defects, but its blight may make itself evident on the part of the nervous apparatus during the period of growth or in adult life, modifying cerebral or spinal functions and at times leading to histological changes in the central and peripheral parts, which may vary in degree up to destructive lesions. Diabetes and Bright's disease must not be overlooked.

Personal History.-The investigator should go most carefully into the medical life-history of his patient. While doing so, indeed, whenever opportunity offers, the conduct, attitude, manner, gait, posture, complexion, expression, gestures, and individuality of the person should be keenly watched. This observation becomes in time a trained, almost automatic, faculty, so that minute details subconsciously apprehended at the time can be readily recalled.

In infancy, was there any birth difficulty, possible brain or spinal injury from protracted labor, precipitate labor, or instrumentation, lack of vigor, suspicion of syphilis, or convulsions? During childhood, did the patient present any nervous phenomena, such as marked delirium or spasms under febrile conditions or from irritation of the gums and intestinal tract? Was there enuresis, chorea, somnambulism, or nightterrors? Was he precocious or otherwise, docile or obstinate, cheerful or morose, forward or retiring? At pubescence, were there mental changes of unusual character, moodiness, expansiveness, cruelty? Was the establishment of menstruation attended by pain or hysterical manifestations? Was masturbation indulged in or suspected? During adolescence, what was the career, relation to the opposite sex, success in school and business, and what has been the course of events through adult life? The past illnesses of the patient should then receive attention in the same systematic manner. The fevers and febricula of childhood, the exanthemata and infections. The diseases of the nasopharynx, stomach, intestines, and rectum, of the lungs and heart, of the skin, the special disorders of chest, abdomen, pelvis, and genito-urinary apparatus must not escape attention. Especial inquiry should be made for rheumatism, gout, grip, and malaria. The venereal history of the patient and the possibility of specific infection should in every case be carefully inquired into. This is a rule that has no exceptions. The investigation must be modified and guarded according to individual circumstances, but nothing should deter the physician from making sure that a factor of this sort is not overlooked. If injuries have been received, what were their character and consequences? Regarding habits, it is to be borne in mind that neurotic people are especially liable to carry everything to extremes and are prone to become the abject subjects of some perverted practice or stimulant addiction. Masturbation and venery take firm hold on them. Tobacco, alcohol, morphin, cocain, chloral, and even tea and coffee master them completely. These in turn often break down the moral status of the individual and make him unreliable and untruthful. Only inadvertently or at second hand does the physician sometimes gain the required information, but justifiable suspicion once aroused, he can usually go to the root of the

matter.

In neurasthenic, hypochondriac, and hysterical cases frequently the patient has most seriously overestimated some such habit, is morbidly apprehensive as to its results, exaggerates its every relation, and the entire life seems to revolve around this central erroneous idea. One must avoid being led by such unfortunates into adopting their point of view. The details, duration, and probable effect of the habit being clearly understood, its morbific influence can be properly estimated. Let it never be forgotten that many of these habits are symptoms, not causes, of nervous disturbance, and are the result of an underlying predisposition upon which they are grafted. There they take on a morbid development and, in turn, no doubt, add to the unbalance of the individual.

The residence or habitat of the patient is an important consideration. It calls attention to the climatic and local conditions favoring health or disease. Unhealthful surroundings are of immediate concern, and throw a strong light upon the causation of many nervous disorders.

Occupation. Many occupations predispose to nervous maladies and sometimes furnish the cause. Indeed, a group of diseases is known as occupation neuroses, of which writers' cramp is a type. Workers in metals, particularly those handling lead, phosphorus, mercury, and arsenic; people subjected to illuminating gases or bisulphid of carbon, and those who deal in alcoholics, and who are thereby likely to overindulge, are subject to neuritides and associated mental disturbances. Work requiring exposure to cold and conditions favoring rheumatic processes entail a tendency to cerebral arterial mischief and peripheral palsies. Divers and those working in caissons, or elsewhere, under increased atmospheric pressure frequently present spinal lesions with paraplegic symptoms. Occupations which demand constant mental strain and sedentary habits, as in speculative mercantile life, teaching, and some of the professions, furnish large numbers of neurasthenics. On the other hand, the unoccupied are likely to become selfish, introspective, hysterical, and hypochondriac.

