pulse rate does not increase. Optic atrophy, bladder trouble, and signs of sclerosis of the cord, indicating a degeneration of the lateral columns or multiple sclerosis, point toward organic disease.

Prognosis. Traumatic hysteria is one of the most intractable affections which we are called upon to treat, but most cases recover."

The treatment is that of neurasthenia and hysteria. Suggestion has probably given the best results.

INSOMNIA

Sleeplessness is one of the most frequent conditions which physicians in large cities are called upon to treat. We should aim to discover the cause and remove it.

We may class the causes as follows:

Pain, as with excessive headaches.

Poisons circulating in the blood, as in acute infections, Bright's disease, hepatic disease, and intestinal toxæmia.

Insanity, as in melancholia, mania, paranoia, and paresis.
Ordinary types, seen in nervous people and neurasthenics.

These cases may be divided into:
Those with cerebral congestion.
Those with cerebral anæmia.

Treatment.-INSOMNIA DUE TO CEREBRAL CONGESTION.-This form is recognized by distress and a feeling of distention in the head, muscular irritability, and overexcitability. We may endeavor to remove the congestion in the brain by various means. An enema or laxative may be given in the morning.

There are various forms of hydrotherapy to be tried always before drugs. These are to be used just before the patient goes to bed.

A hot bath sometimes succeeds in causing sleep, but contraction of vessels is likely to follow soon, and again cause congestion. A cold sponge bath after the hot bath seems to prevent this. A good plan is to have the patient stand in tepid water which reaches above the ankles, and then wrap around the body a dripping sheet from a pail of cold water, at about 80°, rubbing the body at the same time. Other resources are the cold pack to the abdomen and wearing a flannel cloth wrung out of water at about 75°, covered with a dry towel and then with a rubber cloth. The cold flannel soon becomes warm, and acts as a poultice, bringing blood to the abdominal cavity.

Exercise.-Five or ten minutes of calisthenics or exercising with dumb bells or Indian clubs before going to bed serve a good purpose, also a brisk walk outdoors before going to bed. Forcible respiratory movements, with deep inhalations of fresh air, at bedtime are also helpful.

Drugs.-Bromides are best for cerebral congestion. Give gr. xx to xxv about half an hour before the patient goes to bed. A mixture of two or three of the bromides, such as bromide of sodium, potassium, ammonium, and strontium, seems better than one alone. Chloral hydrate and bromides may be combined. Sulphonal and trional should be given with foodsulphonal about one hour before bedtime, and trional fifteen to twenty minutes before, gr. x to xx, also urethane, 31, and codeine, gr., may be taken together at bedtime, or hyoscine, gr. 80.

Suggestion is of great benefit. Autosuggestion, or the suggestion of the physician, with a sugar tablet, or a hypodermic injection of sterile water, is effective at times.

INSOMNIA DUE TO CEREBRAL ANEMIA.-Patients with this form of insomnia usually sleep well at first, but wake up and cannot go to sleep again. Stimulation is indicated in these cases and the bowels should move regularly.

Beer, whiskey, or gr. of strychnine at bedtime does well. Chloral and chloralamide are good hypnotics in these cases. When a person wakes, and cannot fall asleep again, advise him to get up and eat something light, or to take a little whiskey, to walk around, or to apply hot and cold water to the back. Inhalations of the fumes of whiskey or wine, or of ether, alcohol, and cologne, equal parts, on a handkerchief before going to bed may help in this class of cases. Opium, as a last resort, is indispensable in the insanities.

HYPNOTISM, OR SUGGESTION; TRANCE

Hypnotism may be defined as an abnormal mental insensibility to most of the sense impressions and excessive sensibility to some impressions. There is a certain amount of unconsciousness and an obedience to the suggestion of the one who has induced the condition. "It may be regarded as an artificial catalepsy.'

