true of saprophytic infection. In the slower forms of sepsis the measures advocated by Dr. Futterer are certainly worthy of trial.

As to the assertion of our President, that most doctors are not capable of making a differential diagnosis with the microscope, I will say: First, it is possible for any doctor to distinguish between saprophytic infection and sepsis, without bacteriological knowledge, and that is the first and chief point in diagnosis. Second, there are many members of the Tri-State Medical Society who do know enough of practical bacteriology to make the diagnosis I mention, and, the time will soon come when every doctor must have this knowledge, or be relegated to obscurity in his profession.

Dr. Emil Ries: Dr. Paddock has asked me a question. He wants to know if I would not go into the uterus in a puerperal sepsis case, if the whole placenta was left. I should not regard such a case as one of puerperal sepsis: the woman is in the third stage of labor. Suppose that we had a case in which a large piece of placenta was left in the uterus and the woman had a fever. Do I take it out, or not? Is anybody going to tell me that a large piece of placenta can be left in the uterus and we have no hemorrhage? I have never seen a case where hemorrhage did not result from such a condition. I have stated that where there is a piece of placenta, I stop the hemorrhage by removal of the placenta. If I am called to a case where I suspect that there may be a little piece of the placenta left, but there is no hemorrhage, I leave that little piece alone as long as there is no hemorrhage. I wish to repeat that in a case where there is a hemorrhage from the uterus of a puerperal woman with sepsis, I stop the hemorrhage by cleansing out the uterus. If there is no hemorrhage, but there is a fever, I don't touch the uterus at all.

Cerebro-Spinal Meningitis.-Williams, (Amer. Pract. and News) says this disease is a specific infection, slightly contagious. Whether it assumes the sporadic or epidemic type depends on climatic conditions. Unsanitary conditions and excessive exertion favor its development. It is more frequent in winter and spring, and effect children more frequently than adults. The fulminant form develops abruptly, the symptoms are very severe, and leads to a fatal termination in a few hours. Headache is a constant feature in the common form and is accompanied by intolerence of light and noise. A chill and vomiting are the first symptoms noticed. The temperature may become high, but does not necessarily bear any relation to the severity of the case. Abortive cases occur. In mild forms the duration is from four to five days. In the malignant form, if recovery takes place at all it, is after a long severe illness complicated by involvement of the special senses, and followed by many sequelae. Mortality is from 25 to 50 per cent, being very high in young children. The sick-room should be darkened, noise and excitement avoided. The diet should be liquid and nutritious. The treatment advised consists of narcotics followed after effusion has taken place by iodides and mercury. The ice-bag is very useful.

Monographs on Nervous Diseases

With Especial Reference to Hygiene, Nursing and Therapeutics.

Angio-Neurotic Edema.

BY F. SAVARY PEARCE, M. D.,

PHILADELPHIA,

Professor of Nervous and Mental Diseases in the Medico-Chirurgical College of Philadelphia; Neurologis to the Philadelphia Hospital.

S a condition of edema occurring along the course of nerve trunks and dependent upon a neurosis. Angio-neurotic edema occurs more frequently in early middle life, is a somewhat painful swelling, occurs in any locality of the body rather than in any dependent parts or in little supported cellular tissues, as is the rule with edema from heart or kidney disease. Such edema, too, does not disappear as do other forms of edema by position of the body or depending more upon the condition of vasomotor paresis of the part affected. There is usually the history of some hereditary nervous disease in the ancestry. The edema appears suddenly and is usually circumscribed; it may occur in the face, the eyelids, lips, or cheek, but may appear in the backs of the hands, legs or in the throat. The condition is usually transient and may be associated with gastro-intestinal distress. Generally there is marked periodicity as in one case reported by Matas where the attack appeared every morning between eleven and twelve. Occasionally the attacks are preceded by heat, itching, redness or in some instances, urticaria. Sudden edema of the larynx may prove fatal. The colic accompanying this neurosis is usually intense. The disease is allied to urticaria and certain forms of purpura, i. e., those accompanied by urticarial manifestations. Quincke considers the edema of vasomotor origin. A neurosis under the influence of which the perme. ability of the vessels is suddenly increased.