The Illness. From the patient's statement, his personal history, and the physician's observation, the noting of the details of the illness under consideration is often a simple matter. The medical man from his special knowledge must supplement the impressions of the layman. In the "rheumatism" preceding ataxia he discerns initial features of tabes, and in some long-antecedent moral shock he recognizes the origin of the fixed hysterical idea that may have eventuated in a contracture. For each major group of nervous maladies, psychic, cerebral, spinal, and peripheral, he must follow out the clues his training recognizes or his studies and experience suggest.

Beginning with initial symptoms and alleged, suspected, or positively known causal conditions, the manifestations of the disease are to be systematically, briefly, and clearly developed and noted, with full attention to remissions, intermissions, or relapses. In convulsive disorders a full clinical investigation of the attack is of prime importance. should embrace its exciting cause, onset, features of consciousness, motor signs and phenomena, attitudes, duration, termination, and

It

sequelæ. In sensory disturbances investigate the particular dysesthesia or pain, its onset, exact location, intensity, duration, and associated conditions. In paralytic maladies determine the mode of onset, exact distribution, and the character and degree of motor failure. The mental symptoms are to be noted with equal care, attention being directed to their fixity, emotional character, and reasonableness or complete opposition to facts within the patient's range of knowledge. An important question is whether the patient can correct his morbid ideas by mental effort or is entirely subjugated by his delusional states. Finally, the tendency to improvement or the reverse should be indicated.

Physiognomy of the Patient.-Formerly it was considered sufficient to describe a patient as of the nervous, lymphatic, or sanguine temperament, and this has a certain value, but a better conception of the physical status is to be had from a study of the physiognomy of the individual. Based upon embryological conditions and formulated with some precision by Lombroso, Dejerine, Weismann, Fèrè, and others, we can recognize a type of degenerate or, preferably, defective individuals, from whom are largely recruited the neurotic, the insane, and the criminal classes.

The marks of this type are called the stigmata of degeneracy, and may be divided into the morphological and the functional.

Morphological Stigmata.-Commencing at the crown of the head, the whorl of hair at the vertex which normally is close to the median line may be widely displaced or duplicated. The cranial conformation is often abnormal in outline, capacity, or dimensions. The occipital protuberance and ridges, the frontal eminences, and the mastoid processes are usually excessively developed. The facial angle is reduced, the contour of the face asymmetrical, the lower jaw disproportionately large and prognathic. The hard palate is sharply vaulted, the dental arcades narrow, disproportionate, saddle-shaped, or angular and badly articulated; the teeth defective, misplaced, with sometimes persistence of milk-teeth late in life. The ears are disproportionate in size, misplaced, malformed, particularly at the root of the helix, which may bifurcate, or the tragus and antitragus are misplaced, while the concha is crumpled or has a tendency to stand out widely from the head. The eyes show notable defects, extreme refraction anomalies, squints, different colored irides, and disproportionate lids and palpebral openings. Deviation of the nose, septal deformities, harelip, cleft palate, and remnants of branchial clefts in the neck or in front of the ears, and the presence of other teratological deficiencies are frequent in this class of persons.

On the part of the trunk, spina bifida, sacral growths of hair, deep sternal furrows and concavities, or disproportion between thorax and

abdomen are to be noted.

The Extremities. The upper and lower limbs may be disproportioned to each other or to the trunk. They may be mismated in length and development. The hands and feet may be too small or too large. There is often a tendency to left-handedness and left-sided overdevelopment. Deformities of the fingers, such as syndactyly, polydactyly, deviations, distortions, excessive length or shortness, especially undersize of the

ring and little fingers as compared with the rest of the hand, are common in degenerates.

The genitalia in the male, besides a general lack of growth, are frequently developmentally defective, presenting hypospadias, epispadias, extrophy of the bladder, cryptorchidism, congenital phimosis, scrotal fissure, etc.; while in the female, imperforate hymen, double vagina and uterus, and hypertrophied clitoris and labia are not rare.

Taken as a whole, the degenerate physique is often marked by a diminished stature and an inferior vigor. Many neurotic males present the general body conformation of the opposite sex, including sloping, narrow shoulders, wide hips, excessive pectoral and pubic adipose deposits, with a lack of masculine hirsute and muscular marking. The female may present masculine characteristics, and in each case the opposite sexuality may be further manifest in the actions, dress, manners, voice, and mental qualities of the individual. Both sexes may retain the physical attributes of childhood,—infantilism,—and in these cases the mental development is always retarded.

