recollected that the finer anatomy of the nervous system, as well as the physiology of the cord, was but little known in their time; that the electrical reactions of nerves and muscles were not clearly understood; that the stigmata of hysteria and the symptom-group of neurasthenia were still undeciphered. Unfortunately, there was a tendency to dignify all the morbid conditions following serious injury by such terms as "spinal concussion," "railway spine," "traumatic neurosis," and "Erichsen's disease," without any attempt to distinguish their real significance or differentiate among them.

It must be evident that after a railway injury, as after injuries occurring under any other circumstances, three classes of conditions may arise (1) All sorts of injuries of a surgical character; (2) traumatic hysteria; and (3) traumatic neurasthenia. Various combinations of these three may result, and they are commonly found in association. Surgical conditions and neurasthenia or hysteroneurasthenia may be present, or neurasthenia and hysteria may alone follow concussions, injuries, or frights attending accidents, especially upon the railways. It should be clearly recognized that the nervous disturbances marking neurasthenia and hysteria are likely to develop in proportion to the predisposing tendency in the individual, and also in proportion to the amount of mental shock attending the accident. In railway accidents the element of fright reaches its highest development, and consequently there is a preponderance of neurasthenia and hysteria, or their combinations, in persons the victims of such accidents.

In the consideration of a case in which physical conditions and nervous symptoms have originated from injury, it is necessary to look at it first as a surgical case, and secondly to consider it as a nervous case. Cranial fracture, cerebral hemorrhage, focal epilepsy, or traumatic insanity may follow injuries to the head. Dislocations and fractures of the spine, lacerations and hemorrhages of the cord, myelitis and meningitis, muscular strains, and ligamentous ruptures may follow blows and injuries to the back, either directly or indirectly applied. Concussion, if sufficiently severe, even without apparent local physical injury, may induce hemorrhages in the meninges or in the cerebrospinal apparatus. Accidents producing such injuries may at the same time so disturb the nervous equilibrium that neurasthenia is developed or hysteria is provoked. The neurasthenia of traumatism, or of fright associated with the possibilities of traumatism, is exactly the same as neurasthenia arising from any other source. Hysteria associated with traumatism, or conditions associated with traumatism, is exactly the same as hysteria occurring from other causes. The combinations of organic with nervous diseases of a character not yet associated with known organic changes must be deciphered on distinct lines. The surgical features have their own prognosis; the nervous disorders have their proper outlook, and they are not necessarily related.

Cases of this character may be considerably complicated by litigation. In exceptional instances there is dishonest and outright simulation. More frequently the anticipation of legal proceedings, the numerous special examinations, the suggestions arising from attorneys and phy

sicians, and the very natural tendency to exaggeration serve to highly accentuate the subjective side of the clinical picture. Corporations and their legal and medical officers usually look upon all such claimants as dishonest, and by their bearing, if not by their words, antagonize and aggravate the patients who come to take an almost morbid, spiteful pleasure in cultivating their aches and bodily and mental distress. They see damages in every symptom, and the hopeful expectation of physical recovery that is so potent for good is completely destroyed. It not infrequently results that, upon the completion of litigation and the cessation of irritation and introspection, prompt improvement takes place. From a medical standpoint, it is always better that an immediate settlement be made.

The profession should recognize that traumatic neurasthenia and traumatic hysteria are serious and disabling conditions. Every case must be specialized and the amount of disability and the probability of its duration must be estimated from all the facts.

CHAPTER X.
TICS.

Tic, Maladie des tics, Mimic Spasm, Habit Spasm.-Recent French writers, following Tourette, make a sharp distinction between a tic and other varieties of spasm. After them a tic is a spasm which is identical with movements of volitional intent and contains, therefore, a psychic element which may be subconscious. It is a psychoneurosis. In facial tic they call attention to the winking of the eye, exactly like that which excludes a flying particle of dirt; to the movements about the mouth and nose, analogous with those produced by sensations of taste or smell, and to the occasional functional association with these of swallowing efforts, laryngeal motions, the production of sucking or smacking sounds, of grunting, and sometimes of articulate words, usually of an indecent character (coprolalia). A facial appearance that is expressive of some emotion, as of grief, pain, fright, or joy, may be repeated by the tic. Some cases, becoming more wide-spread, involve the neck and upper extremity so that attitudes and gestures are produced in conformity with the underlying mental idea. These facial tics, of which blepharospasm is a type and coprolalia the extreme development, are more or less under the control of the patient, who can, by an effort of will, do considerable to repress them. After such repression "tiquers" are likely to feel more or less vague discomfort and often yield to a regular spasmodic debauch, which seems to give them a feeling of relief. During sleep this spasm completely subsides. Such patients frequently present a most marked neurotic heredity, and sometimes other neuroses,

as writers' cramp and hysteria, or mental and moral obliquities are present.

Ordinarily, the facial tic is lightning-like in quickness, and is repeated with the greatest rapidity from two to scores of times, when a lull occurs for a few minutes, or perhaps an hour of quietude may intervene. Any excitement or embarrassment promptly recalls and intensifies the morbid motions. The spasm has a tendency to invade neighboring muscles of associated function, and frequently becomes bilateral, but is seldom symmetrical. While, ordinarily, the spasms are purely clonic, they may, in a part or the whole of their distribution in long-standing cases, present tonic features of greater or less duration. In some instances the eyelids are so firmly closed that the pressure upon the eyeball is painful. Rigidity in the lips is complained of at times as a feeling of stiffness, and the action of the zygomatics and buccinator may keep the angle of the mouth persistently retracted and elevated. The neck may be rigidly held in a given position.

