PUERPERAL INSANITY AND STERILIZATION
From 8 to 10 per cent. of all insanity in women develops during the
puerperium--the incidence is about one case to 400 births. Puerperal
insanity in nearly 70 per cent. of the cases begins within the first
two weeks after parturition. Next in frequency of occurrence is
the period of lactation, especially in multiparae. Insanity during
pregnancy itself is relatively rare, and it begins usually after the
fourth month.
As in other forms of insanity, hereditary predisposition is found
in from 25 to 30 per cent. of the cases. Alcoholism, sepsis, and
neuroses like hysteria, chorea, and epilepsy, are the predisposing
elements. The most common immediate exciting cause during pregnancy
is toxemia from faulty metabolism and excretion. Other frequent
direct excitants are mental worry from poverty, desertion, seduction,
and the like troubles.
Prolongation of the lactation period beyond the usual time for
weaning, from the ninth to the twelfth month, is common among
ignorant and lazy women. Some women prolong lactation in the
erroneous notion that it prevents renewed impregnation. Such
lactation is injurious to the child, as a rule. Ploss says
hyperlactation is frequent in Spain, and that some Japanese,
Chinese, and Armenian women may nurse their children for years, but
this practice is undoubtedly injurious, especially among European
races. The women get tabes lactea with emaciation, asthenia, anemia,
backache, pain in the breasts, neurasthenia, cramps, and blindness.
The uterus atrophies in some cases and may be permanently injured.
Insanity is not unusual.
The forms of mental disturbance commonest in puerperal insanity are
mania with or without delirium, melancholia, and dementia. Dementia
is the final stage in the cases that become chronic. Mania is the
prevailing type in insanity after labor, and melancholia in insanity
during gestation. The melancholy of insanity during gestation is
often suicidal, and must always be watched. Religious and erotic
symptoms are also observed.
The onset may be very sudden during labor. An outbreak after labor
may be suicidal or homicidal. Maniacal puerperal women are dangerous.
They have delusions and hallucinations, with very rapid and incessant
changes that range from obscenity to prayer. Melancholy in the
puerperium is likely to be suicidal.
About 75 per cent. of puerperal insanity cases recover within five or
six months. From 2 to 10 per cent. die from sepsis, exhaustion, or
intercurrent diseases; the remainder become permanently insane. The
nearer the delivery the insanity appears, the better the prognosis.
Menzies found that of cases which began during gestation 56.7 per
cent. remained insane; of those that began during the puerperium 25
per cent. did not recover; of those that began during lactation 43.5
per cent. remained insane. Melancholia is more favorable than mania
in pregnancy, but after labor mania gives the better prognosis. The
maniacal patient is more likely to die, but the melancholic is more
likely to remain insane. The older the woman, the greater the number
of her pregnancies, the more the depression, and the higher the
temperature, the worse the prognosis. Alcoholism is an added risk
always.
All puerperal insanities should be treated in sanatoria or asylums
and not at home. When a woman with puerperal insanity is allowed to
remain at home she cannot get proper treatment, and is a constant
menace to her own life and the lives of her family.
A woman who has had puerperal insanity and has recovered her mental
health is likely to have a recurrence of her malady at subsequent
pregnancies. The question has been asked me a few times, "Would
it not be justifiable to sterilize such a woman to prevent this
recurrence, with its dangers and terrors?"
It would not be justifiable: 1. Because it is not licit to inflict
a grave mutilation to avert a possible or probable future evil.
2. There are other means to escape the danger: a woman with this
tendency is justified in denying the debitum. 3. Once crazy, always
crazy, is an aphorism with much truth in it, and it is doubtful
that sterilization in itself will prevent ultimate insanity. 4. The
conjugal relation of a sterilized woman would be no better than
onanistic. 5. The sterilization would fall under the decrees and
penalties described at the end of the chapter on Cesarean Section.