with edema, a peculiar mustiness of the breath, the presence of albumin and tube-casts in the urine, and the existence of degenerative changes in the retina. If obtainable, the previous history may determine the diagnosis.

Hysteria.

What are the symptoms of hysteria?

Hysteria is a disease of the nervous system, more common in females than in males, and in early adult life than at any other period. In many cases a neuropathic heredity can be traced. The manifestations of the disease may be induced by mental emotion, anxiety, visceral disease and other disease. As a rule, they are sudden in onset and as sudden in disappearance. They may be dissipated by a profound mental impression. The symptoms are protean; some are continuous, others paroxysmal. Among the former are derangements of sensibility and motility, visceral, vaso-motor and cerebral disturbances; the paroxysmal symptoms include convulsive seizures. That which fundamentally characterizes the disease is a loss of self-control, a deficiency of will-power, a heightened self-consciousness, a tendency to exaggeration and a morbid desire for sympathy. The patient is moved to laughter or tears with undue readiness and without adequate cause. Duplicity and deception are practised, and there is an irresistible tendency to imitation. Sensation may be lost or heightened, or otherwise abnormal, locally, or upon one-half of the body, or in irregular distribution, with unsteady station and gait when the eyes are closed. Spinal tenderness is common. There is frequently a recurrent sensation of obstruction in the throat, as of a ball rising from the stomach, or of a sense of pharyngeal constriction-the so-called globus hystericus. At times, there is a feeling of intense pain in the head, such as might be occasioned by the driving in of a nail--the clavus hystericus. The special senses may be variously impaired. Motor palsy of diverse distribution may exist, occasioning paraplegia, hemiplegia or monoplegia, unattended with muscular wasting or alteration in the elec-, tric reactions or impairment of activity of the sphincters.

The reflexes are usually unaltered; in a number of cases, they are exaggerated. There may be aphonia, loss of the power of articulation, retention of urine, constipation, stammering. Contractures may take place and give rise to troublesome deformity. Laryngeal spasm may occasion distressing dyspnea, or a peculiar barking cough. Independently of any spasm, there may be increased frequency of respiration, with shortness of breath. Spasm of the pharynx or of the esophagus may entail the rejection of all food ingested. There may in addition be such repugnance to food that little is taken. On the other hand, the appetite may be strangely, even disgustingly perverted. There may be local flushing and perspiration. In females, menstruation may be deranged; ovarian tenderness is common. The paroxysmal attacks of convulsions are marked by tonic and clonic spasm, without loss of consciousness or biting of the tongue. The arms and legs are wildly thrown about by coördinated muscular activity-purposive movement. The patient may shriek and bite the lips. Opisthotonos and trismus may be developed. At times, there are evidences of profound psychic disturbance, as manifested by hallucinations and delusions, perhaps of an erotic nature. Lethargy and catalepsy are sometimes observed. The temperature may display decided irregularity.

How are hysterical paralysis and the cerebral paralysis of organic origin to be differentiated?

The palsy of hysteria, hemiplegic, paraplegic, diplegic or monoplegic, is usually atypical.

The face is rarely involved. Sensory derangement is common. The evidences of secondary descending degeneration: contractures and exaggeration of reflexes, are wanting. There may be constipation and retention of urine, but not incontinence.

While the onset may have been sudden, it will not have been apoplectic. Other symptoms of hysteria may make the character of the palsy clear, but the mere existence of the symptoms of hysteria should not obscure the possible simultaneous existence of organic disease.

How are the convulsions of hysteria and those of epilepsy to be differentiated?

An epileptic paroxysm takes place without special excitation, and sets in abruptly, often with a cry; an hysterical attack may be brought on by emotion, sets in gradually, and is attended with screaming. The convulsions of epilepsy pursue a regular sequence, and are associated with cyanosis, biting of the tongue, and insensibility of the iris to light; in the hysterical attack, the members are wildly thrown about, the pupil responds to stimulation, while the patient may bite the lips or hands or other persons or things. Involuntary extrusion of urine and feces may take place in epilepsy; but does not occur in hysteria.

Loss of consciousness is complete in epilepsy; consciousness is retained or perverted in hysteria, the paroxysm of which is characterized by talkativeness.

The epileptic attack lasts but a few minutes; the hysterical, ten minutes or longer. Opisthotonos is common in hysteria, exceptional in epilepsy.

