have spoken highly of the beneficial influence of a trip along the Nile. Courses of treatment with cold water also are not rarely attended with good results. Not much is to be expected from medicinal treatment. Nervines have been employed, among which the bromids, arsenic, valerian, and strychnin are to be preferred. Greatly emaciated individuals are frequently improved by a course of over-feeding. Electricity and courses of treatment at the springs are frequently badly borne by neurasthenic patients. Successful results are but rarely obtained from hypnosis and suggestion. Recently organotherapy has been employed. Improvement is reported to have resulted especially from injections of testicular fluid, spermin, and sheep's brain.

TRAUMATIC NEUROSES.

Etiology. The designation traumatic neuroses is applied to disturbances in nerve-function unattended with anatomic alterations in the nervous system, and resulting in the sequence of traumatism. The first cases were observed after railway-accidents, but a traumatic neurosis may just as readily develop after any other accident. At times the condition is attended with concussion of the entire body, while at other times only individual portions of the body are affected by the accident. Signs of external injury may be wholly wanting. It is noteworthy that not only physical, but also mental shock may be the cause for traumatic neuroses. Thus such a condition has been observed to develop in locomotive-engineers who have considered collisions between railway-trains unavoidable, but who have succeeded in averting them at the last moment. Often violent natural phenomena, such as an earthquake or a lightning-stroke in the vicinity, act as causes for traumatic neuroses. Traumatic neuroses are encountered with extreme frequency at the present time. In the first place, the extensive use of machinery in modern life is a most prolific source for causes of most varied kind; and, in addition, the laws relating to damages cause those interested to make special inquiry into the symptoms of the traumatic neuroses. There is, however, a certain justification for the statement with regard to accidentinsurance that traumatic neuroses are imaginary diseases, as they are said to occur but rarely in countries in which the injured person is not entitled to damages. Nevertheless, hallucinations play an important part in the development of traumatic neuroses, and, without doubt, mental infection may occur among the injured. The disorder occurs principally in adults and in men, who are more commonly exposed to the risk of accident than are children and women. The traumatic neuroses develop more readily in aleoholics and in syphilitic epileptics than in those previously healthy. Symptoms. The symptoms of a traumatic neurosis may

follow immediately upon an antecedent traumatism, or days, weeks, and even months of unimpaired health may elapse before nervous symptoms make their appearance. It is especially cases of the latter variety that often require a medico-legal opinion. Cerebral disorders are exceedingly frequent. Patients often complain of headache, a sense of pressure in the head, and vertigo, and these may be constantly present or appear paroxysmally. The patient readily becomes fatigued from mental exertion, and often exhibits apathy and indifference. Sleep is interfered with, and often disturbed by unpleasant dreams, and the memory becomes impaired. In some patients dementia and marked mental derangement develop. Some patients complain of peculiar sensations referred to the interior of the skull; as, for instance, that of a rolling or a dropping body. Also, severe pain at the vertex of the head is occasionally complained of, and this may resemble the hysterical clavus already described. Occasionally the patient suffers from states of fear, with especial frequency the fear of places-agoraphobia. The temperament almost always undergoes change. The patients become fearful, peevish, and capricious, are abnormally concerned about their condition, and are harassed with especial frequency by the fear of losing a suit for damages, or of the damages granted being too small. The patient is injuriously influenced especially by the circumstance that he may be considered ill by one physician and be declared a malingerer by another. Such patients often go from one physician to another, from one hospital to another, from one attorney to another, and become extremely contentious.

Spinal symptoms are manifested with especial frequency in abnormal sensations referred to the vertebral column. Impaired mobility and a sense of rigidity in the vertebral column, painful points on pressure, and a sense of burning in the situation of certain portions of the spinal column are frequently complained of, but a girdle-sense and a band-like feeling about the trunk also occur. Many patients complain of uncertainty in gait. They walk with the legs held far apart, swaying to and fro, and become readily fatigued. Tremor not rarely sets in, and this may be confined to but a single member or it may involve the entire body. Paralysis and contractures in monoplegic, paraplegic, and hemiplegic distribution have been observed. In the presence of hemiplegia the cerebral nerves, especially the facial and the hypoglossal, remain uninvolved. It is often noteworthy that numerous muscles on percussion and on exposure exhibit active fascicular twitching. The knee-jerks are frequently increased, although in rare instances they are wanting. Paresthesia in the lower extremities are often complained of. Hyperesthesia and anesthesia also occur in most varied distribution and extent.

