Jones also gives data pro and con as to the causation of this condition. One of his investigators found always negative blood cultures while others have found, as did Williams, streptococci, staphylococci, and the colon bacilli. It was rare for any of his cases to have fever and some were admitted as early as the second day. He also noted in some cases the signs of endo-toxin development. But he asks, “If these cases be toxic (and he means either chemical or bacterial), how is it that insanity occurs most often after the first confinement?” Before we proceed to the subject of symptoms and pathology, let me suggest these conclusions: Our disease is decreasing in frequency, as all evidence shows us. We coincidentally are increasing our aseptic technique and obstetric skill and we are continually recognizing the different types of toxemias both bacterial and chemical, more quickly, with resultant more rapid institution of treatment. On the other hand the strong mental shock and emotions that come to women in connection with, or as a coincidence to, childbirth are getting no less in this world of ours and I feel that we must all agree that sepsis and toxemia in the puerperal and anæmia in the lactational types of insanity are our real causes:—the emotional factors being secondary or only the exciting causes in the majority of cases. The other cases are, however, those of lability of the mental and nervous systems of probable types and with the same exciting causes. The pathology of many morbid mental states is, I am sure, poorly defined and not well worked out. Jones, in his very exhaustive, though hardly recent article in 1903, gives us, however, very suggestive thoughts on the subject. “Immediately after confinement the morbid and effete material which is taken into the maternal circulation during early uterine involution, must tend to produce in the predisposed a profound irritation of the nervous system, and especially so should secretion and excretion be modified by interference, chemical or bacterial, with the normal functions of the venous, lymphatic and other excretory organs.” It is in the early stage of puerperium, the stage of septic infection, and by that I mean all bacterial disturbances, that the most violent delirium occurs. The lactational type shows impoverished blood supply, uterine sub-involution, and general cachectic condition. SYMPTOMS. Williams has found that the puerperal psychoses are usually characterized by great excitement during the first few days, associated with all sorts of hallucinations. Later, the maniacal symptoms disappear and the patient passes into a condition of depression with frequently suicidal tendencies.