panion often works wonders. As a rule, the more outdoor air and recreation that does not entail effort, the better, but to put a neurasthenic on a bicycle or on long walks adds fuel to the flames. A carefully selected, nourishing, fattening, unstimulating diet is of considerable importance. If the scales show a gain of a few pounds, success is assured. Men, unless practically bedridden, do not respond favorably to the Mitchell rest-treatment. The enforced idleness and confinement to bed is rarely tolerated by them if they can possibly be about.

In the severe female cases, and sometimes in young males or completely prostrated men, we must have recourse to the full rest plan laid down by Mitchell. The details of this are furnished in all modern works on therapeutics and need not be repeated here. By this plan expenditure of energy is reduced to a minimum, strength is conserved and increased by the massage and electricity, and flesh is rapidly made by the constant feeding. There are several essentials in carrying out this procedure, and their neglect means failure nearly every time. The first is isolation from relatives and friends, and the establishment of an entirely new and hopeful atmosphere. In some instances the slightest infraction of this rule causes immediate relapse. Equally important is it to have an experienced and tactful nurse.

Any amount of general hospital training does not make a good nurse for this class of patients or furnish the endless tact and self-repression needed to manage them. It is difficult to induce nurses, accustomed to grave operative cases and severe physical illness, to appreciate that the endless complaints and fault-findings of neurasthenic patients are symptomatic of their state and not merely petulant crankiness. It is also very important that the treatment take place in a suitable location, free from disturbing noises. The room and immediate surroundings of the patient must be bright and cheerful. If isolation with a suitable nurse, preferably one able to give massage, can be had, the other details of treatment are less important. The absolute milk diet does well in some cases, and is indispensable in a few at the beginning, but if food is digested it is immaterial what the patient cats so long as it is nourishing, abundant, and administered at frequent intervals. Sleep, usually disturbed, under the massage and forced feeding soon becomes sound and prolonged. Hot milk, an alcohol rub, or a glass of beer at bedtime is commonly a sufficient hypnotic.

No scheme of treatment in neurasthenia is complete that ignores the mental element of the disorder. These patients are frequently impressionable, and particularly so as regards their own health and prospects. Their fears can not be laughed to scorn. They should be carefully estimated, fully explained, and then dismissed. It is not advisable to allow these patients to reiterate their complaints to the physician and the nurse, and the family must be instructed to refuse to hear or discuss them with the patient. Encouraging suggestions and hopeful assurances constantly repeated have the force of hypnotic suggestion, and a very real therapeutic value. For this reason the physician must usually see his patient frequently. In this way the daily use of static electricity, hypodermic injections of strychnin or water, or any other objective ex

cuse, impresses the patient and permits and emphasizes the repeated encouraging suggestions.

Thus far nothing has been said about drugs, and there is very little to say. Iron and arsenic against the anemia, trional and bromid for the insomnia, laxatives for constipation, may be given. Strychnin in large doses, or bromids and sedatives in large doses, are ill-advised and commonly harmful. The indications are to rest and to nourish, not to stimulate or to depress. Hydrotherapeutics, especially if carried on at a distance from home, yield good results in mild cases. It may be said that the treatment of neurasthenia requires judgment, tact, perseverance, and personal force of the highest order. When the neurosis is secondary to organic processes, its treatment is similarly second in order.

CHAPTER VI.
HYSTERIA.

