PUERPERAL INSANITY 



PUERTO DE SANTA MARIA 483 



hospital was opened, and though it was constructed 

 on tlie most advanced sanitary ideas several fatal 

 cases occurred during the first three or four nionths 

 after its opening. The source of the mischief was 

 never discovered ; but a vigorous antiseptic and 

 aseptic course was instituted in the management 

 of the practice, and since then no single case of 

 septicaemia has occurred. 



A similar result has been attained in the great 

 maternity hospitals on the Continent, and indeed 

 it is found everywhere that the more rigorous the 

 antiseptic practice the more nearly perfect is the 

 immunity from the disease. In no department of 

 practical medicine have the discoveries and teach- 

 ing of Lister produced more brilliant results. For 

 while it might well have been said that until 

 recently a woman in entering a maternity hospital 

 took her life in her hands, it now appears that 

 since antiseptics in midwifery have been rigorously 

 adopted a woman is actually safer in such an insti- 

 tution than in her own home. For while careful 

 antiseptic practice is practically a routine in the 

 hospital, it is apt to be faulty in a private house by 

 reason of some constructional fault in the dwelling 

 or ignorance or carelessness on the part of the 

 attendants. And thus, while septiciemia is practi- 

 cally stamped out of hospital practice, it is still far 

 too common in private. 



The chief points attended to in hospital practice 

 are ( 1 ) the thorough cleanliness of the bedding 

 and clothes of the patient all soiled articles living 

 at once removed and disinfected before Ix-ing 

 washed. (2) The scrupulous cleansing of the wards 

 and delivery rooms from time to time. (3) The 

 extreme personal cleanliness of all attendants 

 accoucheur and nurses the hands being carefully 

 disinfected on every occasion before a patient is 

 touched. (4) The rigid exclusion from the clinics 

 of all who are in attendance on infectious or septic 

 cases or in the post-mortem or dissecting rooms. 

 (5) The prevention of septic absorption by the free 

 use of antiseptic lotions and dressings. \\ hile such 

 practice can, with due care, be constantly main- 

 tained in hospital, it is obvious that the conditions 

 of private practice render its application more 

 difficult ; and while antiseptics have rendered the 

 disease immensely less frequent, it is doubtful if we 

 can hope for the almost complete immunity in 

 private which we have attained in hospital practice. 



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 preg- 

 nancy 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 dif- 

 ferent places varies greatly. A very large propor- 

 tion 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. 

 Primipane 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 

 Cloiiston's statistics. He says that 25 per cent, of 

 all insane puerperal women are unmarried. This 

 apparent close relation may be somewhat mislead- 

 ing, 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 sys- 

 tem 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 excite- 

 ment, 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 l>e elicited with 

 difficulty. The eyes are lustreless and downcast, 

 and the whole bearing suggests profound dejection. 

 Suicidal attempts are not uncommon in the melan- 

 cholic 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 l>otli the melancholic and maniacal 

 forms there is an aversion to food, the tongue 

 Incomes coated, and the secretory and excretory 

 functions are greatly disordered. Sleeplessness is 

 very pronounced, and hysterical outbursts, delu- 

 sions, and hallucinations occur, and mania or 

 melancholia rapidly supervenes. It is satisfactory 

 to know that in spite of the violence of this dis- 

 order 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 com- 

 plete 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 de- 

 ferred. 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 under- 

 stands that early recovery depends on early treat- 

 ment, the propriety of the patient's early removal 

 scarcely admits of question. 



See Clouston, Mental Diseases; Bevan Lewis, Text- 

 book of Mental Dii,ea4es ; Lloyd, * On Insanity and 

 Diseases of the Nervous System in the Child-bearing 

 Woman ' (American Si/stem of Obstetrics, vol. ii.). 



Puerto Bello. See PORTOBELO. 



Puerto Cabello, a seaport of Venezuela, in 

 Caralrabo state, 78 miles W. from Caracas. It 

 stands on a long, low, narrow peninsula on the 

 Caribbean Sea, and has a safe, deep, and roomy 

 harlmur, defended by a fort and batteries. It is 

 the port of Valencia, which is 34 miles distant by 

 rail. There is an active foreign trade, which 

 averages 1J million sterling annually ; the chief 

 exports are coffee, cacao, indigo, cinchona, cfltton, 

 sugar, divi-divi, and copper ore. Pop. 10,145. 



Puerto Cortez, a port of Honduras (q.v.). 



Puerto de Santa Maria, a seaport of Spain, 

 stands at the mouth of the Guadalete, on the Bay 

 of Cadiz, 22 miles by rail (all round the bay) NEL 

 of Cadiz and 8 SW. of Xeres. It is one' of the 



