strain, abnormal conditions of the nose or nasopharynx, and carious teeth. In young patients we should suspect a reflex origin. The exciting cause may be mental or bodily fatigue, emotions, indigestion, constipation, or some particular article of food. There is a periodicity to the attacks, which usually cease after the climacteric in women and at about the same age in men.

Pathology. We know nothing as to the pathological conditions. The theory that it is a nerve discharge from sensory centres, a sensory equivalent of epilepsy, seems tenable. Some call it a vasomotor neurosis.

are common.

Symptoms. Many cases show premonitory signs, such as malaise, lassitude, depression, or a sense of chilliness, lasting from a few hours to several days. Visual prodromes, such as hemianopia, spots of dimness of vision or scotoma, apparitions, balls or flashes of light, and zigzag lines There may be a condition of intense emotional activity. The prodromal symptoms are not always present, or they may constitute the entire attack, the headache not taking place or being very slight. Confusion of ideas, a feeling of stupor, depression, and marked disturbances of memory for several hours may exist without the headache and constitute the complete attack.

The most characteristic feature is the violent paroxysmal headache. The pain usually starts in one side of the head, over the eye, but may begin in the occiput. It increases and becomes excruciating, involving one half of the head or, more often, the whole of it. The quality of the pain is tense, throbbing, and blinding, and it is increased by jars, light, and noises. Prostration, although temporary, is extreme. The face may be pale and pinched, and there may be a difference between the two sides. During the attack there is usually mental confusion, with temporary loss of memory. The pulse is small and hard and may be slowed. When the headache reaches its climax, nausea and vomiting commonly appear, and they afford relief. Repeated vomiting causes a regurgitation of bile and bitter vomitus, which has given the affection the improper name of "bilious headache."

The attack varies in length from a few hours to several days. After the patient has vomited and the pain has become easier, he usually falls asleep and awakes much refreshed, and the next day may feel better than before the attack. The attacks occur with considerable regularity, monthly, fortnightly, or even weekly. In women they often occur during menstruation. After a severe attack we may observe small hæmorrhages in the sclera of the eye.

Prognosis. Although the disease cannot be promptly cured, much can be done to lessen the frequency and severity of the attacks.

Treatment. Patients are frequently aware of the causes precipitating an attack, and if they are avoided, the paroxysms are much less frequent. In children, after eliminating eye strain, nasal hypertrophies, adenoid growths, enlarged tonsils, etc., we should endeavor to keep them in the best possible health by exercise, proper diet, and freedom from excitement and overstudy. As it has been demonstrated that the attacks are much less frequent during good health, the patient should be built up, the gouty and rheumatic tendencies should be corrected, and the digestive tract be kept. in order by catharsis and the administration of dilute muriatic acid.

OCCUPATION NEUROSES

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During the paroxysm, the patient should be put to bed and kept absolutely quiet. A cup of strong coffee often relieves the pain. Antipyrine or phenacetin, in small repeated doses, frequently gives relief. In cases where there is marked pallor, nitroglycerine, in doses of T of a grain every two hours, is helpful. Cannabis indica, gr. (Herring's English extract), sodium bromide, gr. xxx, and chloral hydrate, gr. x to xv, are of service. A prolonged course of cannabis indica has been recommended.

General massage and active outdoor exercise are to be advised. In the interval between the attacks the patient should have tonic baths and all forms of tonic hydrotherapeutics.

Tic convulsif is a very chronic disorder characterized by quick, electriclike spasms of groups of muscles or single muscles. There is a period of rest. between the violent spasms. We see it limited to special nerves, especially the facial (mimic tic), or to branches of nerves, as in the orbicularis, zygomaticus, diaphragm, or tensor tympani. Sometimes the spasms are accompanied with bursts of speech, as when the patient uses obscene language (tic impulsiv, coprolalia) or involuntarily repeats the last words of a sentence (echolalia) or spasmodically imitates a gesture (echokinesis) or involuntarily speaks out a thought, sometimes against his will (tic de pensée).

The disease begins with these violent movements, which can be controlled for a time. They cease during sleep. The disease may last for years, and is best treated by isolation, when children are afflicted, by tonics, and ordinary antispasmodics, also by vibratory massage.

Tic coördiné (habit chorea, habit spasm), which sometimes represents aborted chorea, is a peculiar trick of speech, gesture, grimace, shrug of the shoulder, twitching of the eye, or sniff, with which a person may go through life. When it is seen in children, the treatment is moral, hygienic, and medicinal. Head nodding is a form of habit spasm (see Pædiatrics). Stammering is an improperly regulated motor impulse from the cortex of the brain.

