These difficulties are most successfully met by attacking them, as we would a skein of tangled silk, at the easiest or most vulnerable point, and the subject is an illustration of the fact that the best theorists are often the poorest practitioners. Year by year has seen the position of gynæcological surgery, as a specialty, grow stronger; each year has furnished new and rejected or modified old operations, and the general tendency of the past as of the directly preceding years, has been, while it narrowed and circumscribed, to make more pointed and direct the principles governing surgical interference in gynæcology.

While the use of the carbolized spray in general surgery, has been for some time generally accepted as beneficial, in the more important operations, as that of ovariotomy, it was for a time considered of questionable utility, if not a disadvantage. In this respect, however, a change has, notably during the past year, taken place, and those who doubted its efficacy or condemned it one year ago now advocate and use it; experience having obliterated its disadvantages while it preserved its benefits.

The forceps as an adjunct to labor has, with the many and decided improvements which the instrument has passed through, steadily advanced in medical favor; and from the probably just condemnation of such men as Hunter, whose criticisms were evidently caused more by the defective instrument of his day than from any defect in the principle involved, the prospect is that an era of forceps mania is at hand, and we may yet learn that some will advocate their use in every alternate labor. Doubtless, the maxim "In medio tutissimus ibis" will receive here a fresh exemplification, and those practitioners who study to make of themselves aids to, not substitutes for Nature, will find themselves on the safest ground.

The year has witnessed the birth as usual of some new styles of forceps, but whether the delivery was natural or instrumental I am unable to say. Judging from the lack of anything natural in some of the specimens which I have seen, I should suppose the labor must have been tedious if not in

strumental. It will probably be a long time before any decided improvement is made upon some of the forceps that have been for from half a dozen to a score of years in use, and the chances to acquire immortality are better in some other directions than in that of affixing one's name to a peculiar kind of forceps.

Removal of the ovaries for the purpose of modifying or entirely restricting the growth of uterine fibroids, is an operation whose usefulness is still sub judice; present appearances indicating its applicability to small growths as most useful, while for larger tumors its effects are doubtful or nil. The results of castration seem to confirm the hitherto accepted interdependence of the ovaries and the menstrual flow notwithstanding the researches of Biezel have led him to accept a different view. Some cases of the beneficial use of the Ustilago Maidis in fibroid tumors of the uterus have been reported to me, and my own experience would incline me to consider it as a remedy worthy of further trial. Its painlessness as compared with the hypodermic use of ergotin or preparations of the secale cornutum will, should future trials prove its usefulness, be no small argument for its use.

In the April number, present year, of the Am. Journal of Obstetrics, appears an article by Prof. A. J. O. Skene, concerning two hitherto undescribed "glands" of the female urethra; an inflammation of which, it is thought by the writer, may often be mistaken for urethral caruncle, the appearance of which is simulated by their reddened everted mucous membrane. A knowledge of their physiological use is disclaimed, and it is recommended to make medicinal applications to the long slender duct by means of a probe-pointed hypodermic syringe.

The subject of obstetric diagnosis and in some cases even the treatment of malpositions by external manipulations, while nothing new, is attracting some attention this year from the medical profession. The obvious advantages it possesses especially in times when puerperal inflammations are epidemic, the possibility, if not probability, of being able to convert an abnormal into a normal vertex presentation, instead

of the breech-labor brought about by podalic version, with the increased hazard to the mother produced by the introduction of the operator's hand into the uterus, make the subject worthy of a candid and careful consideration.

PUERPERAL INSANITY.

By P. D. YOST, M.D., Prof. of Diseases of Women and Children in the American Medical College of St. Louis.

Every practicing physician should be sufficiently familiar with insanity, especially that occurring during the puerperal period, to be able to recognize and successfully treat the acute stage. For it is at this time that judicious and skilful treatment is followed by speedy recovery in many cases, that would otherwise have resulted in chronic insanity. It is not always convenient, nor, indeed, is it desirable, to send the patient at once to an insane asylum for treatment; and the family physician who manages the case may, by knowing the family history, the predisposition to this disease, and the premonitory symptoms, be able to anticipate and ward it off in many instances.

