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A U Rehman, D St Clair and C PlatzPuerperal insanity in the 19th and 20th centuries.

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BritishJournalofPsychiatry(1990),156,861—865

Puerperal Insanity in the 19th and 20th Centuries

ANIS-UR-REHMAN, DAVID ST CLAIR and CHRISTINE PLATZ

All patientswith puerperalpsychosisadmittedto the RoyalEdinburghHospitalwithin90 daysof childbirthduringthe periods1880—90and 1971—80werecompared.The majorityof casesinbothgroupshadan affectiveillnesswith anacutepresentationanda fixedintervalof onset.The 19th-centurycaseshada morefloridpresentationanda greaterlengthof admission(mean,151 days)to the hospitalthan the 20th-centuryones(mean, 39 days). The incidenceof thedisorderrosefrom 0.34 per 1000 childbirthsper year in the 19th-centurygroupto 1.04 inthe 20th-centuryone, but thiscouldbeexplainedby nosocomialfactors. Most 19th-centurycasesoccurredinmulitgravidwomen,whichquestionsthe associationof puerperalpsychosiswith primiparae.

Although the presentation of psychiatric illness hasgenerallyremainedunchangedoverthepastcentury,the intensity of mental disorders seems to havealtered over time (Kiaf & Hamilton, 1961; Hare,1974;Ellard,1987;Hare,1988).Casesofdeliriousmania and catatonic excitement common a centuryago are rarely seen now. Furthermore, Loudon (1988)studied patients with puerperal psychosis admittedto Warwick County Lunatic Asylum between 1880and 1888 and commented on the florid presentationcompared with the present day.Itispostulatedthananimprovementinthegeneral

health of the population over the past century hasbroughtaboutanoveralldeclineinthefloridnessofmentaldisorders(Hare,1974).However,definitiveevidence to support this view is lacking. It is hardto compareequivalentpatientgroupsover sucha longtime epoch since most 19th-century psychiatric classifications differed from contemporary operationaliseddiagnostic criteria which are based on a Kraepeliniandivisionof psychoses.A rareopportunityforacomparative study on 19th- and 20th-century patientswas recentlyidentifiedat theRoyalEdinburghHospital. Each patient selected for study wasadmitted during one of the periods 1880-90 and1971—80and had a diagnosis of puerperal mentalillnessbasedoncontemporarycriteria.Thechangesinsymptomsandepidemiologyofmentaldisordersfollowing childbirth could thus be investigated usingequivalent groups over a 90 year period.

Subjects

Nineteenth-century cases

when Dr Mackinnon was Physician Superintendent. Thecasesusedarefromtheperiod 1880-90when it was standardpractice to use two parallel diagnostic systems: divisions intomania, melancholia and monomanias similar to contemporary ones, and a second diagnosis based on the classificationsystem bySkae(1863). This system allowed thepresent studyto identify all patients admitted with psychiatric disorderfollowing childbirth since all were labelled as suffering fromeither ‘¿�puerperal'or ‘¿�lactational'insanity. A diagnosis of‘¿�puerperal' insanity was given if symptoms occurred withinsix weeks of delivery. ‘¿�Lactational'insanity began after thisperiod or following prolonged lactation.

A systematic search through a full year's admissionsduring the study period was made to determine whetherany patients with mental illness followingchildbirth hadbeen overlooked by Skae's classification. None was found.Thus, the present study included all women admitted tothe Royal Edinburgh Lunatic Asylum with a mental illnesswithin 90 days of delivery from 1880-90. The total numberof patients identified was 63. Although there were 38 caseswhere only approximate dates of childbirth were given inthe hospital case notes, a search of birth records at theScottish Register Office allowed the exact date of deliveryto be determined in 28 of these.

Twentieth-century cases

A follow-upstudyofcasesofpuerperalpsychosisoriginallystudied by Dean & Kendell (1981) was in progress at theRoyalEdinburghHospitalatthetimeofourinvestigationand thus we used its findings. In this study, since thehospital served a catchment area of the whole city, computerlinkage of obstetricand psychiatricrecords enabled all

women who had received in-patient care at the hospitalwithin 90 days of childbirth to be traced. The total numberof cases identified during the period 1971-80 was 108.

