All authorities disagree markedly on this most important aspect.
Williams tells that the progress is three to six months and if longer
the prospect is very poor, 20–40 per cent fail to regain mental
equilibrium and 5–10 per cent die, this high mortality due, he feels, to
the underlying infection and not the mental derangement itself, and with
these figures Hirst is in practical accord.
Lewis tells us 25 per cent of the infection cases die, but the progress
of toxic cases is not so bad. Death occurs usually from sepsis or the
exhaustion on account of the motor excitement. Lactational cases recover
in 50 per cent, and they take eight to nine months.
Webster quotes from Clouston of Edinburgh that 75 per cent of his cases
have recovered; one-half of those in three months and 90 per cent in six
months, and occasionally recovery takes place after years of impaired
mentality and, surprisingly, he states that there is probably a larger
number of recoveries in acute and severe cases than in mild ones. Dr.
Lee states that the prognosis is fair—recovery in the majority of cases
in from six weeks to six months.
Edgar tells us that exhaustion is the usual cause of death but recovery
is the rule even from the insanity; if not, it goes on to a terminal
dementia or paranoia. A high pulse-rate is a bad sign.
Berry Hart says the prognosis is good under proper treatment and the
return of menstruation is such a good sign that emmenagogues should be
employed.
Tweedy & Wrench say some 60 per cent of all cases recover, but if, as
the patient gets fatter and stronger the mind does not improve, the
prognosis is bad.
In the subject of treatment our authorities again differ, but not in the
usual way. Webster briefly dismisses it with advising an asylum, as does
Hirst, except in cases of refusal of families or friends to commit the
patient, when general symptomatic treatment is necessary. Edgar and De
Lee both are no more explicit. Berry Hart with his regard for the return
of menstruation, says when the patient gains weight to use hot sitz
baths, aloes and iron pills and binoxide of manganese two grains in
pills thrice daily should be administered. In lactational insanity
immediate weaning of the baby is indicated. Williams feels that it is a
good deal of an obstetric problem because of its presumably infective
causes and we must search for the underlying etiologic factor for the
cause. The symptomatic treatment he refers to only generally and
suggests, if immediate improvement is not seen, to refer to a
psychiatrist.
Tweedy & Wrench logically prescribe rest, food, excretion, and exercise
as the key notes of prevention and cure. When the attack is established,
use forty grains of bromide and ten of chloral every two hours. With
acute mania, hyoscine is the best stand-by.
Lewis of Chicago gives many practical suggestions.
The deduction and conclusions that we may draw from this summary of the
literature and from our own experience are these:
First: We have a definite clinical entity.
Second: Its etiology is in a great number of cases toxic, either
bacterial or chemical, except in the lactational type which is one
of general impoverishment of the body from prolonged nursing.
Third: It occurs in about one in 2,000 labors at present and it
causes about 6 per cent of all insanity in the female.
Fourth: Its types, which I am poorly equipped to discuss
technically, I will group briefly as manias and melancholias. At
first thought we would expect the former to be the strictly
puerperal type, and the latter the lactational and in general this
classification is correct.
Fifth: Symptoms of the former have a more or less sudden onset
frequently preceded by a febrile disturbance and a pulse that either
fails to fall as the temperature does or even climbs higher. There
may or may not have been foul lochia previously. The onset is
characterized by hallucinations, sexual and religious excitement,
suicidal and infanticidal promptings, the latter more common in the
lactational type.
Sixth: The prognosis is fairly good and as time goes on is
improving, especially for the class of cases due to infections or
intoxications.
Seventh: Treatment will tax all our ingenuity. General bodily health
must be closely watched. The cause of infections must be met on
surgical principles, as in any other infection, and the emunctories
must be carefully looked after in this class, and, in those of
chemical origin, its particular cause must be run down and met,
whether in liver, intestine or kidney.
Rest must be obtained in the proper way. Restraint without
resistance must be used, a constant attendant rather than a straight
jacket. Pleasant surroundings make for mental rest as well.
Food must be nutritious and easily assimilated and its elimination
must be watched and the kidneys stimulated with all the means at our
command.
Exercise to the point of stimulation, but not fatigue, is as
necessary as in any disease.
Medication must be studied very thoroughly. Of the hypnotics,
hyoscine is the best. The suggestion of Berry Hart as to the
emmenagogues is well worth a trial.
In the lactational type, we have profound exhaustion to deal with,
and rest, more than exercise, will be indicated, but the most
important indication is immediate weaning for the mother’s sake;
while in the early puerperal type, weaning is indicated to remove
from the mother all thoughts of the labor and also to avoid
infanticide. If early improvement is not observed, a psychiatrist
should be consulted and personally, I feel that a joint conduct of
the case, particularly the early ones, of obstetrician and
psychiatrist will give the most happy results to these
unfortunates.—_Long Island Medical Journal._