An epileptic seizure may occur at any time and under any circumstances; hysterical attacks take place only in the presence of a second person. The hysterical patient is careful in the paroxysm to suffer no injury; the epileptic falls, whatever the attendant dangers, powerless to avert them.

An hysterical patient may, however, also be epileptic.

What are the distinctions between spastic paraplegia and hysterical paraplegia ?

Spastic paraplegia develops at an age when hysteria is common; but in hysteria the reflexes are not exaggerated and the peculiar muscular spasm of lateral sclerosis does not occur, while sensory and emotional symptoms cannot escape observation.

How are acute myelitis and hysterical paraplegia to be differentiated?

Myelitis should not be overlooked because it occurs under circumstances amid which hysteria is to be expected. Exaggerated reflexes, trophic changes, wasting, derangement of sphincters and girdle-pain indicate the existence of more than hysteria.

How are the symptoms of hysteria and those of meningitis to be differentiated?

If symptoms of meningitis appear in an hysterical individual, their true significance may be overlooked. Convergent strabismus may be hysterical; but divergent strabismus always depends upon organic disease. There may be retention of urine in hysteria, but there is never incontinence. Trophic changes and continued elevation of temperature are evidences of the existence of something more than functional disease.

How are hysteria and cerebral tumor to be differentiated?

Hysteria may present any of the imitable symptoms of cerebral tumor, but in addition there will always be indubitable evidence of their nature. Optic neuritis or ptosis, of course, is not to be duplicated. Hysterical manifestations in association with cerebral symptoms should not be permitted to obscure the existence of organic disease.

Tetanus.

What are the symptoms of tetanus?

Tetanus is a spasmodic disorder dependent upon a specific infection contained in soil and introduced into the system through wounds or abrasions. It is manifested by painful rigidity of the head and jaw, soon progressing to trismus, and by stiffness of the tongue. In turn, the rigidity involves the muscles of the face (resulting in the risus sardonicus), the muscles of the trunk, the respiratory muscles and the diaphragm. To the tonic spasm of the muscles are added frequently recurring clonic exacerbations, which may be induced by external irritation.

The body may be arched in strong extension and supported only on the head and heels, constituting opisthotonos; it may be strongly arched forward (emprosthotonos), or laterally (pleurosthotonos), or it may be rigidly straight (orthotonos). The symptoms of tetanus set in at a variable period after inoculationfrom a few hours to several days. The duration of the disease likewise varies from a few days to several weeks. Recovery is

exceptional. Towards the close of life or even after death, the temperature may rise to an extraordinary height.

How are hysterical trismus and opisthotonos to be distinguished from tetanus?

Hysteria is an unruly disease, the symptoms of which are disorderly in appearance, while the symptoms of tetanus appear in fairly regular succession. Should trismus or opisthotonos develop as a manifestation of hysteria, it is likely to be associated with other symptoms of hysteria. The paroxysms remit and recur and do not go on to a fatal termination.

How is strychnine-poisoning to be distinguished from tetanus? Strychnine-poisoning gives rise to some of the manifestations of tetanus. If trismus develops in strychnine-poisoning, it does so late; in tetanus, it is one of the first symptoms.

The convulsions of strychnine-poisoning are intermittent, but may be induced by external irritation; those of tetanus are continuous, with paroxysmal exacerbations; inquiry into the history of the case may elicit important evidence.

How are hemorrhage into the spinal membranes and tetanus to be differentiated?

Meningeal hemorrhage is sudden, tetanus gradual, in onset. Pain is a more prominent symptom in hemorrhage than in tetanus. Trismus is wanting in hemorrhage; it is characteristic of tetanus. Spasm is constant in tetanus, with exacerbations; intermittent in meningeal hemorrhage.

How are acute spinal meningitis and tetanus to be differentiated?

Meningitis sets in abruptly with a chill, followed by elevation of temperature; tetanus is of gradual development, usually after an injury, and is at the outset unattended with elevation of temperature. Trismus is characteristic of tetanus, but exceptional in meningitis.

The convulsions of tetanus are excited by slight peripheral irritation; the muscular contractions of meningitis are induced by efforts at movement.

Tetanus is far more commonly fatal than is meningitis. Motor and sensory impairment are common sequelæ of meningitis.