sible to determine at first which of them is dominant. Typical cases of the neurotic type in which the paroxysms exhibit all the features of a vaso motor reflex in that the onset is sudden and the interval free from symptoms other than those of nervous depression often experience immediate relief and immunity above a certain altitude or during a sea voyage. Again, there are districts where some cases are immune and others unaffected during a single season; while the following year no relief is obtained. The influence of heredity as a predisposing cause is unquestioned, and in a large percentage of cases we find a history of some neurotic manifestation in other members of the family. Haig Bishop and others who have studied this subject extensively attribute hay fever to an excess of uric acid in the fluids of the body. Bosworth claims that some intranasal abnormality always exists as an exciting cause. Price Brown traces the outbreaks to an antecedent hypertrophic rhinitis. Kyle concludes from the results of rather extensive research in the etiology of hay fever that an important causative relaxation exists between the chemical reaction of the saliva and nasal secretions and diseases of the mucosa of the upper air tract. Cases are cited in which changing the reaction of the nasal mucus from alkali to acid promptly relieved attacks of hay fever. He believes that a study of the nasal secretions (the saliva is the same in reaction and more readily studied) in a patient suffering with hay fever will often suggest treatment which will relieve the disease. In common with other special branches of medicine, rhinology has suffered a certain measure of disrepute in consequence of the extravagant and misleading statements of its votaries, and by the wholesale sacrifice of intranasal structures as taught and practiced some years ago, and to a lesser extent to-day. The concurrence of hay fever, asthma, and nasal polyps, has been so long observed as to prove the occasional causative relation of the latter. Pressure from deformity or growth of some kind, inflammatory swelling or oedema and hyperæsthesia are conditions to be sought for as possible causes of reflex disturbance. Formerly much stress was laid on the presence of certain supersensitive areas within the nose, where, independently of any perceptible lesion or change in appearance of the mucous membrane, the terminal nerve filiments were unduly responsive to the slightest irritation. This theory was the basis for the treatment very properly designated by a recent author as the "electro cautery fiasco," which in the hands of some of its over-zealous advocates led to disastrous result.

Francis reports brilliant results in asthma from cauterization of the septum opposite the anterior end of the middle turbinate. In his recent announcement the number of cases were 543, of which 316 were completely relieved, 188 more or less relieved, 24 results negative, 15 lost sight of.

Nodes or thickened patches of inflammatory infiltration are sometimes found in the location mentioned, and when present are so highly sensitive that the merest touch with a probe causes immediate symptoms of a reflex nature. These spots are found less frequently in other parts of the nose, and naso-pharynx. This

region is the one most exposed to friction by contact with the opposite structure (the middle turbinate at its anterior end) and from this fact most likely to be the seat of local inflammatory action and thickening of the membrane. Is it not reasonable to suppose that any existing hyperæsthesia may result from the pressure of an inflammatory exudate or the resulting fibrous contraction on the terminal nerve filiments? In a considerable number of cases we find material lesions such as polypi or hypertrophies in constant contact with the septal walls, and in most of these subjects suitable operative measures will effect a cure. Disease of the accessory sinuses, particularly the ethmoid cells, is not infrequently present and may or may not be associated with polypoid degeneration. Removal of the anterior half of the middle turbinate and breaking down and drainage of the cells is the first and most important procedure in the treatment of such cases. Contact between a ridge on the septum or an hypertrophied inferior turbinate is a condition not. infrequently observed, and when present encroaches on the breathing space, causing a most distressing stenosis. Submucous resection and other operations on the septum are very popular at this time, but for very practical reasons better results are obtained in my judgment by removal of a portion of the inferior turbinate. The septal scar after removal of a spur or ridge is apt to be the seat of unpleasant dryness and often the formation of crust. On the other hand the more vascular structures of the turbinate renders the healing process more rapid and a healthy secreting membrane is formed over the wound.