Data

Information for both 19thand 20th-century cases, includingdemographic details, obstetric variables and symptoms, wasrecorded. Symptoms were identified according to a varietyof different criteria. The presence of ‘¿�moodswings' required

Method

Detailed case records of each patient admitted to the RoyalEdinburgh Lunatic Asylum areavailable from l840onwards

861

Obstetricvariables19th-centurypatients

(totaln= 63)20th-centurypatients

(totaln=108)Previous

pregnancies':number(¾)primigravidae14

(31°lo)58(55¾)multigravidae31(69¾)48(45¾)Mean

(s.d.)intervals:daysDelivery

and admission33 (24)32(25)@Deliveryand onsetofsymptoms16

(26)17(21?Onsetof symptomsandadmission21

(28)16(l7)@Perinatalcomplications2:number(¾)absent13

(45¾)55(60¾)present16(55¾)37(4OO1@)@P<0.05.

19th-centurypatients(n=63)20th-century

patients(n=108)Schizophrenia2

(3%)5(4¾)Schizoaffectivedisordermanic

type4 (6°lo)5(4%)depressedtype03(3°lo)Manic

disorder27 (43¾)15(14%)Hypomanicdisorder02(2¾)Major

depressivedisorder23(36%)45(42¾)Minordepressive disorder1 (2¾)18(17¾)@@Unspecified

functionalpsychosis1(2¾)10(9¾)Organic

disorder5 (8¾)1(1°lo)Personalitydisorder!no

psychiatricdiagnosis04 (4¾)

862 REHMAN ET AL

the shifting of mood from elation to depression or viceversawithin the first month of admission. ‘¿�Confusion'was ratedaccordingto theDSM-III(AmericanPsychiatricAssociation,1980) criteria for delirium with modifications (Rehman,1986). Patients were considered to be definitely confused if criteria for any three of the four stems (ABCD)were fulfilled or if there was strong evidence of confusionfrom clinical records. The coding for ‘¿�delusions'wasaccording to the Present State Examination (PSE)glossary of definitions (Wing et a!, 1974). Furthermore,Research Diagnostic Criteria (RDC) (Spitzer et a!,1978) diagnoses were derived for patients in bothgroups.

The case notes for both the study periods were wellrecorded. The 19th-century case histories were especiallyimpressiveand contained meticulous details about symptomswhich facilitated retrospective application of RDC criteria.Quantitative information was obtained by analysis ofvariance,@ and Fischer's Exact Probability using theStatistical Package for Social Sciences (SPSS, 1983).

Incidence of puerperal psychosis

Figures from the General Register Office for Scotlandwere obtained in order to ascertain the population andbirth rate in Edinburgh for the periods studied. Thecatchmentareaforthehospitaloverbothperiodswasalso estimated. Using these data, an approximate estimateof the incidence of puerperal psychoses was made (seeResults).

TABLE IObstetricfeatures of puerpera! patients in the 19th and 20th

centuries

Results

The mean age of the 63 19th-centurycases was 28 (s.d. 5.1)while that of the 108 20th-century patients was 26(s.d. 5.0)( P<0.05). Seventy-four per cent of the 19th-centurypatients were married as compared with 80¾of the 20thcentury ones. A past history of mental ifiness was notedin 18¾of the 19th-century group as against 44¾of the20th-century one ( P< 0.001). Twenty-seven per cent of19th-century patients had a family history of psychiatricillness as opposed to 41¾of the 20th-century ones.Interpretation of these results is difficult as they may nothave been meticulously recorded in 19th-century patients.

Table I lists the obstetric variables of the two groups.Significantly ( P<0.05) more 20th-century patients wereprimigravid compared with 19th-century patients. On theother hand there were no differences between the twogroups in the length of time of any of the importantobstetric intervals and the onset of symptoms. Similarly,there were no significant differences between the two groupsas regardsobstetriccomplications. It should be mentioned,however, that information was not available for all cases,as shown in the table.

Table II lists RDC diagnoses of the two groups. Mostcases in both groups had an affective disturbance. Therewas a preponderance of manic disorder in the 19th-centurypatients (P<0.00l). This difference persisted when all caseswith elevated mood presenting as part of the illness (i.e.schizophrenic, manic and hypomanic patients) werecombined in each group.

