Specimens of these necrotic infiltrates were shown by Orth. They consisted of masses, the size of a walnut, yellowish with a reddish centre; looking much like inspissated abscesses, but really being aseptic and consisting of dead muscle tissue with a few leucocytes at the periphery. On account of this tendency to cause necrosis 606 has by one observer been considered to be contra-indicated in patients with severe diabetes. Another contra-indication, according to Wechselmann is a flabby, weak heart, such as is often found in tabetics. In the treatment of tabes itself not much is to be expected of 606, though Wechselmann has seen lancinating pains and unsteadiness of gait much improved by an injection. He seems inclined to think, however, that these were cases of pseudo-tabes and suggests that there may be many patients with pseudo-tabes and pseudo-paralysis that my be helped by the new remedy. In more than 1,100 cases in which he has used injections of .45 to 6 grm, he has not seen a single case of serious intoxication. He considered nephritis no contra-indication. Earlich, himself, points out that of the baker's dozen of fatal cases from 606, all but one were desperate cases, and the patients would almost certainly have died soon of the disease itself. Ehrlich also calls special attention to the remarkable rapidity with which 606 sometimes relieves pain. A number of cases have been reported in which patients who for weeks or months had, in spite of other treatment, been unable to swallow solid food on account of painful lesions of the mouth or pharynx, could eat all kinds of things, within a few hours after an injection of 606. In other cases, pain from a cranial gumma has ceased, or the vision in iritis has wonderfully improved in a remarkably short time, after the injection. As Earlich says it is impossible that anatomical changes can have occurred quickly enough to account for such effects, and he believes that the pains are caused by the secretion products of the spirochaetes, and that these products are neutralized by 606, as a toxin is neutralized by an antitoxin. For the cases in which a contrary effect, the so-called Herheimer's reaction, has been observed, the subjective symptoms being made worse by the injection of small doses of 606, Ehrlich assumes that this is an indication of too small a dose, the spirochaetes being merely excited by it to greater activity. Regarding relapses, it is certain that they may occur after 606, but it seems equally certain that they are staved off for a longer period than by any other treatment. Moreover since Margulies has shown, that in the lower animals, while it is easy to produce a race of trypanosomes that can stand any amount of 606; the attempt to make the spirochaete immune to it by graduated dosage succeeds only partially or not at all, it is altogether probable that 606 can be used repeatedly in the same person without losing its effect. Neisser indeed recommends that in every fresh case of syphilis, a second injection be given after three to six weeks, and that in the meantime a mercury injection-cure be instituted. With regard to its effect on the eye, so far, no case has been reported in which 606 has done harm, and although Dr. Schalek informs me that as it is obtained in this country, 606 comes with strict instructions not to use it when there are eye complications, this is obviously an excess of caution. The fear that 606 might injure the eye arises from its similarity to atoxyl; but as the only part of the eye injured by the latter was the optic nerve, there can be no reason why syphilitics with inflammation of the iris, choroid or retina, or with ocular paralysis from intracranial lesions should be barred from the benefit of 606, and even in inflammations of the optic nerve, atrophy will certainly be the less likely to occur the sooner the syphilis can be checked. As a matter of fact, Wechselmann, in conjunction with the oculist Fehr, has treated a number of cases of syphilitic optic neuritis with 606 and has had good results. Whether it should be used in cases with a marked tendency to optic atrophy remains to be determined by clinical experience; but even here, Wechselmann has used it without apparent harm, in some cases where other complications made a speedy cure most important. GIFFORD (Omaha). ORIGINAL ARTICLES. The Insanities of the Puerperal Period. *By JOSEPH M. AIKIN, M. D., Omaha, Neb. The clinical picture in mental disorders incident to child bearing is not essentially different nor separable from insanity arising from pathological conditions wholly apart from the puerperal period. This must be true since the same general causes have established the pathology from which the insanity of pregnancy is evolved, as in some other forms of mental derangement. Our want of facts regarding the etiology and pathology of mental diseases precludes a classification predicated upon the morbid anatomy which certainly is present, but is so frequently unknown and unascertainable. The etiological basis for classification is equally defective for like reasons. In patients where the etiology and pathology, one or both, are pretty certainly known, the mental symptoms cover wider extremes than is usual from known pathology in purely physical diseases. We are, therefore, practically limited to the clinical symptomatology-unsatisfactory as it often is-for guidance in naming mental disorders. Clinically the psychoses of the puerperal period are separable into three groups: 1st. Those of the gestation group. 2nd. Those of the parturient and involution group. 