal insanity after six years' residence in an asylum.
The stuperose stage of confusional in sanity is usually passed through by puer peral cases on the way to recovery or dementia.
Diagnosis.—The diagnosis of puer peral insanity cannot be made from the symptoms. It is not a special variety of insanity symptomatically, but etiolog ically. The cases of insanity occurring early in pregnancy, which are so often classed with the puerperal insanities, have generally no etiological relation with them. On the other hand, cases of lactational insanity frequently belong to the same class of toxcemic psychoses.
When the premonitory symptoms of puerperal insanity are observed—that is, change of manner and fe.eling with ex citability — extreme quietude of sur roundings must be insured, and careful, skilled supervision of the patient en forced to guard against infanticide or suicide by impulse. The bowels must be attended to, and, if there be early in somnia, a sedative draft of potassium bromide, drachm (2 grammes), and chloral hydrate, 15 grains (1 gramme), must be given at night. The diet should be liberal and sustaining. In all cases the urine must be tested for albumin. The free use of sedatives and hypnotics must be avoided as much as possible. In all eases in the maniacal form opium and its preparations are to be avoided. The child is to he weaned at once. In the melancholic type the preparations of opium and diffusible stimulants are indicated. A gain in weight, except when dementia has supervened, is a favorable sign. E. W. White (Brit.
Sled. .Tour., Feb. 7, 1903).
Causation.—As stated in the defini tion, the writer believes puerperal in sanity to be due to toxmmic infection. The reasons for this opinion are the fol lowing:— 1. Puerperal insanity occurs, in the great majority of cases, within the first ten days after delivery—about one-half in the first five days—the same period during which puerperal infection usually Occurs.
2. It is usually accompanied by eleva tion of temperature and other evidences of febrile disturbance.
3. The clinical form in which puer peral insanity manifests itself is, in the majority of cases, that of acute, delirious, or confusional mania. Depressive states are rare except as secondary forms. In other words, the most frequent condition is one most closely resembling febrile delirium.
4. The death-rate is much higher than in simple mania. Death occurs from ex haustion, usually with high temperature and rapid pulse.
5. Post-mortem examinations, though apparently infrequent in these cases, have shown grave involvement of the pelvic viscera.
6. Examinations of the pelvic organs during life show lacerations of the peri neum and cervix uteri (facile channels of infection in the puerperal woman). As secondary conditions are found intrapel vie (peritoneal) inflammations, and con sequent abnormal locations, fixations, and congestions of the uterus, tubes, and ovaries.
In the Rotvold Lunatic Asylum dur ing the years 1892-1900. out of 1674 women, 82 (4.82 per cent.) were suffer ing from puerperal psychoses, but as 17 of these cases had suffered from previous mental affections, the percentage of primary puerperal eases was 3.88 per cent. Infection can undoubtedly lead to mental affection in the puerperium, but ot her causes play their part,—child birth itself. for instance, as in one pa tient, who a couple of hours after each of her five confinements fell into an abnormal mental condition that per sisted two or three months. Other causes are to be found in intoxication (autointoxication.—c.g., eclampsia), pro fuse haemorrhage, overexertion, and mental impressions, and, as a rule, vari ous etiological factors are combined. Puerperal psychoses have no special syndromata. The prognosis appears from these comparative statistics to he good, even for cases due to infection if the infection is not fatal in itself. Prog nosis is better for primiparfe than for women who have previously had chil dren, and more favorable the younger the patient. Wideroe (Tidssk. fiord. IZetsmed. Psyk., 1902).