Postpartum Depression in the 19th Century

One of my goals with my writing is to help those suffering from mental illness. In Shores of Chaos: Shipwrecked I tackled postpartum depression (PPD). In my first draft of this story, I unfortunately fell into the trap of making a villain out of my character, Frances Ashman, who is suffering from this illness. For the final draft though, I did more research and expanded her character, making her more sympathetic and trying to make the reader understand what it would be like from her point-of-view. Due to the supernatural elements in the story, there is one stereotype of the postpartum mother that I did include, but hopefully not in a too egregious manner.

First, I will discuss a bit about PPD and its symptoms. Today, there are generally three known mental illnesses associated with childbirth. The first is the mild “baby blues” which usually last no more than two weeks after birth. Baby blues include anxiety, mood swings, crying, irritability, trouble sleeping, and appetite issues. The more severe postpartum depression lasts longer than baby blues, usually happens within a few weeks to up to a year after birth, and can cause major obstacles for a mother. In PPD a woman will experience depression, constant crying, trouble bonding with her baby, eating and sleeping too much or not enough, fatigue, reduced interest in activities, irritability and anger, hopelessness, feelings of inadequacy as a mother, anxiety and panic attacks, thoughts of harming her baby or herself, and thoughts of suicide or suicidal attempts. A third, more rare condition is postpartum psychosis, which I will discuss in a moment.

In order to keep the story true to the time period, I had to research how PPD was treated in the 19^th century. During this time, the illness was known as puerperal insanity and was responsible for about 10% of admissions of female patients to asylums.² It was believed that puerperal insanity was caused by a hereditary link, constitutional predisposition, situational factors, or physical ailments. Situational factors could include the stress and anxiety that came from spousal abuse, illegitimate pregnancies, rapid succession of pregnancies, being overburdened by children or household duties, traumatic birth experiences, the birth of male children, use of anesthetics during labor, poverty, or other nervous ailments or emotions.^{2,3, 4, 5} It was noted, however, that the rich and educated could suffer from the illness too.⁵ Between the 1870s and 1890s, some gynecologists thought the insanity was caused by physical problems in the reproductive organs and would perform surgeries to these organs, often removing them.^2,3 By the 1890s, doctors saw the insanity as in line with other forms of mania and female physicians helped to drop the link between physical causes.²

The medical community usually divided the insanity into three stages: insanity of pregnancy, puerperal insanity, and insanity of lactation. Insanity of pregnancy was the rarest and occurred when a woman was still pregnant, puerperal or parturition insanity occurred one week to six weeks after birth, and insanity of lactation was any time after six weeks.^2,3,4 Lactation insanity was generally seen in women who had multiple pregnancies, was more melancholic in form, and could have long term effects.^2,3 Puerperal insanity was the most common type and could take either a melancholic or manic form. Dr. M. D. Macleod, Superintendent of the East Riding Asylum, observed that puerperal insanity would include symptoms such as depression, irritability, problems eating and sleeping, lack of concern for or aggression towards the child, and suspicion of the husband and relatives. In the melancholic form, the woman would be sad, anxious about her husband and child, fretful, have delusions that her husband and child were ill or dead, talk little, and have a tendency to suicide. The mother would exhibit pale, cold, and clammy skin, listless eyes, poor circulation, slow pulse, poor sleep and appetite, constipation, and a white, indented tongue. ⁴ The melancholic form was considered to be the more chronic form and harder to cure and therefore more in need of institutional care.^3,4

So far, many of the symptoms are in line with what we would consider postpartum depression today. The manic form of puerperal insanity, on the other hand, could have symptoms such as incessant talking, restlessness, irritability, inability to sleep well, refusal of food, use of profanity, removal of clothing or promiscuous behavior, and an aversion to husband or child.^2,3 These women could often have violent tendencies towards their children or husbands, extreme strength, hallucinations, and delusions; sometimes believing those around her are monsters or enemies.^3,4,5 The physical symptoms were dry tongue and lips, dislike of food (usually through delusions that it is poisoned), constipation, little urine, abnormal lochia, high temperatures, tender abdomen, and small milk supply. If the illness did not abate, the patient could die from exhaustion, uterine inflammation, sepsis, or kidney, heart, or lung disease. In other cases this period of excitement was followed by dullness in behavior and stupor.⁴

