In reference to its frequency, we find among the authorities a great
deal of variation and it again shakes our faith in the value of
statistics.
In an edition of forty-one years ago of Fordyce Barker’s “Puerperal
Diseases,” he gives the ratio of cases of puerperal mania to total
labors in Bellevue as 1–80. I have purposely referred to the age of this
book because I shall refer to it again in discussing an attributed
etiological factor. Not long ago after this work appeared, McLeod took
the statistics of births in England and Wales for four years (1878–82)
and found the proportion of women committed for puerperal insanity was
1,794–3,500,000 labors, or 1–2000. Baker himself was interested in the
variation of statistics and explains part of the difference from the
fact that there were many unmarried women at Bellevue; and while there
were also among the foreign records, in the old countries, the fact of
being a mother and not a wife was felt far less keenly, if at all than
in America! (Pp. 160–191.)
Williams refers to more modern statistics of Berkley and of Jones, who
noted it in 1 in 616 and in 1,100 labors respectively, but Williams’s
own experience has been less frequent.
Hirst states “About one in 400 women confined become insane;” a flat if
not grammatical statement, and this proportion agrees with, if not taken
from, the experience of Clouston of the Edinburgh asylum. Hanson’s
figures are about the same, 1–386.
Let us get at this subject of frequency from the opposite point of view.
Among cases of insanity how many are associated with childbearing?
Clouston, of Edinburgh, among 1,500 women, found 10 per cent were
classified as suffering with puerperal psychoses and most of the earlier
figures (and here we have the first real thought) before the antiseptic
era give similar percentages—the New York State hospitals from 1888 to
1895 give only 5 per cent as puerperal in origin. Before we draw a too
hasty conclusion, let me quote Lane based on observations in the Boston
Insane Hospital for ten years, “that insanity associated with childbirth
occurs only one-half as frequently as does insanity among women in
general of childbearing age. The vast majority of women who become
insane are between the ages of twenty and fifty. The task of bearing and
nursing children occupies a considerable portion of the time of the
average woman during these ages. Therefore, we should expect a large
proportion of cases of insanity to begin during such time even without
casual connection.” According to Lane’s view the childbearing process
gives a certain degree of immunity to insanity instead of predisposition
thereto!
On the other hand he points out that there are many more single than
married women in asylums—perhaps unmarried on account of their defects.
Hirst says of all cases of insanity in women about 8 per cent have their
origin in the childbearing process, while Berry Hart gives the lower
percentage of five. De Lee, in his textbook—the most recent at my
command—gives the high percentage of 10–18 of female inmates affected at
this time.
The most reliable figures I have yet obtained came recently to hand
through the courtesy of Dr. Ziegelman, one of the resident psychiatrists
at Kings County Hospital, and he tells me that of 454 female admissions
to the observation ward there, from October 1, 1914, to March 18, 1915,
there are twenty-six cases of puerperal insanity, practically 5¾ per
cent. These are not very different, except suggestively lower than
Jones, of London, who, in 1903, found from 6.4 per cent, private, and
8.1 per cent poor class patients then in the London Asylum.
With so much information, vague and meagre as it is, let us pause a
moment and weigh the evidence. As our ideas of pathology change with
time, so must our viewpoint as to morbidity and the most recent ideas
must settle such questions.
Williams, Hirst, Edgar, Webster, De Lee, Jones and Tweedy & Wrench,
refer to it absolutely as a disease. Wright of Toronto and the
Englishmen Berry Hart and Let are more vague, and only Lewis, of
Chicago, calls its occurrence a coincidence. When we consider its
frequency, if only we accept the very conservative estimate of Williams
and the definite figures from McLeod, of England, of 1–2000 births and
are not so radical as Hirst the obstetrician and Clouston the Edinburgh
alienist, who state 1–400, to say nothing of Fordyce Barker’s 1–80, we
must feel that there is more than a coincidence, and if we consider the
large percentage who are confined to asylums suffering from it, I feel
we have all the evidence needed.
Causes must be studied before we can put pathology on a sound basis, to
say nothing of diagnosis and treatment. Here again we find many
authorities in disagreement and at times extremely vague.
Williams, of the school that, I think we all feel has, through the
laboratory, magnified the science of medicine perhaps sometimes to the
detriment of its art, says:
“Puerperal psychoses may be due to one of three causes: Infection,
auto-intoxication, or direct liability of the nervous system. Of these,
infection is by far the most important. This fact has long been
recognized, but it is only of late that the bacteria concerned have been
identified, and then only in a small proportion of cases. In two of the
three instances which have come under my observation, the infection was
due to the streptococcus, and in the third to the streptococcus and
colon bacillus.”
Berkeley likewise reports a case due to the organism first mentioned.
Auto-intoxication is also a frequent etiological factor, and it is
probable that the vast majority of mental disarrangements following
eclampsia are due to this condition. Ordinarily, insanity is regarded as
a rare complication of eclampsia, though Olshauser observed it in 6 per
cent of his 515 cases. According to Hansen and Picque infection and
auto-intoxication are responsible for more than 80 per cent of all
cases, while the remainder are to be attributed to other causes,
occurring particularly in women afflicted with hereditary tendencies,
“the exciting cause of the insanity being shock, extreme mental
depression or the rapid loss of a large quantity of blood.”
The general trend of investigation of etiology and pathology has been of
course to ascribe definite tangible factors as the cause of definite
organic changes, and we hear less and less of idiopathic diseases and
functional conditions, and while the view of Williams may seem to be
almost too definite, please contrast it with the causes ascribed by
Hirst, which he divides into “predisposing—the nervous excitement of
gestation in women predisposed by hereditary influence to mental
breakdown, great reduction in physical strength and prolonged mental
strain or worry * * *; the exciting causes may be exaggerated anæmia, as
from prolonged lactation, septicæmia; albuminuria; profound emotion or
exaggerated fear of impending danger; remorse and shame of illegitimate
pregnancy; the grief of a deserted woman; accident or hemorrhage; great
physical or mental exhaustion. In my experience insanity in the
childbearing woman has almost always resulted from some profound
emotion.”
Webster, of Chicago, says: “Frequently there is a predisposing
cause—e.g., bad heredity and prolonged mental or physical strain.
Anæmia, sepsis, albuminuria, marked emotional disturbance and the pain
and excitement of labor.”
Berry Hart only mentions the predisposing causes of a neurotic
constitution, too frequent pregnancies, too prolonged lactation, and in
some cases the shock of a seduction ending in conception.
Wright, of Toronto, as I have stated before, says: “Constipation is
frequently very marked,”—whether he means as a cause or a symptom is
problematic.
De Lee, of Chicago, says: “Puerperal infection, mastitis, eclampsia and
allied toxemias, post-partum and other hemorrhages, especially if
grafted on a bad heredity, exhausting labor and the drain of lactation
are the most common causes. The attack may be developed by a violent
psychic shock, such as the death of husband or child.”
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.