On the part of the skin, albinism, melanism, and multiple nevi are sometimes degenerate accompaniments. A general lack of thorough development in the dermal structures is manifested by defective hair and nails and simplicity in the papillary lines of the finger-tips.

The functional stigmata of degeneracy show themselves: (1) Mentally, in defective mind qualities. These vary in degree from idiocy to simple retardation of speech development, in aberrant mental and moral tendencies, among which may be enumerated destructiveness, wilfulness, indecency, deceit, and sometimes extreme acuteness and even precocity in limited fields. Genius is essentially abnormal however valuable it may be to the individual and to the race. It is often attended by many of the physical stigmata of defect.

(2) Physically, may be mentioned backwardness in walking, stammering, incontinence of urine, merycism, color-blindness, deaf-mutism, perverted tastes, and cravings leading to alcoholism and other stimulant addictions. Perversions of the genesic sense, marked by sexual crimes and debasing practices, are also common. Degenerates have frequently a lack of adaptability to their environment, and so more or less strongly depart from the type and tend to extinction, subjugated by the law of survival of the fittest.

In estimating the various marks of degeneracy it is clear that very few of them, taken alone, are sufficient to enable the classification of their possessor among the defectives, and that a very great many of the minor stigmata may be present in a given case, associated with strong mental, moral, and physical attributes. All of them, from cleft palate to moral imbecility, are referable to defective development. In the presence of numerous indications of physical defect we are entitled to expect the association of their mental and neural analogues. Hence their importance to the neurologist.

The mental condition of the patient should not be overlooked. Disturbances in the psychic sphere are very common in nervous disorders and often overshadow them. Persistent depression or excitement

out of proportion to their causes, and delusions and hallucinations that may or may not be properly recognized and corrected by the patient, require close scrutiny. Especially in hysteria are we confronted by a train of mental symptoms, attitudes, and reactions that may easily be confounded with insanity or which actually carry the patient over the rather broad, dividing neutral ground into the realm of alienism. Loss of self-control, irritability, increased emotionalism, and vague or formulated apprehensions are the ordinary concomitants of neurasthenia. Many cerebral diseases produce unconsciousness.

Sleep in nervous patients is one of the most important practical considerations. If it is disturbed, seek the cause, remembering that habits of wakefulness are easily formed. Distressing, formulated, and repeated dreams and nightmares are the neurasthenic's portion and the expression of his lowered nervous and physical tone. Some patients find difficulty in falling asleep, others in remaining asleep; others are simply unrefreshed upon awaking. The selection of soporific remedies and the time of their exhibition turn upon such considerations.

Memory. Nearly every nervous invalid asserts a loss of memory, which rarely, however, exists. This mental faculty varies not only greatly in individuals, but is subject to great modifications in a given individual under different conditions of health and age. To the keen perceptions of a child everything is novel, is deeply imprinted in the mind, and is rarely forgotten. Later in life a new face or name is no rarity, is not sharply apprehended, and its recollection is consequently difficult or impossible. The old, in part for this reason, remember their early experiences better than more recent happenings. In physical ill-health and in conditions of mental abstraction or introspection, as in hypochondria, hysteria, and neurasthenia, the alleged loss is really a lack of the mental concentration that constitutes the essential basis for good memory. In such cases this may be demonstrated by a few questions on remote personal happenings, which will usually be recited with extreme minuteness and detail.

CHAPTER II.

THE GENERAL PHYSICAL EXAMINATION.

Present Condition.-What has gone before prepares the way for a thorough physical examination. Whenever possible, the clothing of the patient should be entirely removed, as study of the physical human outlines is most valuable. Without this step spinal deviations, chest. deformities, lack of symmetry in the limbs, or other serious defects of the most important diagnostic character may escape notice. Upon sketch outlines of the human figure supplied in text-books and by dealers abnormalities of form and function may be indicated with precision. No lesion is too slight to be overlooked, and no assertion of functional health is to go unquestioned. Remote conditions are not infrequently causal of central disturbance, and central mischief is mani