The power which one person has over himself and over another, to make himself or another do or believe a thing, is a form of hypnotism or suggestion. When the physician enters a sick room, sympathetic and in a cheerful mood, he knows his power of making his patient comfortable by assurances of an improved condition and by removing from the mind unhappy and sad thoughts. This is a form of hypnotism or suggestion.

Many people are using this power of suggestion, consciously and unconsciously, and have been for centuries. Parents, teachers, ministers, employers, and physicians are constantly using suggestion, but few of them could define it or few use it scientifically. It does not take a pathological mind or a pathological nervous condition to receive suggestion. Charlatans have done an infinite amount of harm through a knowledge of this power. As we look back over centuries of history of all countries, we may, understanding the power of suggestion, appreciate the many sects, cults, and societies which have had their origin in some minds conscious of this power. The present time is replete with examples. A number of scientific men have investigated the subject and have learned a great deal. But there is still much that we do not understand.

Hypnotism with partial or complete suppression of consciousness is the condition which we usually understand by the word. Bernheim says that the majority of people of both sexes and of all ages and temperaments can be put into the hypnotic condition. Others maintain that only hysterical people and people whose nervous system is not in a proper equilibrium can be hypnotized. Bernheim maintains that the profound sleep which may be induced by suggestion is not a pathological condition or a neurosis analogous to hysteria.

There are different methods of inducing the hypnotic condition. One is

CLASSIFICATION OF MENTAL DISTURBANCES

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to have the patient fix his eyes on a bright object, in a manner to tire the eye muscles, and, on the operator's suggesting sleep, the patient closes his eyes from fatigue, and soon is asleep, or in the hypnotic condition. Bernheim's method is to assure his patients that there is nothing occult or mysterious in hypnotism, that it is not harmful or unnatural to produce this sleep, and, in order to reassure his patient, he hypnotizes one or two patients in his presence. After assuring him and making him believe that he can be cured or benefited by such procedures, he gains his cooperation and assistance, and puts him to sleep, by merely talking to him in a monotonous, sleepy manner, sometimes with the assistance of passes before the face and having him fix his gaze on an object, with the purpose of tiring the eyes.

There are various degrees of intensity of the hypnotic condition. There is comprised in these degrees phenomena extending from a simple numbness in the simplest forms up to entire unconsciousness of what has transpired during the hypnotic condition, catalepsy, automatic movements, contractures, hypnotic hallucinations, and posthypnotic suggestions.

The clinical symptoms which can be cured are mainly neurotic and hysterical, but in the larger cities we see such a number of such cases that the value of hypnotic suggestion is apparent. The marvelous sudden cures of paralyses and other conditions, as at Lourdes and by those so called "healers," are probably all hysterical conditions and the healing power is suggestion.

CLASSIFICATION OF MENTAL DISTURBANCES, AFTER KRAEPELIN AND MEYNERT

a. Acquired mental disturbances.

Acute and chronic conditions of collapse with delirium.

Acute amentia and dementia.

Acute and chronic intoxications.

Metabolic disturbances with insanity, as in myxedema, cretinism,

dementia paralytica.

Insanity with cerebral disease.

Syphilitic dementia.

Paretic dementia.

Senile dementia.

Alcoholic dementia.

b. Psychical degeneration in weak brain or maldeveloped brain.

Periodical psychoneuroses, confusional, emotional, impulsive, depressive (melancholic) forms, with imperative ideas or sexual perversions. Maniacal forms-dementia præcox.

Paranoia.

Epileptic insanity.

Imbecility, idiocy.

VASOMOTOR AND TROPHIC DISTURBANCES

GENERAL REMARKS

The nutrition of a part is governed by the nervous system. A disturbance of this part of the nervous system results in disorders designated as trophic disturbances or trophic neuroses. Hypertrophy or atrophy of nerves, muscles, and cutaneous and mucous tissues, joint degeneration, and various skin eruptions are examples of trophic neuroses. If joints are affected, we speak of arthropathies; if muscles, atrophies, hypertrophies, and dystrophies; if nerves, degeneration; if fat is substituted for atrophy, or associated with atrophy, we call it lipomatosis or fatty degeneration, as in some dystrophies. Herpes, pemphigus, and other eruptions, pigmentation, leucoderma, non-parasitic alopecia, and bedsores are examples of trophoneuroses of the skin.