The treatment of the condition would depend upon the cure of the neurosis. The rest treatment would be ideal. Tonics are also indicated, and particularly doses of strychnine; if anemia exists, hematics would be of value through reconstruction of the blood. Continued doses of ergotin may be of some benefit. Frequently the disease resists all therapeusis; or if the patient survives the exacerbations of the disease, which, as mentioned above, may be located in a vital part as the larynx, he may "outgrow" this manifestation of a neurosis of the gravest form.

THE INTERNATIONAL CONGRESS OF GYNECOLOGY AT ROME.-At this congress, which is to be held September 15 to 21, the first address to be delivered will be upon the medical indications for inducing delivery. by Dr. Barton Cooke Hirst, of Philadelphia. Among the other papers to be read is one on the surgical treatment of cancer of the uterus, by Dr. Cullen, of Baltimore.

MENTAL AND NERVOUS DISEASES.

BY FRANK PARSONS NORBURY, M. D.,

Physician-in-chief and Superintendent Maplewood Sanatorium for Nervous Diseases; Neurologist to Our
Savior's Hospital; Physician to Passavant Memorial Hospital; Consulting Physician Illinois
Institution for the Blind; Formerly Resident Physici n Pennsylvania Institution for
Feeble Minded Children; Formerly Assistant Physician Illinois Central
Hospital for the Insane.

AND EGBERT W. FELL, B. S.,

JACKSONVILLE, ILL.

Puerperal Insanity (Hirsch, Med. Record). This does not exist as a specific form of mental disease, the disorders occurring during gestation being the same as those seen in other patients. Pregnancy may under certain circumstances act as an etiological factor in insanity. Psychoses occurring in connection with parturition are produced by trauma, by anemia or exhaustion after hemorrhage, or by intoxication in septic cases or uremia. The form is usually an acute delirium which may recover in a short time or pass into a secondary psychosis. Lactation, as such, plays no role in the production of insanity.

Neurological Observations in the Hawaiian Islands (Brower, Med. News). The general effect of the climate on the Anglo-Saxon, at the sea level, is depressing, neurasthenia being not uncommon. The uniformity of temperature is beneficial in the spinal scloroses, these being less common than in this country. The types of insanity are mild, the proportion being about one to a thousand. It is not usual to have violent mania, and general paresis and paranoia are unknown in natives. Suicide is very

Lepers are segregated on the island of Moloki, there being 1200 here at present. This disease is regarded as purely contagious, being transmitted by the nasal and oral secretions, its rapid spread being counted for by their lowered resistance of the natives caused by the great prevalence of syphilis, and their socialistic tendencies. About 25 per cent of cases are of the nervous or anesthetic form. These cases begin with an erythematous eruption and hyperesthesia which gives place to anesthesia and then to motor symptoms. The ulnar and peroneal are the usual seats of attack, the invasion of the ulnar producing the characteristic claw hand. It is probable that the bacillus begins its work in the sensory end organ of the skin and traveling up the nerve involving the motor filaments as well, thus producing muscular atrophy and contraction. The nerve is enlarged and nodular. In some cases the symptoms were much like Reynaud's disease and syringomyelia. The anesthetic cases are long lived, the tuberculous, short. The treatment is mildly tonic, alterative and when necessary anodyne, strychnine and hot baths have been followed by good results. Climate seems to exercise an influence over the progression of the disease.

The Early Diagnosis of Idiocy, with Case (West, Columbus Med. Jour.) Instruction of this class of patients should be begun early by the

parents and afterward they should be removed to an institution. The first class considered by the author is that of the so-called Mongolian idiots, a case being presented. In these patients the head is smaller than normal, and they are generally short in stature Eyes are oblique and watery, nose flat over the bridge, lips thick and rough, teeth and breath bad, tongue rough and furrowed. The hands are short and stubby and the joints remarkably flexible. The breathing is rough, being more pronounced at intervals. Most of the actions are slow. The recognition of this condition even in the first few days of life is not difficult, the child being usually apparently lifeless and very slow to respond to stimuli. Microcephalous and hydrocephalous are easily recognized; the great majority of the latter are mentally deficient. The distinction between hypertrophic and hydrocephalic idiocy is not usually difficult, and should be made, as much can be done for the latter while the former class is hopeless. Prenatal meningitis or other lesions existing before or acquired soon after birth may cause mental impairment accompanied by convulsions, rigidity or paralysis. Although imperfect development and abnormal movements are not pathognomonic of mental taint, the presence of stigmata is of great aid in making the diagnosis. On the borderland is the class of children designated as backward. They are poorly developed in mind and body, they are slow in learning and slow in giving up what they have learned for something better. Some become truly idiotic, other developing into useful citizens, a great deal depending on their early teaching.

