deserve the greatest confidence. In the treatment of Ménière's disease quinin hydrochlorate (0.5—71⁄2 grains-thrice daily) has proved efficacious.

CATALEPSY.

Symptoms and Diagnosis.—Catalepsy is attended with attacks in which the patient is unable to execute voluntary movements, while passive movement of the members can be effected without resistance, and the attitudes thus induced may persist for several minutes or more, so that the movements are suggestive of those of a wax doll, and the condition has been designated waxy flexibility of the muscles. The duration of the attacks varies between minutes and days. The eyes are generally closed, the pupils dilated and unresponsive. Consciousness is lost in greater or lesser degree. The patients respond but sluggishly and feebly, if at all, to cutaneous or other irritation. The skin frequently feels cold, and is pale, while the temperature of the body may be elevated to 39° C. (102.2° F.). The conclusion of a cataleptic attack is often indicated by a deep sigh; consciousness is restored, and the patient generally has no knowledge of what has taken place. At times the disease is terminated with a single attack, but not rarely it persists for weeks, months, years, and even throughout the whole of life.

In contradistinction from simulation, it should be borne in mind that in malingerers tremor of the elevated member will take place within a short time, and this will soon be followed by a lowering of the member from muscular fatigue. Involuntary muscular movements (cardiac, respiratory, vesical, rectal, deglutitory) are executed without interference during the cataleptic attack. In cases of considerable duration there may be danger of death from inanition in consequence of involvement of the muscles of mastication in the rigidity, but if the food is introduced into the esophagus it will pass into the stomach without obstruction.

Etiology. Catalepsy is an uncommon disorder, and it occurs with preference in pallid and neurotic individuals. It frequently appears in the course of central neuroses, particularly hysteria and epilepsy. It has been observed also in association with disease attended with anatomically demonstrable alterations, as, for instance, meningitis, cerebral hemorrhage, cerebral softening, and tumor of the brain, as well as with progressive paralysis of the insane. Occasionally it is a result of profound emotional disturbances (grief, fright, joy). Toxie catalepsy has been observed as a result of the inhalation of ether and of chloroform. Possibly autotoxic catalepsy occurs in cases of gout and nephritis. The designation. infectious catalepsy has been applied to cases in which the disorder develops in the course of infectious diseases. It should further

be mentioned that cataleptic states can be induced intentionally by hypnosis and suggestion.

Prognosis and Treatment.-The curability of the disorder depends upon the nature of the fundamental disease. During the cataleptic attack active stimulating measures should be employed (douches of cold water, inhalation of ammonia, tickling of the nose with a feather, etc.), and, with the termination of the attack, efforts should be directed to the relief of the primary disease.

CENTRAL NEUROSES IN WHICH SENSORY DISTURBANCES PREDOMINATE.

NERVOUS HEADACHE.

Symptoms, Diagnosis, and Prognosis.-The designation nervous headache should be applied only to such cases of headache as are not dependent upon anatomically demonstrable disease of the brain and the cerebral meninges. The disorder is generally a most troublesome one, and it not rarely persists from earliest childhood to advanced age, and is therefore known also as habitual headache. Often, naturally, it diminishes in severity in old age. The character of the pain is variously described, sometimes as boring, at other times as beating, occasionally rather as a sense of pressure in the head than headache. The distribution of the pain likewise varies. At times it is referred by the patient to the frontal region, at other times to the occiput, but not rarely it is distributed over the entire skull. At the time of the attack nausea and vomiting occasionally occur. Often the scalp is markedly tender to touch and when the hairs are pulled. The face is at times hyperemic and congested, and at other times pale and anemic, so that a distinction has been made between hyperemic and anemic nervous cephalalgia. Some patients are free from headache for scarcely a day, while in others it occurs only at long intervals, and particularly if mental over-exertion, excitement, gastric and intestinal disorders have preceded. In women it occurs frequently at the menstrual period. The duration of the individual attack varies between a few hours and an entire day; the pain often disappears after sleep.

Although headache is not a serious disorder, it incapacitates a good many persons from the pursuit of their work, and compels them to withdraw from society and seek seclusion in a quiet and if possible dark room until the attack has terminated. Some patients become morbidly reserved and hypochondriacal in consequence.

In the differential diagnosis the confusion of headache with an anatomically demonstrable cerebral disorder should be guarded

against, and consideration should be attached especially to the presence of other general cerebral symptoms (inequality of the pupils, slowing of the pulse, papillitis). The pain due to neuralgia of the nerves of the head corresponds with the distribution of the affected nerves, in the course of which pressure-points can generally be discovered. Inflammation of the bones of the skull and their periosteum is generally attended with thickening, which is especially sensitive to pressure.

Etiology.-Headache is frequently an inherited disease, although it is not always transmitted as such, but alternates with other central neuroses, particularly hysteria, neurasthenia, and epilepsy. Often it is the result of mental over-exertion and emotional disturbances. It occurs frequently, therefore, in students, in men of learning, and in merchants. The headache of smokers and alcoholics, and that which follows excessive indulgence in coffee and tea, belong among the toxic varieties of headache. Autotoxic headache occurs in association with uremia, cholemia, gout, diabetes mellitus, gastric and intestinal disorders. Infectious influences are operative in the production of headache in the course of infectious diseases. Thus, severe headache occurs quite frequently at the commencement of typhoid fever and of syphilis. Occasionally headache results from states of exhaustion. It is, therefore, encountered in association with chlorosis, following loss of blood and suppuration, and after long vigils at night, and the like. Headache of reflex origin includes cases in which the condition occurs in conjunction with disease of the liver, the kidneys, the sexual organs, and other viscera. Occasionally headache is dependent upon ocular disorders, particularly errors of refraction and eye-strain.

