spasms, convulsions and paralysis are quite common; they have appeared only in a single case among my many patients. The muscular debility may be excessive, and compel the patient to go to bed; I have known a case, where a man after he had improved a great deal, tried to split some kindling wood, but could not accomplish it, on account of his weakness; he was taken with a feeling of collapse, violent trembling and had a regular crying spell; this man had been accustomed to hard work from his childhood, and had before his sickness always been very industrious. The backache which in my cases was quite a common symptom finds its probable explanation in the inability of the spinal muscles, especially the erector spinal, which always is subject to a certain strain in holding the body erect; this symptom is very common in anæmic persons, for instance chlorotic girls, whose backache depends upon the defective nutrition of those muscles, and disappears when they under appropriate treatment are nourished by richer and better blood; neither in neurasthenia nor in chlorosis is this a reflex symptom from the pelvic organs, but simply an exaggerated weariness.

We should in neurasthenia-debility of the nerves -expect the most prominent symptoms in the nervous system, and this is also the case. A vague feeling of something wrong is usually present; it frequently finds its expression in fear, which may have no peculiar object, may be only a fear that something is wrong, or that something will happen; some of my patients have mentioned an aversion to go out amongst people, others have been afraid of being alone. Allied to this feeling is a dissatisfaction with everything but especially with themselves, somewhat allied to a bad conscience, not on account of any particular sin or fault, but as a general feeling of unworthiness.

The sleep is often disturbed, usually not giving the sensation of rest, which it does in health, so that the patient often may be led to the false conclusion that he has not slept, although he may have done so. One of my patients mentioned a peculiar profound sleep, alternating with insomnia, but without the refreshing feeling that he used to have. In the daytime the patients have suffered from peculiar sensations in every part of the body, not exactly pains, but indescribable sensations of an unpleasant nature, which change their localities, especially under treatment; as the patients say, the medicines drive the pains from one place to another.

But the pains may also be fixed and have the same seat for years without any assignable cause. Flying sensations of a burning character are very common in the extremities, and the patients are often surprised that the doctor can find nothing wrong with their arms and hands, where they often imagine that they see discolorations, swellings, etc. Sometimes they describe these sensations by saying that they feel that their blood is diseased, because they feel the vessels burn and prick in different parts.

Subject to all these mysterious sufferings it is not to be wondered at, that the patients are depressed in mind, they think of little else than their diseased condition, and take great interest in their cases. They resent with scorn the idea that their cases are of quite common occurrence, it seems to wound their egotistical appreciation of themselves, if the physician makes the remark that he is familiar with a number of similar cases and thus denies them the distinction of pathological curiosities.

The duration of the disease is quite long, it is counted by years rather than by months and complete restoration to the previous vigor is certainly very rare. Even if they get apparently well, the tendency to relapse shows that the nervous system has not completely recovered. But some cases have recovered so far that they became useful members of society, and enjoyed life fairly well.

ETIOLOGY. Of the 98 recorded cases 58 were males, 40 females. But this I think does not fairly represent the proportion between the sexes. I have more male, than female patients, and I have excluded from my list many females, who suffered from palpable uterine or other pelvic disease, as I wished only to include cases without complications.

In only 20 of my cases could I prove a family disposition to nervous disease; but I am confident that this represents a far too small per centage. In view of the difficulty of getting patients to admit that they spring from a defective race, and in view of their ignorance in these matters I think that we should make a very liberal addition to these 20 per cent.

Amongst causes which the patients have given I will first mention over-work, in 25 cases. It has not usually been the daily habit of working very hard, but the special excessive work on some one particular occasion. For instance, efforts to fight a prairie fire, to save crops from impending rain, to walk great distances against a

snow storm, etc. In 13 additional cases the effect of heat is mentioned, either as sunstroke during heavy work or as a simple heat prostration; if I add five more cases of mental over-work, we find that not less than 43 of the 68 cases refer their illness to excessive work. In the five cases of mental over-work, there was, at least in four, reason to suspect that there had been defective nutrition caused by insufficient and improper food.