It is not my intention to enter into an exhausting discussion of insanity in all its phases, but, I will confine my remarks to the manifestations of the disease as seen in the

pregnant, parturient and nursing woman. I have been urged to do this by the President of this Association, Dr. Green, who, in a recent letter, makes the following pertinent suggestions: "This is a very important subject and one that is not often discussed fully in medical journals; in its discussion there is not much said except on puerperal insanity proper.* ** To every fifty or sixty cases of puerperal insanity proper, we usually get fifteen or eighteen cases of insanity of pregnancy, and twenty-five to twenty-eight cases of insanity of lactation. It is very seldom that families are willing to allow patients to go to an insane asylum when suffering from any form of puerperal insanity, and any general practitioner ought to be

thoroughly conversant with this subject in all its phases; as it is a well-established fact, that the earlier puerperal insanity is brought under treatment, the greater is the percentage of recoveries * * *. I trust you will favor the Association with an essay on this subject much more full and complete than we usually read." Now, this would seem to be sufficient ground for a severe" infliction," but I promise to be as brief as possible, consistent with the subject.

Let us see, first, what we understand by insanity. All now admit it to be a disease of the brain, although its origin may be in a distant part of the system; not a disease of the mind as formerly thought, but of the organ of the mind. Shephard says: "It is a disease of the neurine batteries of the brain." Maudsley defines it thus: "Insanity is a morbid derangement, generally chronic, of the supreme cerebral centres, the gray matter of the convolutions, or the intellectorium commune, giving rise to perverted feeling, defective or erroneous ideation, and discordant conduct, conjointly or separately, and more or less incapacitating the individual for his due social relations."

There is an unstable condition of the nervous elements connected with the moral and intellectual faculties, which may be born with the person; and when this condition is present, an exciting cause, such as pregnancy, parturition, uterine disease, or the debilitating effects of lactation, will produce insanity. This is established by the fact that some females become insane every time they are pregnant, some during or immediately after parturition, and others during lactation. It is in these cases, as in most others, a secondary disease, and seldom an idiopathic affection. It should be constantly borne in mind that the psychological phenomena so often witnessed during pregnancy and the puerperal state, are merely indicative of the presence and operation of some disturbing influence resulting from the physical condition. While the ordinary irritability and capriciousness that often obtain during pregnancy, would not be considered as constituting insanity, yet when the emotional faculties are beyond control, the hysterical disposition predominating, a disturb

ance of the mental faculties, to a greater or less degree, may be expected. In such a case, a casual observer could readily see that the patient was not in a normal mental condition; her affections and passions are unnatural; she is not her natural self; she is insane.

Van der Kolk, of Utrecht, treats of insanity under two principal forms, viz.: Idiopathic insanity, or that which arises primarily in the brain, there having been no appreciable cause affecting any other part of the organism; and Sympathetic insanity, which includes all forms proceeding from different parts of the body, especially from the abdomen and pelvis. Maudsley's classification includes the following divisions: 1st. Mania, acute and chronic. 2d. Monomania. 2d. Melancholia. 4th. Moral Insanity. 5th. Dementia. 6th. Idiocy and Imbecility; and 7th. General Paralysis of the Insane.

“An hallucination is the imagination of unnatural ideas, without any facts for their support, and totally opposed to reason."

"An illusion is a deception having a material or sensible basis upon which to rest, usually occurring through an imperfect impression made on the senses."

"A delusion consists in erroneous preceptions, resulting in hallucinations and illusions, and resisting the investigations of the reasoning faculties; and although opposed to common sense, persisting in spite of vigorous intellectual scrutiny and analysis."

It may not be amiss to present in a condensed form the predisposing and exciting causes of insanity, recollecting that a combination of causes is generally necessary to produce lunacy. 1st. Unhealthy climate. 2d. Mode of living-civilization. 3d. Sex; the female being particularly liable to certain forms of aberration. 4th. Age, puberty and the menopause. 5th. Lack of moral restraint. 6th. Religious excitement. 7th. Individual predisposition, and the insane diathesis. 8th. The presence of albumen in the urine.

The exciting causes are physical and moral: 1st. A disturbance of the normal function of any organ of the system; disease of acute or chronic character. 2d. Sexual abuses,