into consideration as were mentioned on pp. 115 and 116 in connection with the diagnosis of nervous headache.

Vasomotor hemicrania, ophthalmic hemicrania, and the hemicranic equivalent should be mentioned as special clinical varieties of hemicrania.

In cases of vasomotor hemicrania the cervical sympathetic is obviously involved, for in the first place vascular changes are prominent upon the painful side of the head, and, in addition, the cervical sympathetic is tender on pressure. Two varieties of vasomotor hemicrania can be distinguished, accordingly as the vasomotor nerves are paralyzed or irritated, and the designations sympathetic-paralytic hemicrania and sympathetic-spastic hemicrania respectively are employed.

In cases of sympathetic-paralytic hemicrania the face upon the side on which the headache is present is greatly reddened; the corresponding carotid and temporal arteries exhibit marked fulness and pulsation. The skin of the face exhibits a higher temperature, and it is not rarely covered with sweat. The pupil is contracted-paralytic myosis. The palpebral fissure is narrowed and the eyeball is retracted; slight ptosis exists. The ocular conjunctiva is markedly injected, and hyperemia of the retina is visible in the fundus of the eye. Pressure upon the carotid artery not rarely mitigates the severity of the headache. The pulse is generally diminished in frequency. At the conclusion of the attack of pain the redness often is replaced by transitory pallor of the side of the face.

Sympathetic-spastic hemicrania is attended with pallor of one side of the face and smallness of the pulse in the corresponding carotid and temporal arteries. The affected half of the face is cooler. The pupil upon the same side appears dilated. Occasionally the secretion of saliva and of urine is increased, and the pulse is not rarely accelerated. Pressure upon the contracted carotid artery increases the unilateral headache, while pressure upon the carotid on the unaffected side affords relief. At the termination of the attack of pain increased fulness of the blood-vessels upon the affected side of the face generally takes place, and, in conformity therewith, increased redness of the face.

Ophthalmic hemicrania is characterized by the fact that the attacks of unilateral headache are preceded by scintillating scotomata, or these may appear only in the course of the attack. The appearances generally consist in bright zigzag figures suggestive of fortification-lines, whence the name fortification-seotomata. Often unilateral, but occasionally bilateral, hemianopsia and amblyopia also occur. At times other nervous symptoms are superadded, especially roaring and ringing in the ears, impairment of hearing, disorders of smell and taste, aphasia, agraphia, paraphasia, hemiparesis, hemiplegia, muscular spasm, hemianesthesia, hyper

esthesia, paresthesia, excitability, depression, and mental confusion. Ophthalmic hemicrania especially exhibits intimate relations to epilepsy, which it may precede, or follow, or at times replace.

The hemicranic equivalent consists in attacks of vertigo and vomiting, spots before the eyes, aphasia, hemianopsia, mania, or mental confusion, which may occur instead of a well-developed attack of hemicrania or may alternate with it.

Treatment. The treatment of hemicrania is governed by the principles that have been laid down on pp. 116 and 117 for the treatment of nervous headache.

VASOMOTOR NEUROSES OF THE EXTREMITIES.

Two varieties of vasomotor neuroses of the extremities are known, the spastic and the paralytic.

The spastic vasomotor neurosis of the extremities most commonly involves the fingers, the hands, and the arms, and occurs especially after prolonged exposure to cold. The condition is often encountered in washerwomen, so that it has been designated also vasomotor neurosis of washerwomen. The vascular spasm occurs paroxysmally, especially immediately after the action of cold. The patient experiences a sense of prickling, stinging, and formication -paresthesia-that frequently appears first in the tips of the fingers and then extends over the entire arm or only a portion thereof. The affected parts are pale and cyanotic, they feel cold, and the tactile sensibility of the overlying skin is lost in greater or lesser degree. Occasionally the skin is puffy. The muscles become stiff and weak, and the use of the arms is greatly impaired. The duration of an attack varies between seconds and minutes. The frequency of recurrence varies, as well as the duration of the entire disease. In some the disorder persists throughout life. Often but one arm is affected. If both upper extremities are involved, the symptoms frequently appear earlier and in more marked degree in one than in the other. At times an attack of vascular spasm is complicated by symptoms of stenocardia (vasomotor angina pectoris).

Spastic vasomotor neurosis of the extremities is a troublesome disorder, but unattended with danger, and it is best treated by abstinence from all work in cold water and in the cold generally, and by spirituous frictions of the skin, or by brushing, or application to the skin of the electric brush at the time of an attack.

In all probability related to spastic vasomotor neurosis of the extremities is the condition known as acroparesthesia, which is

attended with prickling, burning, and painful sensations in the fingers and the toes in the absence of signs of vascular spasm.

Paralytic vasomotor neurosis of the extremities is known also as erythromelalgia, and occurs most frequently in the toes. The patient complains paroxysmally of severe burning and stabbing pains in the toes, particularly in the ball of the great toe, and the skin over the painful parts is greatly reddened and feels warm. Occasionally cerebral disturbances are superadded, such as vertigo, a sensation of fear, headache, pain at the nucha, impairment of vision, and mental confusion. The symptoms are aggravated by heat, and therefore during the summer, as well as by the upright posture. The disease occurs principally in men between the twenty-fifth and the fortieth year of life, who are neurotic and have suffered from rheumatism, exposure to cold, or over-exertion. Many physicians refer the seat of the disease to the lateral horns of the spinal cord. In the treatment of the disorder immersion of the affected members in cold water, faradization, hydrotherapy, and residence in a uniformly mild climate have been recommended.

INTERMITTENT VASOMOTOR ARTICULAR NEUROSIS (INTERMITTENT DROPSY OF THE JOINTS).

