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. CHAPTER XII NEPHRITIS IN PREGNANCY