3d. Those evolved during the nursing period two or more months subsequent to parturition. (1) Those of the gestation group. Gestation is a physiologic process, yet under modern modes of living the nutritional disturbances to which most women are subjected do not allow the pregnant woman to escape some changes from her normal mode of feeling, speaking and acting. Her disposition is altered. She is nervous, irritable, depressed or excited. Her appetite is capricious, excessive or diminished Nature is very considerate of the pregnant woman and even though such symptoms are variously presented, these perversions seldom get the control of her reason, unless there be a strong taint of hereditary insanity in her antecedents. The mental symptoms are mainly marked by depression or exaltation. Depression is the more common and is manifested physically by digestive disorders, with their concommitant symptoms, while mentally there is apathy usually short of stupor, yet with *Read before the Nebraska State Medical Association, Lincoln, May 10-12, 1910. a decided lowering of her interest in husband, family or friends. If delusions appear they are usually of the self-accusative type. They impel toward suicidal acts. The nervous disorders probably predominate during the first half, and the mental perversions sometimes begin with conception and do not abate till a few days or weeks after delivery. Symptoms of exaltation are less frequent than those of depression. They usually succeed a brief period of restlessness and insomnia. Loquaciousness and increased motor agitation, with or without hallucinations and delusions, dominate the clinical picture. Delusions in the exalted type are commonly of a persecutory or changed personality character, and hallucinations are of the aural rather than the visual senses. Albuminuria is not more common in these than in other types of mania, but hyaline casts are often to be found in the urine. If chronic renal lesions exist, the prognosis is of necessity less favorable. At least 50% of these cases recover either during gestation or within a week or two after delivery. The greater number of the rest gradually assume their former places in the home but with a more or less restricted mental horizon than they formerly enjoyed. A few rapidly dement and die from pneumonia or some other intercurrent disease. (2) The parturient and involution group: The involution period of from two to eight weeks after delivery is fertile with opportunities for infections by way of the genital tract, fissured nipples and surcharged glands. This is the period when we see the so-called puerperal mania cases that bring imminent danger to the infant at its mother's side, terror to the family and much anxious thought to our best clinicians. All with one accord, as if by prearranged plan, ply the doctor with questions as to the cause of this sudden manical outbreak. The lochia has not ceased, there is little if any fever, the excretions are satisfactory, food is relished, but almost like lightning from a clear sky, her reason is dethroned. Our resources are taxed to the utmost. We think first of infection through the genital tract, or mammary glands, and wonder if we have been careless. Second, we reason that within the body certain chemical products resulting from tissue changes during pregnancy, have not been eliminated, and this mental perversion is a result of their toxic effect. Third, we recognize the direct liability of the nervous system to the shock incident to delivery, and the cumulative importance of apprehensions in a woman of unstable brain power, when considering the dire possibilities of her present or impending experience. These sudden maniacal outbreaks occur more particularly at the time of delivery or a few hours later, when infection seems almost certainly excluded. They usually run their course without febrile reaction, except that where the issue is fatal, pyrexia precedes the closing scene. The psychoses during the first and third periods most probably evolve from a toxin, while in the second period, infection would seem a more obvious cause. Third, those evolved two or three months subsequent to dedelivery. Lactation debilitates the entire organism and thus by a species or physiological overactivity establishes an irritability of the entire nervous system. This acquired irritability plus an added responsibility, destroys normal stability with resultant weakening perversion or destruction of healthy mental and nervous functions. The probability of an infectious element, though not impossible, is less likely here than in the second period. It is more certainly autotoxemia from an unequal exchange between constructive and destructive processes necessary to physiological activities. The supply of food does not equal the demands for mother or child and both suffer. In the child we label in inanition from anemia. In the mother it is nervous exhaustion' neurasthenia, peculiar mental and motor actions, imagination, insanity, with the prefix, lactational-from overwork or an inadequate food supply. The treatment throughout should be dietetic and hygienic, especially elimination by the skin, kidneys and bowels must be maintained. Nervous irritability and insomnia yield best to warm tub baths, a hot pack or sponge bath and hot liquid nutritive drinks. Morphine is contra-indicated for it tends to lock the secretions and not infrequently acts as a cerebral excitant. Hyoscine should not be used and the H. M. C. tablet more often harms than benefits the patient. Fluid extract of gelsemium with sod, bromide and chloral by the mouth and rectum, or gelsemine hydrochloride subcutaneously is a safe and efficient reaxant for excessive mental and motor activities. In my experience the best and least injurious soporifics are the worm bath, hot sponge or pack, plus veronal and sulphonal in combination, also sodium bromide and chloral hydrate. Whatever the drug used, a small dose frequently repeated and always with a drink of hot milk or other nutritious hot liquid, has in my experience given the best results. Treatment at home necessitates constant care and attention by a trained nurse. Summarizing, we find that rather less than 10% of puerperal women become insane; that puerperal insanities are on the decrease, owing to better modes of life and cleaner conditions at |