Germicides, such as bichloride of mercury, carbolic acid, quinine, etc., were employed at one time on the theory of microbic origin, but of late years have been practically abandoned. Cocaine, so confidently heralded as a remedy for hay fever, has long been discarded because of its injurious effects on the nervous system and the danger of contracting the "drug habit." It should only be used for diagnostic and operative purposes. Adrenalin has fallen short of being the specific that its early advocates expected, but in a large majority of cases it is very useful in contracting the swollen and engorged tissues, relieving stenosis and lessening irritability and hypersecretion. Occasionally in the 1-1,000 solution, its action is irritant, but when diluted with two or three volumes of salt water, this difficulty may be overcome. I have recently used stovaine in a one per cent solution in combination with the above with very gratifying results.

Kyle's theory, previously alluded to, is that a subacid condition of the nasal and buccal mucus resulting from faulty elimination, is attended by an excess of ammonium salts in the secretions. He claims to have demonstrated the truth of this hypothesis in several cases by rapidly changing the reaction to acid and thereby warding off an attack.

Dunbar of Hamburg has been conducting a very interesting series of experiments along the line of serumtherapy. He succeeded in isolating a toxin from the pollen of certain grasses and plants capable of causing hay fever in those who were susceptible, while it is inocuous in others. An antitoxic serum was prepared by a series

of animal inoculations which antidotes the disturbance caused by the toxin and when used in hay fever modifies or relieves the paroxysms of the disease itself. The experience of Dunbar and other observers in this country and Europe justify the expectation that the antitoxic serum, (perhaps in some modified form) will prove a valuable adjunct to our therapeutic resources in the treatment of hay fever. Of the homœopathic remedies employed, the most useful have been bellad.. ambrosia-artimisiæfolia, camphor, gelsenium, and arsenicum iodide.

In estimating the value of any method of treatment the following facts should be borne in mind. The varying atmospheric conditions from one season to another. The influence of suggestion must be eliminated and the experiments to be conclusive must be continued for several years and include considerable number of patients.

FUNCTIONAL NEUROSES*

BY FRANK C. RICHARDSON, M.D.

In conference recently with one of our leading practitioners, he stated that in his opinion there was "nothing in the world the matter" with the patient under consideration, and that he had advised him to "hire somebody to boot him around the square." Yet this patient was hypochondriacal as a result of well-marked neurasthenia of toxic origin. This is a single instance illustrative of the very general misconception which exists concerning the nature and importance of most of the functional neuroses. Because the patient presents no evidence of organic disease it is too often considered that the symptoms complained of are purely imaginary, as such to be best treated by a general denial of their existence, and an effort to persuade the patient that "there is nothing in the world the It is believed that a better understanding of the subject of non-organic nervous diseases would teach us that the assertion "there is no pain; all sickness is but error" is as irrational as applied to functional neuroses as to those of organic origin. How often in these days the vagaries of nerve stimulation incident to our artificial lives lead to woful conditions of nervous instability in which nerve cells and their connections become irritable, functionate too much. or too little, and give rise to all sorts of jangled messages; pains, numbness, tingling, sensations of cold or heat, morbid thoughts, tears or laughter without tangible physical basis or visible adequate cause. To tell these patients, because they have no organic disease, that there is nothing the matter with them, is not only unjust and cruel to them, but a display of regrettable misapprehension on the part of the physician. The majority of these pains and disagreeable sensations are not imaginary and controllable; they exist, and it is this lack of comprehension so frequently found, that is in considerable measure responsible for the conscious or sub

*Read before the Essex County Homœopathic Medical Society, 1906.

conscious exaggeration of symptoms by patients who know they are sick and fear they will not receive the sympathy and consideration which they deserve.

While a comprehensive treatise upon functional neuroses is entirely beyond the scope of this paper, it has seemed possible and desirable to briefly review the possible etiology and explain the symptoms of some of the commonest functional disorders of the nervous system. The usually accepted definition of a functional disorder is a condition in which there can be found no anatomical or structural changes to account for the symptoms; and it is implied that the symptoms in such cases are due simply to an alteration of function. Modern medical science tends to the belief that all disturbance of normal function has for its physical basis some structural or chemical change, however transient this may be. Untiring investigation is being carried on for the purpose of demonstrating these changes, but with our present means of research no definite conclusions have been reached. But while the laboratory has as yet furnished us with no positive data concerning the morbid anatomy of these functional neuroses, clinical observation has enabled us to determine some of the factors which bring about alteration of function, and by studying the clinical features resulting from these causes to arrive at a reasonably accurate classification, at least from an etiological standpoint.