Psychotic cases were identified separatelyin each of thetwo groups. They weredefmed as majormental illnesswithdelusions or hallucinations. This comparison removed thedilution effect of admissions for minor psychiatric illnessrestricted almost entirely to the 20th-century group. Thenumber of psychoticpatientsin the 19th century was 49

TABLE IIRDC diagnosis of puerpera! patients in the 19th and 20th

centuries

1. Informationonly availablefor 45 19th-and 10620th-centurypatients.2. Information only available for 29 19th- and 92 20th-centurypatients.3. NS.

P<0.OOl.

19th-centurypatients(n=63)20th-century

patients(n=108)Delusionsdefinitely

present45 (71¾)49(45°lo)probablypresent7 (11¾)3(3¾)absent8

(13°lo)56(52°1o)@uncertain3(5¾)0Hallucinationsdefinitely

present16 (25¾)24(22¾)probablypresent6 (10¾)4(4°lo)absent12

(19¾)78(74%)*uncertain29(46¾)2(2¾)Motility

disturbancedefinitelypresent46 (73¾)46(43¾)probablypresent13 (21°lo)15(14¾)absent4

(6¾)47(43¾)Confusiondefinitely

present23 (37¾)34(32¾)probablypresent24 (38¾)10(9¾)absent16

(25¾)64(59°lo)Length

of stay inhospitalMean(days)151.739.0s.d.118.837.8*P<0.0o1.

863PUERPERAL INSANITY IN THE 19TH AND 20TH CENTURIES

differences were found between the two groups as regardsmood swings but when the psychotic populations wereexamined separately, more 19th-century patients hadevidence of such disturbance ( P< 0.05). The severity ofmood swings was also greater.

Nineteenth-century patients also stayed longer in hospital.This held for the group as a whole ( P<z0.001) as well asthe psychotic cases alone ( P<0.001).

Incidence of puerperal psychosis

The population of Edinburgh which was 414 372 in theperiod 1880—90,rose to 459 193 in the decade 1971—80,registering a mean increase of 44 821. The mean birth ratefor Edinburgh during 1880—90was 12 982 and during1971-80 was 5246, a mean decline of 7736 over the studyperiod. No substantial alteration in the sizeofthe catchmentarea for the Royal Edinburgh Hospital was noted over the90 year period (Eagles, 1983;Rehman, 1986).The incidenceof puerperal admissions to the hospital was calculatedduring both periods for cases with psychotic illness andfound to be 0.34 per 1000childbirths per year for the 19thcentury and 1.04 for the 20th century.

Discussion

This study shows that puerperal psychosis in the 19thcentury is similar to that of today in that most caseshave an affective disorder, the period of onset is afixed interval after childbirth and the presentationis manic. In addition to this similarity, several factorsare not significant for both 19th- and 20th-centurycases. The proportion of unmarried mothers in bothgroups is essentially the same which mitigates againstan explanation based on social rejection or stigma.Furthermore, no significant association has beenshown, now or then, with obstetric complications.The results do not lend support to the evidence thatpost-partum psychosis is an illness of primigravidwomen (Thomas & Gordon, 1959; Kendell, 1981;Kendell et a!, 1987). In the 19th-century cohorts mostcases occurred in multigravid women which relatesto the fact that, at this time, most pregnanciesoccurred in such women.

Certain differences have been highlighted howeverbetween 19th- and 20th-century puerperal psychosis patients. The former showed a more floridpresentation,similartothatobservedby Loudon(1988)overthesameperiod.Theyalsohad morenumerous symptoms. Moreover, this excess morbiditycouldnotbe whollyattributedtoorganiccauses.Visualhallucinationswhich areseldompresentnow in functional illness were mainly seen in19th-century patients in whom an organic illnesshadmostprobablybeenexcluded.Someofthe19thcentury clinical descriptions are given in theappendix.

TABLE IIISymptoms and outcome of puerpera! patients in the 19th

and 20th centuries

(82¾) and in the 20th century, 55 (51 °lo),the differencebetween the two groups being significant (P<0.001).

