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need of special study, but viagra price drug inevitable confusion has J2Q MEDICAL RECORD. [May 1 6, 1896 arisen from the fact that the term has been continu- ally used without a proper conception of its exact meaning a fault, however, not to be attributed to its originator. Trauma" has come, in the popular viagra cialis prescription mind, to be identified with "accident"; a "traumatic neurosis" means popularly an "accident neurosis." Experience will no doubt show that the term "trau- matic neurosis" should be used with more and more caution, and never as indicating a special disease. No doubt both practically and scientifically we shall do as well to speak of " accident hypochondria," " ac- cident neurasthenia," "accident hysteria," since it is evident that not every trauma is an accident. Fre- quently the diagnosis between an organic lesion and one due to a purely mental effect is easy to make by methods which are familiar to every viagra price drug experienced physician. The general appearance of an accident patient and his attitude toward himself are exceed- ingly characteristic. Almost without exception his tendency is to exaggerate, and, as a natural con- sequence of his self-observation, pain and weakness are felt with an increasing intensity. This is the re- sult of the introspective frame of mind into which the accident with its attendant circumstances and the further prospect of litigation have plunged him. The point of importance is entirely apart from the question of simulation that the symptoms, in large measure, are attributable to a subtle mental condition and are therefore mentally produced. A clear realization of this fact is essential to a proper judgment as to the so-called "objective symptoms" of accident cases. Most common of these are the anaesthesias, or, better, viagra cialis prescription analgesias. Naturally, beyond the patient's state- ments, the physician has no means of judging of their presence. There can be little doubt that such condi- tions, whose actual existence is not to be doubted, have their being through suggestion and may be so increased; hence the advisability of not making too detailed an examination of sensibility. Much stress has been laid upon these anaesthesias; they have been ex- haustively studied, and in the future should be rele- gated to a position of less importance. Especially is this true in determining ability for future manual work, since onlv rarely do sensory disturbances affect one's power in this direction. For practical purposes the determination of the visual field is of still less importance, especially when no complaint of defective vision is made. It is also a matter of common knowl- edge tiiat respiration and heart action are strongly in- fluenced by the psychical state, although of course not actually determined by it. The same may be said of the deep reflexes. On analysis, therefore, it appears that the so-called objective symptoms are in reality subjei 1 i.e. an 1 that their diagnostic worth lies in the fact that their presence points more or less distinctly to the absence of organic disease. The stumbling-block in the whole matter of the ac- viagra cialis prescription cident neuroses lies i:i the interpretation and signifi- cance of the term " simulation." Recrimination and argument without end have centred about this word, certainly to a quite unnecessary degree. Recogniz- ing the fact that we have to do with a clinical picture largely of psychic. 1 origin, it at once becomes evident that a changing set of symptoms by no means points to viagra cialis prescription conscious simulation. Theoretically the distinction between hysterical or hypochondriacal conditions and simulated ones is easy to draw and is of the viagra price drug most ex- treme importance to define with accuracy. In the first case we have to do distinctly with pathological fixed ideas which are deeply rooted in the patient's mental life and entirely beyond his control; in the second case, in simulation, we have viagra cialis prescription to do with ideas which the patient evolves at will and which he may lav aside at will. The distinction is, of course, fundamental. viagra price drug The hysterical person himself believes in the existence of his paralysis, and has, viagra cialis prescription for example, actually lost the means of normally innervating his arm. That he may raise the arm under the influence of certain stimuli in no way implies, as is too often supposed, that he is thereby a simulator. The true simulant naturally wilfully ^inhibits the normal innervation of the arm. In other words, in one case the will is involuntarily in abeyance; in the other voluntarily. It hardly need be said that the practical application of these self-evident principles is not always easy; on the con- trary, the most skilled diagnostician must often fail of a perfectly correct determination. The problem is a psychological one and must depend for its solution upon a great variety of factors, which will vary with the varying character and mental endowment of the subject. The reproach so often heard viagra cialis prescription that expert physicians of viagra cialis prescription equal education frequently testify in viagra cialis prescription diametrically opposite ways is only in part justified. The personal attitude and point of view of the phy- sician toward his patient may with all conscientious- ness be widened to the extent viagra price drug of apparent contradic- tion. A definite rule of diagnosis is impossible to apply, as must unfortunately so often be the case, in dealing with matters in the psychical sphere. Es- pecially viagra cialis prescription difficult of diagnosis are head injuries of varying degrees of severity. The point of vital inter- est is, whether from a so-called " commotio cerebri" without gross lesion of the brain, finer viagra cialis prescription material changes may persist and give rise later to cerebral symptoms as, for example, headache, vertigo, mental disturbances which otherwise would be interpreted as of purely psychical origin. Such a possibility is, at least, always present, however unlikely in many cases, and we should certainly be on our guard in the esti- mation of viagra price drug such true " traumatic neuroses." The whole subject of treatment is one of peculiar interest. Its essence, as Striimpell points out, is so far as pos- sible to prevent the establishment cf the hypochon-