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tory of a slowly developing condition, in contrast to the sudden onset in polioencephalitis, and the fact that lumbar puncture relieves the pressure S3'mi)- toms for but a very short time, while the relief is much greater and more permanent Can You Buy Viagra Over The Counter In Mexico in polioenceph- alitis, were of diagnostic service. The recovery would also aid, for while we had instances of this in tuberculous meningitis in cases in which the diag- nosis was confirmed by the bacteriological examina- tion, they were so extremely rare that they might safely be disregarded in the diflferential diagnosis. The observation of Fehling's reduction in Can You Buy Viagra Over The Counter In Mexico three of the cases of polioencephalitis might be of service, since this was never found in tuberculous menin- gitis. \'on Pirquet's test was diminished in value by the fact that an old tuberculous lesion might be present in a patient suffering from polioencephalitis. Serou.s meniui^itis was recognized by the cytological findings and the clinical history. In three Can You Buy Viagra Over The Counter In Mexico of the case> of polioencephalitis tdche ccrcbrale was noted, but Dr. Merzbach expressed the opinion that little importance could be attached to this symptom in the diagnosis of cerebral conditions, since it was found also in diseases of other character in indi- viduals with an excitable vasomotor svstem. In tlic way of treatment he stated that lumbar puncture, as indicated by the symptoms, was the chief n:cas- ure depended upon. Dr. Leo.x LotjRiA stated that he had had the op- portunity of observing Dr. Merzbach's cases, anrl he proceeded to give some of the particulars of the clinical history, especially the features characteriz- ing the onset of the disease. In one instance the young man was feeling perfectly well, with the ex- ception of some headache, when he was suddenly seized with a convulsion.- This lasted only a short time, however, and after he had recovered from it he felt almost well again ; but the ne.xt evening he suffered from another convulsion, also of short dur- ation. .\fter the second convulsion he noticed that he was unable to raise his left arm. .V tentative diagnosis was made of .syphilitic gumma in the brain, but the Wassermann test of the blood and cerebros])inal tluid proved negative. Later, he de- veloped marked symptoms of meningitis, and the tentative diagnosis was made- of tuberculous men- ingitis : whicli was apparently supported by a posi- tive \'on Pirquet reaction. The cytological examina- tion of the cerebrospinal fluid showed 98 per cent, of lymphocytes, and this also favored the tuberculosis diagnosis, though the bacillus was not found and animnl inoculation proved negative. The subse- quent history of the patient, with recovery, however, disproved this diagnosis. He later developed a par- alysis of the third nerve, while the paretic condition of the left arm entirely disajjpcared. The fatal case occurred in the youngest of the patients, who was eighteen years old. There was some prodromal headache for two days and. while on the street, he was suddenly seized with an epileptiform convul- sion, .-.ocompanied by vomiting, which lasted for two days. The presence of albiimin and casts in the urine and an inadequate excretion of urea afforded basis for a diagnosis of uraemia, but the subsequent course of the disease did not substantiate this opin- ion. The symptoms of meningitis were progressive in character, and he died on the eighth day from the onset of the attack without developing any par- alysis. In the third case the onset was likewise sudden, a convulsion coming on after some intesti- nal disturbance and a very large, prolonged and painful evacuation of the bowels. The patient was carried into a saloon, and some whiskey was poured into him ; so that the ambulance surgeon, finding him in a stuporous, semicomatose condition, and smelling the whiskey, made the diagnosis of acute alcoholism. After having been treated in a hos- pital for this mistaken condition for some two days, he was taken to his home, where Dr. Louria sav,- him for the first time and, making a diagnosis of meningitis, referred him to the Jewish Hospital. This was one of the cases in which blood was found in the cerebrospinal fluid. The fourth patient, while he had no convulsion, was suddenly seized with an attack of dizziness, followed by severe headache and somnolence. When taken to the hos- pital he was still in an apathetic condition, and he liad some photophobia and also n\stagmus, which was followed by a paralysis of the abducens. In this case also the cerebrospinal fluid contained blood. The patient made a prompt recovery from his acute symptoms, though some dizziness remained and his gait was uncertain. The diagnosis in all these cases, the speaker went on to say, presented great difficulty, and it was only after systematic chemical, cytological, and bacteriological examination of the cerebrospinal fluid that it was possible to exclude the common forms of meningitis ; while the devel- opment of focal paralyses substantiated a diagnosis of polioencephalitis. As Dr. Merzbach had stated, the :ctiology of this affection was not yet deter- mined. All kinds of microorganisms had been found in these cases, but none could be held respon- sible as the definite cause. The pathologica' changes Can You Buy Viagra Over The Counter In Mexico in the brain showed evidences of hjemor- rhages Can You Buy Viagra Over The Counter In Mexico and toxic degeneration, rather than inflam- mation, and the opinion of many observers, includ- ing the commissions on poliomyelitis in New York and Massachusetts, was that the Can You Buy Viagra Over The Counter In Mexico cause of the dis- ease is a virus present in the substance of the brain, but not in the cercbrosjiinal fluid. In two of the cases reported by Dr. .Merzbach the presence of blood in the cerebrospinal fluid was a very signifi- cant feature. Both of them occurred in nonalco- holics, and they belonged to the Struempel group of polioencephalitis, .\s regards the treatment, it was necessary in all the cases to give opiates fre- quently, in addition to veronal, iri order to induce rest and sleep. They acted better than bromides. In one of the cases mercurial inunctions were em- ployed with apparent benefit. After the subsidence of the acute symptoms all the patients were treated with a prolonged course of iodides. .\s has been mentioneil, three of the four cases recovered. In one instance some dizziness still remained, and as, according to Oppenheim and other observers, re- lapses were possible, it was the part of wisdom to be guarded in the matter of prognosis. 856 LETTERS TO THE EDITOR.