HYSTERIA has been a problem since the earliest days of human thought. It was often at the bottom of the demoniacal "possessions" of the middle ages, and furnished some of the martyrs of witchcraft and religious fanaticism. Affecting whole communities, it caused epidemics, allayed by appeals to St. Guy, St. Vitus, or other tutelary. It has been seen in the excited religious gatherings of all countries. It was long supposed to be an attribute of the female sex alone, and was traced to vapors or other influences arising from the womb; hence the name hysteria. Only in recent years have the endemic and epidemic forms been recognized, and the male found to share with the female in the liability to the psychoneurosis. For many years the mental element in hysteria has been at least partially recognized. Moebius used the definition, "A state in which ideas control the body and produce morbid changes in its functions." So far as the paralyses and contractures are concerned, English writers have described them as "depending upon idea." The studies of Charcot and his students have placed hysteria upon a firm clinical basis, and enabled nearly all of its manifestations to be traced to disturbances in the psychic sphere or in its substrata. Janet says: "Hysteria belongs to a group of mental diseases of cerebral insufficiency; it is especially characterized by moral symptoms; the principal one is a weakening of the faculty of psychological synthesis." "It results," adds Dutil, "that a certain number of elementary phenomena, sensations, and images are not preserved, and appear to be repressed in the realm of consciousness." In addition, there are a number of organic phenomena-disturbances of nutrition, trophic and vasomotor disorders of a neurotic character. Hence, we may class hysteria as a psychoneurosis.

Etiology.-Hysteria in slight or severe form is one of the most common of nervous diseases. The age of puberty and the years of adolescence immediately following furnish the majority of cases. After twenty-five the frequency of hysteria declines and it becomes rare after forty-five. Before ten it is also uncommon, but children may develop it in very marked form even as early as two or three years of age. Formerly considered almost exclusively limited to the female sex, later statistics go to show that males and females are affected with hysteria in nearly equal ratio. According to Marie, in the lower social levels males predominate; in the wealthier classes females are more commonly affected. Hysteria is a disease of all countries and all races, but the Latin, Slav, and Israelite may be considered as particularly liable. Heredity plays an important part. Hysterics usually, belong to neuropathic families. Hysteria in the mother is very frequently followed by hysteria in the daughter. More commonly, however, the transmission is by transformation from, or to, other neuroses and psychoses. A history of arthritism or phthisis in the antecedents of hysterics plays the same part as in other manifestations of degeneracy.

Inciting Causes.-Emotional disturbance of any sort may initiate hysteria. Fright, grief, worry, chagrin, and every sort of mental and moral strain and shock are the common starting-points of this multiform disease. Traumatism furnishes a large quota of hysterics, especially of the male sex, owing to their greater liability to such accidents. In all such circumstances, unless consciousness be abolished instantly without preceding anxiety or fright, the attending psychic states must be taken into consideration. As a practical fact, the likelihood of hysteria following trauma is in direct proportion to the suddenness and intensity of the mental shock. The physical injury may be insignificant. Lightning-stroke, surgical wounds, and internal conditions, such as gastric ulcers, nephritic and hepatic colics, may act as causes.

Intoxication by lead, mercury, sulphid of carbon, oxid of carbon, tobacco, morphin, cocain, and chronic alcoholism, or even a single alcoholic debauch, may induce hysteria. In many such cases these intoxications furnish a basis on which hysteria develops by the incidental action of some other provocation. Infectious diseases, such as typhoid, diphtheria, influenza, pneumonia, scarlatina, malaria, and syphilis, may provoke hysteria. It may occur in cachectic states due to chlorosis, diabetes, phthisis, and cancer. It is found as an associate of all organic diseases of the brain and spinal cord, frequently appearing in tabes, syringomyelia, and insular sclerosis. Either mental or physical overwork may cause it. Wherever people of suitable age are domiciled together, hysteria may become endemic through the force of imitation and suggestion arising from an initial case of hysteria or some physical disease. Schools, prisons, barracks, and large families may thus become affected. Usually in such instances there is a great similarity among the cases. In this country, under the prolonged excitement and fervor of protracted religious meetings in rural districts, endemics of hysterical spasms and even of dancing, in all respects similar to the medieval epidemic dance of St. Vitus, have developed. Hysterical patients in

hospitals may closely mimic all the symptoms and physical disabilities of other patients with whom they are kept in contact. In other cases they reproduce the manifestations of some disease with which, in their past experience, they have been incidentally made familiar.