Intermittent vasomotor articular neurosis is attended with paroxysmal swelling of several joints, most frequently the kneejoints, in the absence of demonstrable inflammatory alterations and of pain in the affected parts. Such attacks may recur at fairly regular intervals of from four to six weeks, and may persist for as long as a week. In some patients the disorder continues indefinitely, while in other cases it disappears in the course of a few months. The affection occasionally occurs in the course of exophthalmic goiter and vasomotor angina pectoris. At times it has developed in the sequence of malaria. Occasionally only the neurotic state is elicitable as a causative factor. Of remedial agents, iron, arsenic, quinin, and electricity have been employed.

INTERMITTENT ANGIONEUROTIC EDEMA.

Intermittent angioneurotic edema is attended with circumscribed edematous cutaneous swellings, which are pale, less commonly reddened, generally the seat of prickling and burning, and most frequently situated on the extremities close to the large joints, although they may occur upon the eyelids, the cheeks, and the lips. In addition to the cutaneous edema urticaria occasionally occurs. Articular enlargement also sometimes takes place. Not rarely certain mucous membranes are involved in the edematous swelling. Changes in the pharyngeal mucous membrane are attended with difficulty in deglutition, and in the laryngeal mucous

membrane with dyspnea, and this may occasionally attain dangerous intensity. The onset of the attacks is attended with gastric derangement, particularly vomiting of watery material, perhaps in consequence of edema of the gastric mucous membrane. Pulmonary edema also has been observed. Constipation is present at the time of the attack, and this often is followed by diarrhea with the termination of the attack. The urine occasionally contains albumin and blood. Bleeding from the gums and the bronchi also has been observed. The attack has often been preceded by exposure to cold. Some patients are never relieved of their disorder, while in other cases it disappears in the course of a few months. Danger may arise especially when the larynx is seriously involved. The disease is most common in men. The patients are often neurotic individuals. At times hereditary transmission has been observed. The disease has also occurred in the course of exophthalmic goiter. Exposure to cold, alcoholic excess, rheumatism, and auto-intoxication further are considered causative factors. The disorder has, for instance, been observed to develop after the ingestion of fish. In treatment nervines have been employed, and in the presence of marked swelling of the uvula scarification has been practised, and in the face of impending suffocation intubation or tracheotomy.

SYMMETRICAL GANGRENE.

Symmetrical gangrene is known also as Raynaud's disease, in honor of the physician who first described it. The disorder involves preferably the fingers and the toes, thus the peripheral portions of the body; but it occurs also upon the skin of the trunk and the face. The symmetrical distribution of the lesions upon the two sides of the body is noteworthy. The affected parts at once attract attention on account of their pallor, coldness, and numbness, in consequence of vascular spasm-so-called stage of купсоре. This is followed by the stage of asphyxia, which is attributable to blood-stasis. The extremities acquire a bluish and reddish, mottled appearance, vesicles form upon the skin, which becomes black and gangrenous, and some phalanges may be exfoliated. Not rarely ferer, enlargement of the spleen, and albuminuria are present. The disorder generally terminates in recovery. Occasionally repeated variations occur in its course. It may at times pursue an acute, at other times a chronic course. The disorder may be mistaken for ergot-poisoning (ergotism), frost-bite, embolism, and thrombosis of the arteries of the extremities, senile gangrene, leprosy, and syringomyelia; and attention should be directed especially to the history, to arteriosclerotic changes, to the presence of valvular disease of the heart, to the demonstration of leprosybacilli and of partial anesthesia. Little is known with regard to the causative factors. Occasionally the disorder has made the

impression of an independent infectious disease. At times it has occurred as a sequel of other infectious diseases. Auto-intoxication is probably operative in the development of the disorder in the course of diabetes mellitus. It has been observed also in cases of hysteria, after emotional disturbances and neuritis. Women are most commonly attacked by the disease. Massage, electricity, nervines, iron, and preparations of cinchona have been employed, and in addition surgical intervention may be required.

PERFORATING ULCER.

Perforating ulcer generally develops in the course of nervous disorders. At times it appears after injury or inflammation of peripheral nerves, at other times after diseases of the spinal cord, and at still other times after diseases of the brain. Most commonly the lesion is situated over the metatarsophalangeal joint of the great or the little toe, or over the heel. The epidermis at first becomes thickened, then becomes detached by serous or purulent fluid, and eventually drops off, while a generally round and sharply circumscribed ulcer remains, which appears as if cut out with a punch. The floor of the ulcer secretes but a small amount of thin secretion, and exhibits slight tendency to the formation of granulations and to cicatrization, so that occasionally the ulcer may persist for months. The destruction of tissue may extend to such a depth that joints are opened. In the vicinity of the ulcer cutaneous anesthesia often is present. Other trophic disturbances may readily occur in this situation, particularly abnormal growth of hair, desquamation of the epidermis, vesication, and the like. On microscopic examination of the skin endarteritic and neuritic alterations have been found. If the wound becomes the seat of septic infection, death may result from general septicemia. The treatment should therefore be directed essentially to the prevention of septic infection of the wound by the use of appropriate bandages. Occasionally the affected extremity has been amputated.

PROGRESSIVE FACIAL HEMIATROPHY.

Progressive unilateral atrophy of the face is a rare disorder, whose development is frequently preceded by prodromes, partienlarly pain and paresthesia on one side of the face, occasionally also vertigo and headache. The hair upon one side of the head also not rarely becomes light and gray, and falls out freely. The first appreciable changes consist in the formation of oral, whitish, or brownish cutaneous areas in the course of certain nerves, particularly the infraorbital nerve, upon one side of the face. Often