Puerperal Insanity comprehends the forms of mental derangement which may attack a woman during pregnancy, parturition, and the puerperal period. The occurrence of insanity during pregnancy is extremely rare; it is much more frequent during the early puerperium, and is liable to occur, but with less frequency, during the whole period of lactation. The affection presents many varieties, such as acute mania (which is probably the commonest), delusional mania, melancholia, &c. As regards frequency, it would seem that about 8 per cent. of all cases of insanity have a puerperal origin. This is derived from a very large number of cases, and the proportion in different places varies greatly. A very large proportion of the cases show a hereditary tendency to insanity, but it occurs to a great extent among those in whom no such taint can be recognised. Primipare are more frequently the victims than those who have borne several children; and there seems no doubt but that it is more apt to appear in those whose physical state has become depressed from one cause or other.
Illegitimacy seems to exert a potent influence in the production of this disorder. This comes out in Clouston's statistics. He says that 25 per cent. of all insane puerperal women are unmarried. This apparent close relation may be somewhat misleading, because while these unfortunates are no doubt the subjects of great mental distress, and often of physical hardships leading to lowered vitality—conditions which certainly favour the development of this disorder—yet it must be borne in mind that this is the very class who most frequently seek the shelter of lying-in hospitals, from whose wards the statistics are chiefly derived. It may generally be said that a depraved state of the nutritive system precedes attacks of insanity, and whatever tends to induce this favours the development of an insane attack. About 70 per cent. of those attacked become acutely maniacal. There is great excitement, incoherence, and often great and dangerous violence. There is continuous garrulity, and the language is frequently markedly profane or obscene. Violent explosions occur from time to time, often characterised by homicidal and suicidal tendency.
The melancholic form is characterised by an attitude and expression of great mental depression, speech is slow, and replies can only be elicited with difficulty. The eyes are lustreless and downcast, and the whole bearing suggests profound dejection. Suicidal attempts are not uncommon in the melancholic forms, and must always be guarded against. The symptoms usually appear within the first seven days after labour, and may develop with great rapidity. In both the melancholic and maniacal forms there is an aversion to food, the tongue becomes coated, and the secretory and excretory functions are greatly disordered. Sleeplessness is very pronounced, and hysterical outbursts, delusions, and hallucinations occur, and mania or melancholia rapidly supervenes. It is satisfactory to know that in spite of the violence of this disorder the chances of ultimate recovery are very great. Upwards of 80 per cent. recover entirely. Most of the maniacal cases get well within eight weeks, the melancholic within six months. In a small proportion of the cases recovery is deferred until nine months, after which the chances of complete recovery are considerably diminished. In this connection it should be noted that the rapidity of recovery depends on appropriate treatment being early begun. Experience shows that the majority of cases in which treatment is early begun get rapidly well, and that the chances of recovery are diminished in proportion as the treatment is deferred. Repugnant then as may be the removal of the patient to an asylum, there can be no doubt that, in the great majority of cases, this is the proper course to adopt. When one recalls the fact that most of the cases have a suicidal or homicidal tendency which it is often difficult to guard against in a private house, and at the same time understands that early recovery depends on early treatment, the propriety of the patient's early removal scarcely admits of question.
See Clouston, Mental Diseases; Bevan Lewis, Text-book of Mental Diseases; Lloyd, 'On Insanity and Diseases of the Nervous System in the Child-bearing Woman' (American System of Obstetrics, vol. ii.).