Symptoms. The innumerable symptoms of hysteria, to follow the plan of the French writers, may be divided into two major groups: those which are essentially persistent, the stigmata; and those which occur incidentally, are intermittent or transitory, the accidents of hysteria. The stigmata are not necessarily present singly or in combination, but, once developed, tend to persist so long as the affection lasts. The accidents present the greatest diversity in different patients, but usually, if they occur repeatedly, tend to uniformity in a given case. Further, some hysterical accidents, as paralyses or contractures, may be of long duration, and, once thoroughly established, have the force of stigmata.

STIGMATA OF HYSTERIA.

The stigmata of hysteria are sensory, motor, and psychic.

Sensory Stigmata.-In hysteria the sensory disorders are (1) of the negative variety,-anesthesias; and (2) of the positive sort,-hyperesthesias. They are usually both represented in a given case, but the anesthesias are the more important symptomatically.

Hysterical anesthesia may affect sensation in all its modes and tenses, including the special senses. The general cutaneous sensibility may be disaggregated so that only certain elements persist and a limited group of stimuli alone serve to arouse the sensorium, as in a thermoanalgesia that parallels the sensory dissociation of syringomyelia. The diminution of sensibility may be partial or complete, and often varies in the same patient within a very short time. Various degrees of anesthesia may likewise be found in different regions, and the anesthetic area represents remarkable variations of extent and distribution in different. cases, and also in the same case at different times. Some form and degree of anesthesia is rarely lacking in hysteria that has existed any length of time, and often it is developed very early. It is obligatory to persistently search for it in every instance, but care must be exercised not to induce it by suggestion. As a rule, hysterics are themselves ignorant of their sensory deficiencies. The anesthesia may be (1) superficial, affecting mainly the skin and mucous tissues, or (2) it may involve the deeper structures.

Cutaneous anesthesia may be absolute. Pricking, pinching, hot and cold bodies, produce no response. Some patients are merely analgesic, and this is the common defect. Less frequently there may be thermoanesthesia or thermo-analgesia, and, most rarely of all, tactile sensations alone may be wanting. Very exceptionally the hysterical patient feels the faradic current in the anesthetic area or presents an area insensitive to this stimulus alone. Complete anesthesia, hypesthesia, and analgesia are the commonly encountered forms. The mucous membrane within the

range of examination may show the same anesthetic modifications of sensibility. The buccal, pharyngeal, laryngeal, nasal, conjunctival, anal, urethral, and vaginal surfaces may be entirely insensitive or present dissociation of sensation.

The deeper parts are frequently anesthetic. Bones, muscles, ligaments, and nerve-trunks may sometimes be pierced, twisted, wrenched, and contused without giving rise to distress or even provoking a localized sensation of any sort. The muscular sense for a limb may be abolished so that with bandaged eyes the patient has no knowledge of its position, can not estimate weights, recognize pressure, or feel fatigue.

The Special Senses.-Taste and smell may be perverted, diminished, or abolished. Certain sapid articles may fail to arouse the sense of taste, while others are still detected. The loss of taste is usually limited to a portion of the tongue and mouth. Hearing is often greatly diminished, but complete hysterical deafness is very uncommon. Rinne's test (see p. 63) shows the disturbance to be central.

In hysteria vision is very frequently modified, and some of the changes in this special sense are of the utmost importance for diagnosis. Complete blindness is very rare, usually of abrupt onset, a few days' duration, and sudden recovery, but vision is often reduced in one eye to counting fingers or less. Of greater frequency and of more importance are the lesser and commonly persistent defects. These consist of: (1) A reduction of the field; (2) troubles of color perception, and (3) errors of accommodation.

Contraction of the Visual Field.-In the great majority of hysterics the visual field is concentrically contracted. This is usually found bilaterally, but commonly more on one side than the other, and sometimes only on one side. The defect, as in that of all the special senses, when unilateral or most marked on one side, usually corresponds to a unilateral distribution of disturbed cutaneous sensibility, but the opposite situation may be encountered. In total amblyopia the contraction of the field reduces it to zero. In a given case the retraction of the field