muscle, which is conspicuous for its prominence. In the second variety of wry-neck, the muscles involved, most commonly the sterno-mastoid, the trapezius and the splenius, are in a state of active contraction, tonic or clonic, or alternately both. As a result, the head may be rotated or inclined to one side or retracted in over-extension, in accordance with the muscle or combination of muscles that participates in the spasm. Not infrequently, with the spasm of the muscles of the neck is also associated spasm of muscles of the arm or of the face.

Occupation-Neuroses.

What are the occupation-neuroses?

As the result of persistent and long-continued movement of a part in a constrained position, involving the activity of certain groups of muscles, spasmodic interference with the performance of the same movement may develop.

Thus, as a type of the disease, there is produced writers' cramp or scriveners' palsy. An analogous condition may be produced in telegraphers, shoemakers, piano-players, violinists, zither-players, seamstresses, smiths, painters, turners, watchmakers, knitters, engravers, masons, compositors, cigarettemakers, milkers, money-counters.

Writers' Cramp.

What are the symptoms of writers' cramp?

In those who write much, especially in such a way that the burden of the work falls upon the small muscles concerned, there sometimes develops a condition that renders writing impossible. Under such circumstances, as soon as an attempt to write is made, the fingers contract in spasm that may be painful, so that the act, if possible, is imperfectly accomplished. At other times, there may be tremor, and rarely weakness. In some cases, neuralgic pain is the most conspicuous symptom. In aggravated cases, the manifestations are not confined to the

FIG. 52.

Mode of holding the pen favorable to the development. of writers' cramp. (Gowers.)

Mode of holding the pen when writing becomes difficult. (Gowers.)

act of writing, but may appear upon attempts to perform other movements. The onset of the symptoms is usually gradual, but occasionally it is sudden.

Chorea.

What are the etiologic elements concerned in the determination of an attack of chorea?

Chorea is most common at or about the age of puberty, and more so in girls than in boys. At Philadelphia, attacks are said to be more common in the spring of the year than at any other time. It has been observed that chorea is more common in white than in colored children. In many cases, an hereditary influence can be traced-directly, as chorea, or, more commonly, in the nature of other diseases of the nervous system, as epilepsy or insanity, or of rheumatism. Fright is frequently an exciting cause of the disease. Occasionally traumatism has preceded an attack. An obscure but well-determined causal relation exists between acute rheumatism, heart-disease and pregnancy, on the one hand, and chorea on the other.

What are the symptoms of chorea?

Chorea is a spasmodic neurosis, manifested by irregular, involuntary, incoördinated muscular movements, aggravated by excitement or observation. The movements cease during sleep, but they may be sufficiently violent to prevent sleep.

They are often more decided on one side of the body than on the other. Speech is often interfered with. A slight degree of muscular weakness exists. The electric irritability is usually increased; sometimes there are slight qualitative changes. Occasionally pain is felt in the parts affected. The temperature is, as a rule, slightly elevated. There is mental irritability or dulness of intellect. Anemia is often present.

At times, hemic heart-murmurs are heard; at other times, murmurs dependent upon organic disease, either antecedent or coincident, are heard; endocarditis is not an uncommon complication of chorea.

Chorea is a self-limited affection, the average duration of which is about ten weeks. It is said sometimes to involve the diaphragm, and to give rise to obstinate hiccough. It is thought that the irregularity of the action of the heart, sometimes observed in choreic children, is dependent upon involvement of the cardiac muscle; chorea of the larynx has also been seen.

So-called choreoid movement, athetosis, and mobile spasm, are often observed in cases of paralysis of cerebral origin.

What is hereditary chorea or Huntingdon's chorea?

Chorea sometimes appears in families, developing at the middle period of life, and possibly continuing until death, in hastening which it may play some part. The symptoms differ in no essential particular from those of the ordinary form of chorea.

Epilepsy.

What is the etiology of epilepsy?