Etiology. Youth is the preferred age for the development of ties, but adult life is not spared. An appreciation of the mental substratum of tics enables one to comprehend something of their genesis and intractability. There is no doubt that many cases of blepharospasm originate in some irritation of the ocular apparatus that forces the attention of the patient into a groove leading to a mental and motor habit. These ties have for long been well called habit spasms. The term habit chorea, also applied to them, is misleading, though they may be grafted upon a chorea as a sequel by suggestion. In the same way a protracted grief, chagrin, or ecstatic pleasure may, in one neurotically predisposed, furnish the subconscious factor for an expressional tic, which reproduces exactly the facies of the underlying idea, made grotesque by its unilateral distribution. The thread can sometimes be followed by covering the sound side of the face and trying to interpret the emotion expressed by the tic. Sniffing, swallowing, and phonation are merely the manifestations of functional association, and coprolalia is but the vocalization of the imperative concept that may be otherwise subconscious. A facial spasm is sometimes associated with neuralgia of the fifth nerve, and bears the distinctive and classical name of tic douloureux, but a tie in the limited sense is not painful.

Varieties. Aside from the habit movements of idiocy and dementia, which constitute reversionary or degenerate tics, we may enumerate blepharospasm, facial spasm, spasmodic torticollis, mental torticollis, the latah of India, the myriachit of Siberia, the jumpers of New England and Canada.1

In mental torticollis 2 some deviation of the head is customary and is spasmodically maintained. Ordinarily, it ceases when the patient lies down or it can be controlled by a slight amount of manual pressure upon the head or face.

Jumpers and the subjects of latah and myriachit execute any one of

1 Jos. Collins, "Med. News," Dec. 11, 1897.

2 Bompairs, "Thèse de Paris," 1894, and Brissaud, "Leçons," 1895.

several commands or suggestions impulsively, often violently, and frequently against their apparent will. Thus, upon command, they may strike, jump, or unclothe themselves.

Treatment. In all cases of facial tic, after general measures, we are to look for and correct any peripheral irritation that can be associated with the seventh nerve. This is particularly the case in the distribution of the sensory portion of the fifth, but irritation arising even at a distance, as in the intestines or pelvis, may maintain the tic, and when corrected the tie may subside. Pressure upon certain points in the distribution of the fifth, first described by Graefe, often checks the tic. The most usual one is at the supraorbital notch. In a general way they correspond to the tender points of Valleix and the maxima of Head. We should always and repeatedly search for them carefully, going over the neck, shoulders, and upper chest, as they are sometimes distantly located. By exerting pressure upon such a part, the tie seems to be reflexly inhibited, and the habit is arrested, at least temporarily. By repeating the arrest frequently and for long periods, the habit may be fully broken. In the same way the use of faradic electricity will occasionally render service. For this purpose the muscles engaged in the tic should be thrown into powerful tonic contractions for a number of minutes, from five to fifteen. One pole taken in the hand and the other placed over the stylomastoid foramen, or on the particular facial branch indicated, makes a suitable arrangement. The patient may advisably keep a battery at hand and use it as often as the tic becomes marked. It for the time being teaches the muscle a steady contraction and perhaps favorably affects the mental state by the peripherally induced suggestion. At any rate such application is often followed by temporary marked relief, and, in fortunate cases, by practical cure.

Finally, nerve-stretching may be employed. If thoroughly done, it induces paralysis for a longer or shorter time, but, unfortunately, a restoration of motor function usually is marked by the reappearance of the tic, for which the irritation in the healing nerve-trunk may be responsible. A tendency to relapse in these cases is marked. The deeper the mental tare and the more pronounced the neurotic background, the less are they manageable. It is not impossible that suggestion, by reaching the subconscious element, may sometimes yield favorable results.

In mental torticollis, Feindal has reported good results by massage and exercises, the purpose of which was to build up the patient's selfcontrol and mental stamina. With these he associated encouragement (suggestion) and general tonic measures. It is only by attacking the mental element, the obsession, that the psychoneurosis can be managed.

"Nouv. Icon. de la Salpêt.," Dec., 1897.

PART VIII.

SYMPTOMATIC DISORDERS.

THERE are a number of symptomatic disorders very commonly met with in nervous maladies and essentially nervous in character that nearly reach the dignity of diseases. Headache, vertigo, insomnia, and neuralgia are the most important. Headache and vertigo have been specifically emphasized whenever they had a special relation to diseases of the nervous apparatus, and can be easily followed from the index. Neuralgia and sleep disorders require further study.

CHAPTER I.

NEURALGIA.

NEURALGIA (nerve pain) is always a symptom. Difficulty arises from the fact that intense neuralgic affections have often been confused with their most prominent painful symptoms. Neuritis and neuralgia have been differentiated only in recent years. Even now there are many who fail to discriminate between trifacial, brachial, and sciatic neuritides, and neuralgias of similar location. It also appears proven that an irritation at first producing neuralgia may, by its persistence, set up a neuritis, and it is certainly clear that neuralgia is one of the symptoms of neuritis. The distinction, therefore, is not always easy. Neuralgia may be an expression of disturbance acting (1) locally, or (2) systemically, or (3) in both ways at once. Neuralgias may be visceral or peripheral, and many visceral diseases have their corresponding peripheral or somatic neuralgias. In this relation the reader is referred to the section on Pain and the Referred Pains of Visceral Disorders as outlined by Head (p. 55, et seq). Many neuralgias-such as angina pectoris in cardiac disease, intercostal neuralgia in gastrohepatic disease, testicular neuralgia in kidney disease, pleurodynia, gastrodynia, and coccygodynia -are very clearly symptomatic and secondary. There are certain condi