Table III describes the symptoms and outcome ofpuerperal mental illness in the two groups. More 19thcentury patients were deluded (P<0.001). The mostcommon delusions were misinterpretation, misidentificationand referencefollowed by guilt, persecutionand expansiveideation. Some examples of 19th-century delusions are asfollows: “¿�Believesher baby has been changed for anotherbaby―;“¿�stronglymaintains that she is dead and that herhusband must die too and they will both go to helltogether―;“¿�somepeople have been burnt on her account―;“¿�shehas done wrong and will be burnt alive―;“¿�thoughtpeople were going to strip her and hang her―;“¿�believesthat her body is all broken into pieces, that she is blockedup,andcannothaveanypassagefromherbowels,thatshecannot swallow her food and it does her harm―; “¿�believesthatsheisbeingmurderedbytheinmatesofthematernityhospital and that all her relatives have been destroyed―;“¿�devilsare constantly following her―;“¿�abusesthe nurseandblamesherforthewarinEgypt―;“¿�imaginessheisbeing drugged with chloroform―.Patients90 yearsagoalsohadmorehallucinations

(P<0.001). These differences remained significant whenvisual (P<0.O1) and auditory (PzO.05) hallucinationswereseparatelyanalysedandwhenpsychoticsubgroupswerecompared.

There was similarly a clear excess of patients in the 19thcentury who had motility disturbance (P<0.001) andconfusion (P<0.00l). This also was true for the respectivepsychoticsubgroups(P<O.05 andP.<0.001).No significant

864 REHMAN ET AL

century, especially in milder cases, cannot be ruledout.Althoughthe largediscrepancyin puerperal

psychoticadmissionsoverthepastcenturycanbemostlyexplainedby the abovereasons,the possibilityof changein severityof illnesscannotbe fullyexcluded.Severalsupposedriskfactorscouldhaveoperated in combination to cause a more florid illnessinthe 19thcentury.Geneticvulnerability,poornutrition and pre-natal damage to the mother herselfatthetimeofherown birtharesomeofthefactorswhichneedconsideration.

Acknowledgements

The authors would like to thank the Archivist and RecordsDepartment of the Royal Edinburgh Hospital, and the ScottishRegister Office. Mr R. McGuire helped with the statistics and MrsM. Dodd typed the manuscript. We are especiallygrateful toProfessor Kendell for his support and encouragement throughoutthe project.

Case 1

The more florid 19th-century presentation couldhowever be mainly due to nosocomial factors.Nowadays neuroleptics are commonly given topatients on admission and quite often before whatis misleadingly called the ‘¿�initialmental state' hascompletely finished. This could have affected theresults ofthis study, as the RDC diagnoses were basedon all the information contained in the case notesduring the first month of admission to hospital.Certainly the introduction of electroconvulsivetherapy (ECT) and neuroleptic drugs has shortenedthe duration of the illness and the length ofadmission. The 19-century figures could thereforecorrespond to the pre-drug, pre-ECT era andrepresent the natural history of the disorder. Jansson(1964) and Prothero (1969) clearly showed that withintroduction of modern treatments the duration andoutcome of post-natal illness considerably improved.

As the risk of developing puerperal psychosis isdependent on childbirth, it could be expected thatthe greater the number of episodes of childbirth, thegreater would be the risk of the illness. Although datafromtheGeneralRegisterforScotlandshowedthatdespite the fall in the birth rate, the admission rateforpuerperalillnessperbirtheventhad almosttripledoverthestudyperiod,thisriseinincidenceneeds to be put into the context of Clouston's (1886)figuresforEdinburghwhichshow a much higherincidenceforthe19thcentury(1in400labours)thanourstudydid.Thelowincidenceinthe19thcenturynotedinthis

studycouldbeduetoseveralreasons.TherewerefeweradmissionsofpsychoticpatientsthentotheRoyal Edinburgh Asylum, a trend reflected in allpsychiatrichospitalsinScotland(Cameron,1954;Rehman, 1986). By contrast, now there are more inpatient facilities and liberal admission policies andan increasedreadinessby thepublicforin-patientcare. Furthermore, it is possible that in the 19thcentury some patients who also had severe puerperalinfection would have died before being admitted tohospitalandotherpatientswouldhavebeentreatedathome,particularlyifgoodsocialsupportswereavailable(Cloustonquoteda figureof9¾forsuchcases; Clouston, 1886; Thompson, 1984).