In 18 cases exhaustion by disease or otherwise is given as the cause; it has been loss of blood, severe acute diseases, prolonged nursing and rapidly repeated childbirths with occasional miscarriage. In 17 cases severe mental shock is given as the starting point; it has been sudden loss of near relations, fires, frights, etc. There was in six cases a history of exposure to cold; in four of abuse of liquor and tobacco; in three of sexual abuse and excess; in three of prolonged deprivation of sleep,

In many cases several of these causes have probably acted together; in not a few cases, no cause could be found. In several cases a too early return to laborious habits was a cause of relapse after comparative cure.

DIAGNOSIS. I have frequently made the mistake of diagnosticating cases of neurasthenia as simple dyspepsia; amongst diseases which might be confounded with it I shall mention locomotor ataxia, hemicrania, chlorosis, organic disease of heart and lungs in their incipiency, albuminuria, uterine disease.

TREATMENT. I must admit the unsatisfactory condition of my therapeutics in this disease. My plan of treatment has been to improve the general health by means of tonics, strychnine, iron, glycerine, mineral acids, cod-liver oil, etc. When I have tried the nervines, arsenic, zinc, silver, bromides, etc., I have usually been disappointed. In some cases I have seen benefit from mild galvanic currents, usually labile desending currents along spine; the negative electrode being passed over the seat of pain or abnormal sensation. Galvanism of the pneumogastric has occasionally been beneficial in palpitations. But the success has by no means been very common, it has been the exception. Massage has also occasionally been useful, more as an adjuvant to a generally improved hygienic regimen, than as an exclusive medication. Where the circulation has been poor (and that has been the rule), I have thought that I derived benefit from baths followed by cold douches and vigorous rubbing:

a good remedy against cold feet I have found in cold ablutions with frictions, followed by inunction with oil or lard, frequent change of stockings and as much bodily exercise, as the patient's exhausted condition would allow. A remedy which was used with great expectations, but followed by frequent disappointments, is cocaine in sub-cutaneous injections which in a few cases was much praised by the patients; I have of course guarded against the frequently described cocaine habit, used small doses, and never allowed the patient to find out what was used. Two or three of my patients have been enthusiastic in their praise, but several have declared that it made them worse. One patient, whom I suspected of exaggerating the evil consequences, had without his knowledge pure water substituted and declared immediately that the giddiness, faintness and sickness which has followed the cocaine injections failed to make their appearance. The fluid extract of erythroxylon has also in some cases been useful in doses of 30 to 40 drops by the mouth repeated 3 to 4 times a day. Like all other remedies the number of failures has been greater than the successful cases.

In view of the futility of medication I have concentrated my efforts on the general regimen of the patients. I have ordered such proper food, as I thought the patient's circumstances would place within his reach; I have tried to detect the most easily digested and still nutritious food, trying to supply fat, where it was wanted, and advising the obese and flabby to limit themselves as much as possible to dry diet, at the same time advising more exercise than I have dared prescribe for the thin and emaciated. Nearly all my patients have been advised to make 4 meals in 24 hours, hunger always seeming to make them worse. Another feature of the general treatment has been to exist upon the greatest possible regularity not only with meals, but with exercise, baths, and before all, with sleep. It has been my aim to make such patients sleep 10 hours out of the 24 and an afternoon nap has been strongly recommended. Where sleep has been very bad I have not hesitated to prescribe chloral in sufficient doses, but with strict surveillance.

Patients have been forbidden to engage in laborious occupations for very long periods, but absolute idleness has on the other hand not been advised. The day has been filled out, as far as possible with a round of duties and occupations, partly with the view of preventing the patient from giving too much attention to his morbid condition

while at the same time tiring the patient has been avoided as far as possible.

One of the greatest aids in treatment has been to give the patient as plain an explanation of my view of his condition as I could; this has always been done with the strictest regard to truth, freely admitting the difficulty of explaining many symptoms. It has seemed to me that my efforts to inform and instruct, although often only partially successful, have been useful in relieving the patients' minds, and thereby bettering their condition.