This is where our current understanding of PPD differs from the 19^th century understanding. Many of the manic symptoms are more in line with what we call postpartum psychosis today. This psychosis, which develops within a week after birth, includes the symptoms of confusion, obsessive thoughts about the baby, hallucinations, delusions, sleep problems, excessive energy, agitation, paranoia, and attempts by the mother to hurt the baby or herself.¹ Physicians of the 19^th century noted that the manic form of puerperal insanity was more prevalent. As stated before, in reversal of the past, postpartum psychosis is rarer than PPD today. So why was mania more common in the past then today? One reason may be puerperal fever or other infections that caused delirium after birth, especially as medicines for bacterial infections were still being developed and standard hygiene practices were just being accepted.³ For example, Dr. T. B. Hausen observed in 1888 that the insanity derives from septic puerperal infection as the symptoms align with such infections. Of the 49 cases of puerperal insanity he studied, 42 of the women also had puerperal infection.⁶

Regardless of whether the form was melancholic or manic, the treatment was generally the same and some doctors believed the patient was fully cured when menstruation returned to normal.⁴ For mild cases, the illness would be treated at home, preferably with the help of a skilled nurse. The woman would often be isolated from her child, friends, or family and would be kept in a well ventilated, warm, lit bedroom with anything she could use to harm herself removed. She would need plenty of rest and be given a sufficient diet of beef-tea, broths, starchy foods, milk, and eggs with wine; a feeding tube would be used if she refused to eat on her own. To help her sleep, she would be given drugs like chloral, sulfonal, trional, or opium added to food or wine. Warm baths were also suggested and when the woman got better, it was advised she get outdoor exercise, fresh air, amusements, and have light work to do such as knitting or sewing. Those who were too poor or did not have sufficient means for at home treatment were confined to asylums.^4,5 Not all women fared well with this treatment. In 1892, Charlotte Perkins Stetson wrote “The Yellow Wallpaper” in which she described being prescribed a similar treatment, but slowly loses her sanity in the course. She darkly obsesses over the wallpaper in her room after weeks of isolation, lack of diversions, and having her concerns dismissed by her physician husband.⁷ Overall, it was estimated that 60 to 75 percent of puerperal insanity cases recovered and generally within six months.⁵

Some physicians like Dr. Anna Burnet and Dr. Macleod did recognize that what should be a time of joy and excitement for families, turns into one of the darkest and difficult times for them.^4,5 Even today, many women will be ready for the birth of their child only to surprisingly find that they aren’t adjusting well to motherhood. After listening to many stories of women who experienced PPD, some of the most recurrent thoughts they had were feeling overwhelmed, wondering why they weren’t happy about their babies, thinking their child and family would be better off without them, feeling angry at other people, feeling weak and that they will do something wrong, and not caring enough about themselves. Many didn’t understand what was happening to them or who they were becoming, often finding it difficult to discuss with others.  New fathers can experience similar postpartum depression as their partners and even when they don’t, they often have a hard time understanding what is happening to their partners.¹ They feel unable to help the woman and shut out by her and are confused and anxious over the woman’s behavior and her seeming antipathy towards themselves and the baby. They will experience difficulty with trying to help the situation and taking on more household duties and often blame the medical community and society for not helping more. For some families, treatment works and their relationship survives and thrives, for others it sadly ends in divorce and custody battles.⁸

As some doctors of the past recognized, kindness and reassurance were just as necessary as other forms of treatment.² In my research, a troubling theme I often found was that postpartum mothers and their partners often did not get help until weeks into their ordeal or were completely confused by what was happening. I think it goes without saying that there should be more discussion about postpartum depression so that families can recognize it in its earlier stages. The sooner it’s discovered, the quicker it can be treated. Destigmatizing and better education are what are truly needed in society, along with kindness and caring, when it comes to mental illness.

Sources

1. “Postpartum Depression” from the Mayo Clinic
2. “Diagnosing Unnatural Motherhood: Nineteenth-century Physicians and ‘Puerperal Insanity’” by Nancy Theriot. Vol. 30, No. 2, Technology, Medicine and Science in American Culture and Society (fall 1989), pp. 69-88
3. “Puerperal Insanity in the 19^th Century” by I. Loudon. Journal of the Royal Society of Medicine. Vol. 81 (February 1988), pp. 76-79
4. “An Address on Puerperal Insanity” by M.D. Macleod. The British Medical Journal. Aug. 7, 1886, pp. 239-242.
5. “Puerperal Insanity: Cause, Symptoms, and Treatment” by Dr. Anna Burnet. The Woman’s Medical Journal. Vol. 9, No. 8 (Aug. 1899), pp. 267-273
6. “Puerperal Insanity” by Dr. Th. B. Hausen. The American Journal of Insanity. Vol. 45, 1888-1889. pp.536-537
7. “The Yellow Wallpaper” by Charlotte Perkins Stetson. Published in the New England Magazine in Jan. 1892.
8. “Men’s Experience of their Partners’ Postpartum Psychiatric Disorders: Narratives from the Internet” by Inger Enggvist and K. Nilsson. Mental Health in Family Medicine. Vol. 8, No. 3 (Sept. 2011), pp. 137-146.