The nerves which supply the blood vessels and the glands may be affected, and produce a variety of symptoms. Vessels and glands may be affected separately, but usually both are affected by the same neurosis.

Angeioneurosis designates a disorder of the vasomotor centre and nerves. Angeiospasm is applied to the condition where there is a spasmodic contraction of the muscular coats of the arteries with an increase in the vasomotor tone. Angeio paralysis represents an opposite condition. Pallor and coolness, and flushing, and heat are the results of such conditions of spasm and paralysis.

Secretory Neuroses. The skin is the part of the body which most often shows this disturbance.

Hyperidrosis is an excessive sweating. Anidrosis is an excessive dryness. Paridrosis is a perversion of the perspiratory secretion. We may notice peculiar odors and colors to the perspiration. Hamidrosis is bloody sweating.

RAYNAUD'S DISEASE

This is a rare disorder, probably due to a vasomotor disturbance.

Etiology. It occurs most often in children and young women. Anæmia, chlorosis, and neurasthenic conditions seem to create a predisposition. Malarial infection, acute infectious fevers, menstrual disorders, fright, and occupations that lead to exposure, such as washing, seem to be exciting causes. Diabetes and syphilis are underlying causes. The disease comes on rather suddenly and affects most often two or three fingers of both hands. There are three grades of intensity:

1. LOCAL SYNCOPE is the most common form. There are coldness and pallor of the extremities (called "dead fingers" or "dead toes") which can be induced by cold or emotions. The affected parts are stiff and sometimes painful. There is a waxy pallor; the skin looks shrunken, and there. is slight anæsthesia. After a few hours this passes away but returns again and may become almost a constant condition.

2. LOCAL ASPHYXIA may succeed these conditions, or the disease may appear first in this manner. The affected parts, fingers, toes, ears, and nose, become livid and cyanosed. There are numbness, swelling, and some pain. The capillary circulation is exceedingly sluggish. Upon the attack wearing

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off, the parts become bright red from the overactive circulation. Local gangrene may follow severe attacks. Recurrences are common, especially during cold weather. There may be much pain in this stage, but no anæsthesia. Gangrene may follow.

3. LOCAL OR SYMMETRICAL GANGRENE.Spots of ecchymosis and vesicles appear, and at these points a symmetrical gangrene develops. The ears, fingers, and toes are the usual situations. Usually the part becoming gangrenous is small, and when it heals it leaves a scar. Rarely the whole tip of the finger or toe may be involved and separated. Purpura hæmorrhagica, intermittent hæmoglobinuria, peripheral neuritis, and a variety of mental and cerebral symptoms may complicate the disease. The gangrenous stage lasts about three weeks.

Differential Diagnosis.-We have to distinguish from frostbite, senile gangrene, ergot poisoning, alcoholic neuritis, endarteritis, and obstruction of the nutrient vessels.

The prognosis is good except where there is extensive gangrene and in the gangrenous cases complicated by purpura hæmorrhagica, etc.

Treatment.-Avoid exposure to extreme cold. If possible, spend the winters in a warm climate. Galvanism to the spine and limbs, warm applications, anodynes, and tonics are indicated. Internal medication seems to do no good, but we may try nitroglycerine, the iodides, and chloral.

ERYTHROMELALGIA

Erythromelalgia is a very rare chronic disease characterized by severe pain, flushing, and local heat, usually in one or more extremities. The pain is intensified if the part hangs down. It affects the feet chiefly. It occurs usually in men. of middle life after a low fever or severe physical exertion on the feet.

The disease develops gradually from dull pain, worse at night, in the ball of the foot to an almost continuous pain of the whole region supplied by the plantar nerve. The affected part later assumes a dull, dusky, mottled redness. The congestion and pain usually disappear when the part