The Relation of Meningeal Traumas to Mental Disturbances (Bell, Phys. and Surg. ). The dura mater is composed of an outer fibrous and an inner serous layer. The outer layer is more frequently diseased and a simple inflammation often exists. The dura is also frequently thickened and adherent to the calcarium and may give rise to obstinate headaches. Case I.-Male, 56 years old, of a morose hypochondriacal temperament. About January 16 he complained of pain and swelling of the left side of the face. There was hyperesthesia of the skin and sensitiveness of the mucous membrane. Pain along the upper maxillary division, along the auriculo-temporal nerve and over the temporal bone was intense. Mastication and talking were painful. Patient was extremely nervous and forgetful. Cocaine, nitroglycerine, gelsemium and soothing applications failed to relieve the pain. Illusions of hearing, and sight were developed, pain increased and changed to coronoid process. The mental disturbance increased the patient being violent at times. No abscess could be located. Pulse 84, volume very much decreased. Sensation in extremities and locomotion impaired. Delusions were marked. Death from cardiac failure. The post-mortem reveal a thickened dura firmly adherent to the inner table, and also to pia along the longitudinal fissure. A large abscess cavity was found behind the inner angle and ramus of the inferior maxillary extending up to base of skull. The adhesions were of a chronic nature of long standing and probably caused by sepsis or streptococcus meningitis. The mental symptoms may be attributed to the involvement of the external carotid interfering with nutrition. Case II.-As the result of a fall the internal angular process of the supraorbital sack of the frontal bone was

fractured, compressing the cerebral substance and causing the eyeball to protrude. The bone was elevated and meninges replaced. Patient was in a comatose condition, but recovered; the mind remained impaired. Case III. and the one following illustrates a type which might be called psychotraumatic insanity. Immediately following financial reverses the patient, a lady, developed delusions of persecution. She was very reticent and suffered from periods of nervous depression. Great improvement followed change of surroundings. Case IV was a lady who developed a mental aberration after the sudden death of her husband. The patient was neurasthenic and bad disturbance of the vasomotor system and general weakness. Reflexes were exaggerated. There was constant fear of impending danger, hallucinations of hearing and insomnia.

A Case of Paraesthesia Sexualis with Anthropophagous Practices, showing Lesion Pointing to the Angular Gyrus as to the Probable Cortical Centre of the Sexual Instinct (Styel, Va. Med. Semi-Mo.)-Louis August, German, a soldier, aged 26, while intoxicated, murdered a prostitute in a foul and disgusting manner. She was found perfectly nude with an incision in the right iliac region through which the intestines, tubes and ovaries had been removed. The intestines were torn up and scattered about the room, but the tubes and ovaries could not be found. When convicted of the murder August committed suicide. There were no stigmata of degeneration except the serrated teeth of Ferguson, motor functions normal cremasteric reflex much exaggerated. Examination of the brain showed nothing abnormal except a small sac about half an inch in diameter and filled with fluid, in the anterior part of the angular gyrus. There was no evidence of faulty cerebration, and the author explains the perverted sexual act in the following manner. The centres of the sexual organs in the lumbar cord are in connection with a centre in the cortex. The lesion in this case points to the angular gyrus as the location of this center, the lesion causing a departure of the stimuli from their accustomed paths of travel, resulting in perverted feelings and the inhibitory power of the will having been removed by alcoholic intoxication, the perverted act was the result.

An Accurate Sugar Test. The progress of medicine is nowhere more evident than in the modern methods of conducting an urinalysis, the day of questionable solutions of indefinite age and activity is past, the profession of today wants only that which is accurate and rapid. The solution ammonio-cupric sulphate, generally known as Whitney's reagent, meets this demand in so far as the test for sugar is concerned and is now generally used. This solution is delicately graduated in strength, so that one drachm is decolorized by 1-30 grain of glucose, exactness of strength makes accuracy certain and the definite quantity of sugar present may be determined in less time than was formerly devoted to determining sugar without thought of the quantity. The solution as manufactured is stable if protected from the air and light; to provide for this the manufacturers, the Norwood Chemical Co., of New York, put it up in colored bottles carefully corked with rubber, from which it should not be removed except as used.