It seems fair to assume that a large proportion of the functional neuroses loosely characterized as "nervousness" or "nervous prostration" may be classified as neurasthenia, hysteria, or hypochrondriasis. Of these groups neurasthenia will be found in a very large majority of cases.

Neurasthenia, hysteria and hypochrondriasis are often used as synonymous terms. This is especially true of the first two, and the idea seems somewhat prevalent that neurasthenia is a new name for hysteria; it is not so, though it seems more than likely that many of the cases we now know as neurasthenia were formerly grouped in the class hysteria. While each of these conditions forms a distinct entity, it should be borne in mind that they do not always exist. alone, but frequently combine, though generally one or the other predominates. In their essential qualities, however, as drawn from a complete clinical picture of each, they are dissimilar.

These conditions are so inadequately dealt with in many of the text-books in current use that perhaps no apology is necessary for introducing to your notice a few points of differentiation.

Briefly, it may be said that neurasthenia consists of an exhaustion of the nervous system, and the mind nearly always manifests this; in hysteria there is deficient will control and increased reflex irritability; whereas hypochrondriasis is a peculiar mental attitude of exaggerated introspection.

Distinguishing clinical features may be noted in the onset and course. Neurasthenia starts somewhat gradually and runs a fairly even course of moderate duration. Hysteria is essentially a paroxysmal disorder. All phenomena (healthy or morbid) vary from hour to hour, day to day, and nerve storms are frequent. Hypochron

driasis starts very gradually and runs a very even course of most indefinite duration. In the general symptoms: we find in neurasthenia occasional attacks of vertigo or syncope. Convulsion never. Vasomotor disturbance frequent. In hysteria seizures of different kinds frequently arise, a great variety of symptoms occurring in the paroxysms. In hypochrondriasis no attacks of any kind.

In neurasthenia the patient is easily tired, easily startled. A state of debility and exhaustion. Constant headache. Constant headache. Restlessness. Sleeplessness. Atonic dyspepsia frequent.

In hysteria between the attacks no symptoms may be present. but symptoms referable to the nervous or neuro-muscular system may arise, as anesthesia, paralysis, and contracture.

In hypochondriasis the digestion if often deranged, but in the patient's belief he has some grave disease either of the alimentary tract, abdominal viscera, vascular or respiratory system or head.

In neurasthenia hemianesthesia rare. Hyperesthesia and dysesthesia, common. Pain in the back and sometimes in limbs. Reflexes may be increased, or diminished, or normal. In hysteria hemianesthesia and other anesthetic zones very common. Hysterogenic zones, tender spots under the mammæ, in iliac regions and other places. Reflexes increased. Borborygmi, globus, and other spasms of the involuntary muscles are frequent. In hypochondriasis small and insignificant symptoms are endowed with great and perhaps lethal significance. The patient tries an endless succession of remedies and doctors; always striving for a cure (which distinguishes hypochrondriasis from the hopeless and suicidal tendencies of melancholia).

No one questions that a prerequisite of the successful treatment of any disease condition is an observance of the time-honored admonition "tolle causam." This is especially true of the functional neuroses under consideration. Indeed removal of the cause may in many cases leave little else to be done. An appreciation of these causative factors and their mode of operation is, therefore, of the greatest importance.

Although somewhat heretical, the opinion will here be asserted that every alteration of function not due to organic disease is directly dependent upon vaso-motor disturbance. Many and varied causative influences may be responsible for such disturbance, but in angiospastic or in angio-paretic phenomena we must find the explanation of most if not all of the symptoms found in connection with functional disorders. When we remember the close association of the nervous and cardio-vascular systems-the control which the nervous system exercises over all the organs of the body through regulation of their. blood-supply becomes at once apparent, and it is clear how farreaching in its effect would be any derangement of this cardiovascular nervous system. The flushing and pallor of the skin resulting from vaso-dilatation or vaso-constriction, is visible to the eye. It should be remembered that the same flushing and pallor take place in the various tissues, organs, and internal parts of the body. It is by the relative amount of blood entering an organ that its nutrition and its functions are regulated; and if the flushing or pallor of an