OCCUPATION NEUROSES

Occupation neuroses are functional nervous disorders characterized by spasmodic, tremulous, incoordinate, or paralytic disturbances with the feeling of fatigue or pain upon attempting to perform the customary function the overperformance of which has brought it about.

Writer's cramp is a typical form. Among the predisposing causes are heredity and a neuropathic constitution. Excessive worry, intemperance, and all debilitating influences are also predisposing. The exciting cause is excessive writing, but essential to its causation is a cramped position, in which the fingers alone are used, and the little finger or wrist is resting over the table. Free hand writing, with motions by the whole arm from the shoulder, is least harmful. Lead poisoning, exposure to wet and cold, and local injuries are sometimes exciting causes.

SYMPTOMS.-It develops slowly with stiffness in the fingers and uncertain, jerky movements. There is fatigue and sometimes actual pain. Later, as soon as writing is attempted, the pen is likely to fly in all directions, and there is no coordination of movement.

We may speak of four forms or degrees in order of frequency or progression, but they are usually more or less mixed.

1. The spastic form, the most common, is that in which there is a cramp, a tonic spasm of the muscles (sometimes the flexors and sometimes the extensors), usually those of the thumb and the first three fingers. The pronators and supinators may be affected. Then the thumb and first finger may alone be involved. There is also incoordination.

2. The neuralgic form is that in which, in addition to the spasm, there are fatigue, pain, and sometimes tenderness along the arm.

3. The tremulous form is rather rare. Upon attempting to write, there is a tremor of the fingers holding the psa, which may involve the forearm or even the whole extremity. It is an intention tremor.

4. The paralytic form, more rare, 3 that in which the fingers seem powerless to hold the pen. Persistence ar will power will cause pain and weakness, so that writing becomes imposible.

There are other symptoms, ma aly psychical, sensory, and rarely vasomotor and trophic. Mental depr ssion, emotional disturbances, insomnia, vertigo, pain, fatigue, numbness prickling, pressure, weight, tension, constriction, etc., may be present. There may be local swelling and a sensation of throbbing. Local sweating, dryness of the skin, and cracking of the nails may result.

The electrical reactions are riuniform. The electrical examination may show the stage of the disease, as neuritis is undoubtedly present in some forms.

The PROGNOSIS is unfavorable, but cases of complete recovery are occasionally seen and temporary improvement is frequently observed.

Other Forms of Cramp.-Musicians' Cramp.-Pianists', violinists', flutists', and clarionetists' cramps are very similar, with atrophy of certain muscles. Telegraphers' cramp, in which the extensors of the wrists and fingers are most affected, is rather common. Sewing spasm, in tailors, seamstresses, and shoemakers, is occasionally seen. The muscles of the hands are seized with clonic and tonic spasms upon attempting to use them. Drivers' spasm, cigarmakers' cramp, milkers' spasm, watchmakers' cramp, and photographers' cramp are rare. Ballet dancers' cramp is probably a neuralgic affection. Artificial flower makers, billiard players, dentists, hide dressers, electrical instrument makers, stampers, turners, sewing machine operators, money counters, weavers, painters, and pedestrians also may have occupation neuroses.

Sacral nerve twitchings, tremor rigidity, clonic and tonic spasms, myoclonus, and athetoid movements are seen as a part of some general or central disorder or as occupation neuroses. Saltatory spasm involves the legs alone. Chorea is described under the section on Pædiatrics.

Treatment of Tics.-Prophylaxis in writers' cramp. One should use a gold pen, smooth paper, and large cork or rubber penholders, making the motions from the shoulder, having the paper on the desk at an oblique angle

to the edge of the desk, and far enough away from the edge so that the elbow can rest on the desk.

When the cramp has developed, rest is the most important aim. The patient should use the other hand or another holder; use other fingers, one of the appliances purposely arranged, or the typewriting machine. Massage, electricity, and exercises have cured some cases. In the other neuroses we should secure rest by using the other hand or other muscles and by general treatment as above mentioned.

TETANY; PSEUDOTETANUS

This is a subacute or chronic spasmodic disorder characterized by intermittent or persistent tonic contractions, associated with paræsthesia and overexcitability of the motor and sensory nerves.

Etiology. It is rare in this country. It occurs in infancy and childhood, at puberty, and occasionally afterward up to fifty years. It occurs more often among males, and among the poorer classes. The exciting causes are exhausting influences, such as diarrhoea, lactation, sepsis, fatigue, mental shock, and fevers. Alcoholism, dilatation of the stomach, and intestinal parasites are causes. Extirpation of the thyreoid gland may be a cause.