The eye and the ear are not infrequently affected. The pupils

not rarely are unequal, and in exceptional instances the reaction to light-stimulation is wanting. Contraction of the visual fields, however, is of especial importance. The patient often complains of roaring and ringing in the ears, and occasionally there is unilateral or bilateral impairment of hearing. Some patients suffer from subjective or objective palpitation of the heart. Frequently the pulse becomes considerably accelerated on slight mental or physical exertion, or on pressure upon certain parts of the body. Asthmatoid states also occur occasionally. Some patients complain of vesical disorders, at times of retention of urine, at other times of incontinence. Occasionally hyperesthesia of the bladder is present, and is attended with increased frequency of micturition. Alimentary glycosuria has been observed in a number of instances; less commonly, diabetes mellitus. At times derangement in the functions of the generative organs occurs: excess or absence of seminal emissions or of sexual desire and impotence.

The duration of traumatic neuroses is susceptible of great variations. An especially favorable influence is often exerted by the awarding of pecuniary indemnity for an accident received, and some patients become thereafter perfectly well and capable of resuming their occupation. It is especially such occurrences that frequently cause judges and accident-insurance officials to consider all of the previous symptoms as malingering, a view that is often incorrect, for it may be asked why should not morbid mental processes disappear when the mind can continue to operate under more favorable conditions. Not a few victims of accidents have been accused of malingering, and have eventually wound up in hospitals for the insane. There can be no doubt that error in this connection has often been committed by the attending physician and by the judge, whose opinion is based upon that of the former.

Diagnosis. The diagnosis of traumatic neurosis is not rarely a most difficult problem. It is, in the first place, important to have a knowledge of a physical or a mental shock, and in this connection not so much is dependent upon the severity of the accident as upon the intensity of the mental impression. Without doubt there are persons who not rarely simulate the clinical picture of a traumatic neurosis, which they have learned from reports of accidents. It may also happen that they have been instructed in the methods for securing damages by patients who have been successful in attaining this result. It should not be overlooked that the victims of accidents are likely to exhibit a marked tendency to exaggerate their symptoms, and that under such circumstances it is difficult to distinguish the actual from the exaggerated. In forming a medico-legal opinion with regard to a traumatic neurosis it is of especial importance to demonstrate objective alterations, as, for instance, contraction of the visual field, tachycardia on pressure upon certain parts of the body or after slight physical exertion,

and the like. It has been maintained by some physicians, not without reason, that no such condition as the traumatic neuroses exists, but that all of the symptoms are manifestations of traumatic neurasthenia or hysteria, or of both diseases together; but it is, nevertheless, not without practical value to adhere to the conception of the traumatic neuroses.

Prognosis. The traumatic neuroses terminate fatally with comparative rarity, but they greatly impair the capacity of the patient for work, and occasionally they persist throughout the whole of life if the patient has entered suit for pecuniary damages or lives in poor circumstances. The prognosis must, therefore, be made with great reserve as regards complete recovery.

Treatment. The treatment must, above all, be psychic. Little can be accomplished with drugs, of which nervines, and especially bromids, may be employed. Removal from the scene of the accident and a sojourn amid new surroundings are often useful. Occasionally hypnosis and suggestion are helpful.

PART VI.

DISEASES OF THE MUSCLES.

PROGRESSIVE MYOPATHIC MUSCULAR ATROPHY.

Etiology. The motor-trophic ganglion-cells in the anterior horns of the spinal cord, the motor nerve-fibers arising from them, and the related muscular fibers represent a continuous, uninterrupted whole. Disease of the ganglion-cells of the anterior horns is responsible for the spinal progressive muscular atrophy previously described; disease of the peripheral motor nerves gives rise to neural progressive muscular atrophy; and, finally, atrophic processes of progressive character may result in consequence of disease of the muscles themselves. Cases of the last-named variety are included under the designation myopathic muscular atrophy, for which the name progressive muscular dystrophy also has been proposed. In contradistinction from spinal progressive muscular atrophy, myopathic muscular atrophy is a markedly hereditary and familial disorder, which may be found in some families, particularly among the males, through many generations.. This fact seems to indicate that the disease is frequently the result of a morbid predisposition residing in the muscles. Occasionally the disorder has been observed to develop in the sequence of antecedent infectious diseases. Exposure to cold and traumatism also are included among the causal factors. The disease occurs most commonly in males. It often begins in childhood, and generally before the twenty-fifth year of life.

Symptoms. Several types of myopathic progressive museular atrophy have been distinguished accordingly as the disorder has begun in one or another portion of the body, and has given rise to corresponding deformities. We shall confine ourselves to a description of three principal varieties, which may be designated pseudomuscular hypertrophy, juvenile and infantile muscular atrophy.

PSEUDOMUSCULAR HYPERTROPHY.

Some children present symptoms of pseudomuscular hypertrophy from birth, while in others the symptoms appear before