Treatment. Many patients have discovered definite means for the relief of the attack of headache. In some a darkened room, complete rest and seclusion, and a cup of strong coffee are serviceable; in others applications of cold water, or of water and vinegar; in still others marked compression of the head between the cooled hands, and the like. Among medicaments, antipyrin, phenacetin, and sodium salicylate are deservedly in good repute, and of any of these 1.0 (15 grains) may be administered thrice daily. One patient will be helped by one remedy and another patient by another remedy, and not rarely it becomes necessary to employ successively one remedy after another. Also, antifebrin (0.5 -7 grains-thrice daily) and lactophenin (0.5-7 grains-thrice daily) have been recommended. Some patients obtain relief from the use of migrainin (a mixture of antipyrin, caffein, citric acid, in doses of 1.1-17 grains; if necessary, a second powder being given after an interval of two hours). The migrain-pencil, composed of menthol, also is praised by many patients. Preparations of caffein (caffein sodio-salicylate, caffein sodio-benzoate, 0.5-71 grains thrice daily, in powder) may also be mentioned. In

order to prevent the recurrence of attacks of headache the causative factors must be carefully investigated, and causal treatment employed. Among symptomatic remedies the bromids have proved most serviceable in my experience, although it is necessary to employ them for a considerable length of time:

15.0: 200 (ounce:

64 fluidounces);

10 (24 drams);

5.0 (75 grains).-M.

Dose: 15 c.c. (1 tablespoonful) thrice daily.

A sojourn in the country, among the mountains, or at sea may also be recommended.

HEMICRANIA (MIGRAINE).

Etiology.-Hemicrania, also designated migraine, is an exceedingly common and troublesome disorder, whose causative factors are essentially the same as those of nervous headache. Heredity is often an etiologic influence; but it is not necessary that all of the members of the family should suffer from hemicrania, for often the disorder alternates with hysteria, neurasthenia, epilepsy, psychopathy, and other central neuroses. Occasionally migraine occurs in the course of central neuroses. In addition to hysteria and neurasthenia, epilepsy should especially be mentioned. Often hemicrania precedes the development of epilepsy, or is a sequel of this condition, or it may replace the epileptic attack. Mental over-exertion, anemia, and states of exhaustion of all kinds, are not uncommon causes of hemicrania. Toxic hemicrania occurs especially in drunkards and smokers, while autotoxic hemicrania occurs in connection with gout. Infectious hemicrania has been observed also in the sequence of certain infectious diseases. Reflex hemicrania occurs in association with disease of the frontal sinuses, abnormal turgescence of the nasal mucous membrane, and diseases of the female generative organs, the liver, and the kidneys. Hemicrania often begins in childhood and persists throughout the whole of life. It rarely sets in after the twenty-fifth year of life. The disease is more common in women than in

men.

Symptoms, Diagnosis, and Prognosis.-The principal symptom of hemicrania consists in pain distributed over one side of the head, which occurs paroxysmally, and, as experience has shown, more commonly upon the left side. Some patients awaken in the morning with this pain, while in others it sets in only in the course of the day. Occasionally an attack of migraine is preceded for days by prodromes, which consist especially in general malaise, disturbed sleep, loss of appetite, chilliness, and the like.

At times the attack of migraine sets in without demonstrable cause, while at other times it is preceded by emotional disturbances, alcoholic or venereal excesses, or gastric derangement. In women hemicrania occurs frequently with the onset of menstruation. In Zurich hemicrania occurs in many persons with the prevalence of the south wind.

The pain is described as boring, tearing, or beating, and its seat of greatest intensity is referred to the frontal, the temporal, or the parietal region, and less commonly to the occipital region. Often the pain extends down the nucha, and the patient experiences difficulty in movement and painful rigidity of the neck. Generally the scalp is exceedingly sensitive to slight touch, while deep pressure is much better borne. Traction upon the hairs generally induces great pain upon the painful side of the head. Frequently the patient complains of nausea at the time of the attack of pain, and vomiting occurs not rarely, the vomited matter being of watery consistency and containing an abundance of free hydrochloric acid, so that the existence of hypersecretion on the part of the gastric mucous membrane, and of hyperchlorhydria of the gastric juice, must be inferred. Some patients experience rectal tenesmus. After the attack a large amount of light urine is not rarely passed, which at times contains small amounts of albumin. Most patients are so overwhelmed by the pain that they are incapacitated for mental or physical exertion. In many slight mental confusion occurs, and in some instances I have even observed mild delirium. Generally, patients seek seclusion in a quiet, dark room and endeavor to sleep, because on awaking they generally find themselves free from pain. Often a sense of soreness and prostration persists for days after an attack. Many patients exhibit evidence of a threatening or an existing attack, as they appear pale and the face is drawn, the eyes hollow, and the skin is not rarely covered with a clammy sweat.

The duration of an attack of migraine is generally a few hours, but it often extends over an entire day, rarely longer. Some patients suffer from only a few attacks in the course of a year, while others are seized with a new attack at intervals of a few days. Cases are, however, on record also in which a new attack has set in before the preceding one had terminated, and under such conditions the designation migrainous status has been employed. Not rarely the hair becomes coarse and gray and falls out on the affected side of the head in the sequence of hemicrania. It is worthy of mention that at times the headache varies in situation in individual attacks-alternating hemicrania; or that it gradually passes permanently from one side of the head to the other. It may also happen that gradually the unilateral distribution disappears and the headache becomes diffuse.

In the differential diagnosis the same conditions must be taken