Epilepsy is immediately dependent upon an irritable condition of the nervous system that must be referred to changes in the nerve-cells, beyond our present means of recognition. The disease is more common in females than in males. In a considerable proportion, a neurotic heredity can be traced. In many cases, no etiologic factor can be determined. The first attack usually occurs in early life, frequently in conjunction with dentition, or in association with rachitis. In other cases, it may be excited by mental influences, especially anxiety, by fails

or blows, by acute disease, by the presence of parasites in the intestine, by menstrual derangement, by nasal polypi, by phimosis, by cicatrices, and by other sources of peripheral irritation.

When no source of irritation, direct or reflex, can be found, the disease is designated essential or idiopathic.

What are the symptoms of epilepsy?

Epilepsy is a paroxysmal neurosis, characterized by attacks of varying frequency, duration and severity, which may appear as transient loss of consciousness (petit mal, minor epilepsy) or may be preceded by a premonitory sensation or aura, followed successively by a cry, loss of consciousness, frothing at the mouth, tonic followed by clonic convulsions, headache, biting of the tongue and somnolence (grand mal, major epilepsy).

The attacks of petit mal may be so inconspicuous as to escape observation. There may be simply a vertiginous or other abnormal sensation, or an abrupt interruption in speech ; or the grasp of an object held in the hand may be relaxed; or there may be a twitching of the muscles of the face.

When the seizure is preceded by an aura, this may be motor, sensory, visceral or psychic. In the attack the face becomes at first pallid, then flushed, and finally cyanotic; the pupil is dilated and insensible to light; urine and feces may be expelled involuntarily. The urine may contain a trace of albumin.

Mental deterioration ensues in a degree corresponding to the frequency of the attacks. Paroxysms may be succeeded by transient hemiplegia and aphasia, by the automatic performance of some act or by mania.

Sometimes a series of convulsions occurs, one attack scarcely ceasing before another begins, constituting the status epilepticus. Nothing is known of the pathologic anatomy of epilepsy. How are the epileptiform convulsions of cerebral disease to be distinguished from attacks of true epilepsy?

Epileptiform convulsions usually result from lesions involving the cortex cerebri. The most common of these lesions are softening from vascular occlusion, hemorrhage and newgrowths. The convulsions occasioned are likely to be local in

character and not at the onset attended with loss of consciousness; while the convulsions of epilepsy are usually general and simultaneous with loss of consciousness. In the intervals between epileptiform convulsions, some evidences of cerebral disease-hemiplegia, athetoid movements, choked discs-are likely to be present.

What are the distinctions between chorea and epilepsy?

Epilepsy occurs in paroxysms with intermissions, and may persist during the greater part of life; chorea is but a temporary, self-limited condition, the symptoms of which are constant during the continuance of the disease. The movements of chorea do not possess the violence of the convulsions of epilepsy; nor in chorea is consciousness lost or the tongue bitten. How are the attacks of syncope and those of petit mal to be differentiated?

Syncope occurs under well-known circumstances that occasion temporary cerebral anemia; the pulse at the wrist is almost obliterated; loss of consciousness is of brief duration; the return to the normal condition takes place slowly. In case of petit mal, there have been previous attacks of a similar character or perhaps of major epilepsy; the loss of consciousness is sudden and transitory; the normal condition is soon resumed; there may have been slight muscular twitchings; or urine may have been passed involuntarily; or some automatic action is performed. How is eclampsia to be distinguished from epilepsy?

By eclampsia is meant convulsions occurring incidentally and temporarily, as during dentition, or in connection with pregnancy and parturition. The relation of eclampsia to epilepsy and epileptiform convulsions is uncertain. The recognition of eclampsia and its distinction from epilepsy and epileptiform convulsions depend upon its incidental and transient occurrence in connection with one of the conditions that give rise to it. How are the convulsions of uremia and those of epilepsy to be differentiated?

The convulsions of uremia are not unlike those of epilepsy. Their significance, however, depends upon their association