NGV 5 - 1926 LIBRASS NERVOUS DISEASES. PART I. EXAMINATION OF PATIENTS. CHAPTER I. THE ANAMNESIS. DIAGNOSTIC investigation in neurological work is a fine art. A correct opinion depends upon it. It is the first step toward treatment, the legitimate end of medicine. The physician is dealing with morbid conditions, revealing themselves for the most part by functional errors. The large subjective side of the problem, with the unreliability of the patient's responses, adds to the difficulty and calls for keenness of judgment at every step. The use of several tests for determining a given. state is of much importance, especially in conditions that are not objectively evident. By comparison of the results thus obtained, and sometimes by striking an average of such results, exactness may be approximately reached. Dependence upon any one of them, however, might be misleading. On the other hand, by the use of instruments of precision, controlled by anatomical and physiological rules, a definiteness can often be reached in nervous diseases not elsewhere possible. Localization in brain and cord lesions is sometimes exact to a degree, and prognosis is often absolutely clear. But in many instances of the so-called functional diseases, careful study, the shrewdest judgment, and a wide experience enable one only approximately to appreciate the situation. The entire data can be secured only by a systematic and frequently prolonged or often-repeated examination, and it is of the first importance that the medical man should maintain an entirely judicial and non-committal mental attitude toward his patient and the diagnosis until he has every available fact at his disposal. Snap-shot diagnoses may be gratifying to all concerned, if correct, but they are very likely to be wrong and prejudicial to a proper subsequent estimation of the case and are never necessary. It A systematic examination can not be made without a prearranged formula. The nearer this corresponds to the development of the case, the less likely are important matters to be overlooked. therefore should be chronological. Most patients insist on telling their own stories in their own way. It is sometimes well, especially in private practice, to allow them to do so, and when they finish, to begin properly. In nervous diseases the family history is often of paramount importance. Taken with the appearance of the patient, it gives valuable indications as to the constitutional make-up of the individual. The family history, then, is to be investigated first, after noting the name, age, sex, nationality, occupation, and social state of the patient. Neurotic Heredity.—In seeking information regarding the antecedents of a patient, much tact must sometimes be employed. Patients are loath to detail matters of this character, not always from a wish to conceal them, but from disinclination to admit even to themselves any serious shortcoming or morbidity. To the half that is directly learned an equal amount may sometimes be reasonably added. Much can be learned by interrogating other members of the family, especially if related by marriage, the family physician, and old acquaintances, but the confidence and rights of the patient must not be forgotten. Nor is it sufficient to seek for instances of the identical disease in the family history of the case. The significant factor is a neuropathic liability, and this is indicated with more or less force by the appearance of nervous and mental diseases of any sort, of slight or serious degree, in the ascendants. For instance, a hysterical mother has an epileptic child and an idiotic grandchild; or highly wrought nervous organizations in mother and father eventuate in neurasthenic and unstable children. Atavism in mental and nervous diseases is quite common. Insanity in the same or neighboring generations may alternate with neuroses or mild psychoses, and any combination may exist. Consanguinity on the part of parents, in addition to furnishing a tendency to infecundity, is likely to bring together the subjects of similar neurotic taints, which are thereby reinforced in the offspring. In itself, however, consanguinity has probably been overestimated as a causal factor in nervous and mental diseases. The association of crime, precocity, genius, neuroses, and psychoses in related individuals may be encountered. Certain nervous diseases are of direct hereditary character, being transmitted from generation to generation or appearing in a group of cases in a given generation. It is only needful to mention Friedreich's ataxia and Huntingdon's chorea, but tabes dorsalis, paralysis agitans, multiple sclerosis, muscular atrophies, and practically every organic and functional nervous disease occasionally presents family groups of this nature.1 Debilitating diseases, like tuberculosis, rheumatism, and gout, are significant. Indeed, Charcot was inclined to consider arthritism as a congener of nervous diseases. Inherited syphilis is on an entirely different footing. Not only is it capable of producing embryological |