All 19th-century patients required compulsory detention for in-patient psychiatric treatment. Adequategroundsforcertificationnecessitatedthepresenceof signsof insanityand thiscouldhaveresultedin over-reportingof psychoticcasesand manicpatientsinthepresentstudy.Furthermore,althoughstrict catchment areas now make it reasonableto draw inferences on the incidence based onmodern statistics, the possibility of admissionto private nursing homes and asylums in the 19th

Appendix

Mrs X, a housewife living in 11 Falem Place, Edinburgh,was admittedto Royal EdinburghAsylum on 12June 1883with melancholia following the normal birth of a healthybabywhom shedidnotnurse.Shehadhadtwopreviousadmissions to the Asylum for depression. Her admissionwasundera compulsorymedicalcertificateasshewasrestless,perturbed,sleepless,hadapoorappetiteandhadmadedesperateattemptstokillherselfbythrowingherselfout of a window.Shefeltdespondentandcried,sayingthattherewas“¿�a

mist of darkness before her which she couldn't getthrough―.On mental state examination she was found tobeverysadandtearfulwithfranksuicidalideation.Herspeech was coherent and there was no evidence of delusionsor hallucinations. A physical examination found her to bethin, pale, weak and “¿�respectablewith brown hair and greyeyes―.Shehad“¿�aweakphysiqueduetopoormuscularityandfatness―.No evidenceofanorganicillnesswasfoundandhertemperaturewasnormal.

During her stay in the hospital she gradually improvedwith plenty of food and exercise and by 1 September 1883wascheerful,ingoodhealthandanxioustoreturnhome.Shewasthereforedischarged.Unfortunatelythesamemonthshecommittedsuicideby jumpingovertheEdinburghDeanbridgeintothestreambelow.Thiswasreported in The Scotsman.

Case 2

MrsY,a33-year-oldProtestanthousewife,wasadmittedfrom Haddingtonas a privatepatienton 31 December1885,with acute puerperal mania. She had given birth to a sonfourweeksearlierfollowinganeasyandnormallabour.

865PUERPERAL INSANITY IN THE 19TH AND 20TH CENTURIES

Shenursedthechilduntilaweek priorto her admission whenshe became ill. There was no previous history or familyhistory of mental illness.

On admission her mood was generally elated and she wasrestless,excitedand sleepless.She talked oonsense incessantlyandwasverynoisy.Shehaddelusionsthatherchildhadbeen changed and that people were hiding in the house andwerethreateningher.Shealsobelievedthatshehadnohusband and that she got her child from “¿�theLord on adarknight―.Shewasremovedtoapaddedcellandgivenparaldehyde

and potassium bromide. By 4 May 1886 she had become“¿�quitecoherentandrationaleandwasmostindustriousbuthadstillamorbiddegreeofelevationofmood―.By15May1886,shewasfoundto“¿�quitesaneinallrespects―andwassenthomeonpass.Shewasdischargedon31May1886whenshehadfullyrecovered.

Case 3

MrsZ,a31-year-oldhousewifefrom8,GibsonTerrace,Edinburgh, was admitted on 14 March 1881 to the Asylumwitha melancholicillness.Therewasnopastorfamilyhistoryofpsychiatricillness.Shehadgivenbirthtoachildon 17 February 1881 and her labour was “¿�naturalandspeedy―.

She was profusely depressed and constantly moaned andcried. She thought she was lost. There was considerablemotor restlessnesswith wringingandclaspingof hands. Shekept screaming “¿�Oh!the suicide―and had to be restrainedtopreventherfromcommittingsuicide.Hersleepandappetite were poor. She believed that by her own obstinacyshehadcommittedsometerriblecrime,thatGodwastopunishherandwouldneverforgiveher.Shesaidthattherewasnohopeforherandthatshemustgotohell.Hermemorywaspoorastorecenteventsandshewasnotquitesurewhenherbabywasborn.On physicalexaminationsheweighed8stone13pounds,

her “¿�fatnesswas poor and her muscularity was small―.Therewasnoevidenceofphysicaldiseaseexceptthatsheappeared anaemic.Shewasgiventwocustards,extramilk,6 ouncesof

sherry, a pint of porter, a tonic (Fern dialysat), potassiumbromide(45g)andchloral(20g).By22June1881MrsZ hadsteadilyimprovedandhad

been allowed occasional passes to go home for a day. Shewasdischargedas‘¿�recovered'.

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