Symptoms. Paroxysms of bilateral tonic spasm begin in the muscles of the hands, or of the hands and feet, after prodromal tingling and stiffness, and the spasm extends toward the trunk, which is involved in severe cases. The hands assume the obstetric position, the wrists and elbows slightly flexed, arms adducted, toes flexed, feet in the equino varus position, knees and hips extended or rarely flexed, and thighs adducted. The jaw is noi affected until late, if at all. In the intervals, spasm may be excited by pressure on nerve trunks or arteries (Trousseau's symptoms). The galvanic, faradic, and mechanical irritability of the affected muscles is enormously increased.

Treatment. Remove the cause if possible. Prescribe rest, nourishing food, and tonics. Symptomatically, give bromide of potassium, 3jss. to 3ij daily, with chloral. Chloroform and morphine may be necessary. Lukewarm baths may be of service, also ice bags to the spine. Only weak galvanic currents should be used if electricity is tried at all.

PARALYSIS AGITANS (SHAKING PALSY; PARKINSON'S DISEASE) This is a chronic progressive disorder with tremor, muscular rigidity, and weakness, and with a peculiar gait and attitude. There are also sensations of heat, pain, and restlessness.

Etiology. It is oftenest seen between fifty and sixty years of age. Exposure, hard labor, rheumatism, and rheumatoid arthritis seem to be predisposing causes. The exciting causes are fright, injury, and prolonged mental anxiety. Sciatica or rheumatism, sudden severe muscular strain, and fevers are rare causes.

Symptoms. The tremor begins after forty years of age, usually in one hand, rarely in one leg, and slowly extends to the other limb on the same side and then to the limbs on the other side. As a rule it may be lessened

or stopped by effort, but continues during rest. Rarely, in an early stage, it is elicited by effort. Following the tremor, beginning in the same part and spreading in the same order, muscular weakness and rigidity appear, the muscles, especially the flexors, gradually contracting so as to cause a characteristic posture with absence of facial expression. The hands assume the "pill rolling" position. There is a slight flexion of the knees, hips, wrists, elbows, and shoulders. The extensors may be involved. The head and spine are bent forward and the face stares straight ahead. The patients are restless, uncomfortable, and unhappy and often have sensations of heat and cold. The tendon reflexes are generally normal, rarely exaggerated. Nystagmus is not present. The speech becomes affected early. The voice becomes senile, high pitched and weak, and there is a slowness in starting to talk. A patient afflicted with paralysis agitans who is propelled forward or backward cannot stop at will. The rigidity increases, as does the tremor, and finally the patient becomes bedridden and dies of some intercurrent disease. The course averages from three to twelve years.

Differential Diagnosis.-We have to distinguish this disease from senile tremor, multiple sclerosis, and posthemiplegic tremor. In senile tremor, the tremor is an intention tremor. The head is first affected. In multiple sclerosis the tremor is more jerky, and there are nystagmus, syllabic speech, eye troubles, paralyses, and often apoplectoid attacks. Post hemiplegic tremor has the history of hemiplegia; the disease is unilateral and there are paralyses and exaggerated reflexes. Alcoholic and hysterical tremors may be mistaken for paralysis agitans.

The prognosis as to life is good, but bad as to a cure. may stop the increase in the symptoms.

The pathological changes are not known.

Sometimes we

Treatment. Physical and mental rest and fresh air should be advised, also lukewarm baths and mild massage. The galvanic current, daily employed, gives temporary relief. Psychical treatment benefits some cases. For drugs, tonics of all kinds are used, and for antispasmodics, hyoscine hydrobromide, codeine, and morphine are used.

OBSTINATE HICCOUGH

Hiccough is looked upon as a reflex spasm of the diaphragm with simultaneous closure of the glottis, the pneumogastric being the centripetal and the phrenic and recurrent laryngeal the centrifugal nerves involved. When associated with grave organic lesions, it may be of an obstinate type, but generally subsides on the application of one or more of the following procedures if it is due to hysteria or gastrointestinal disorders: 1. Holding the breath for 15 or more seconds. 2. Hot applications over the cervical spine and diaphragmatic area. 3. Firm pressure upon the phrenic nerve over the scalenus anticus muscle. 4. Rapid swallowing of small pieces of ice. 5. The use of such antispasmodic drugs as morphine or chloroform. 6. Traction on the tongue, intermittently applied, as in chloroform poisoning. 7. Galvanization of the phrenic nerve. 8. Faradization of the epigastric region (Erb). 9. Forcible elevation of the hyoid bone by the attendant's fingers (Noth