fested by peripheral states. The nutritive process may first engage

attention.

The Alimentary Tract.-The condition of the teeth in relation to mastication and abnormalities of position or evidence of inherited syphilis, the color of the gums with reference to anemia or evidences of metallic poisoning, such as the blue line of lead and the sponginess of mercury and phosphorus, can be noted at a glance. Particular attention is to be directed to the tongue. Aside from indicating the state of the stomach, it may give important evidence of nervous diseases. The fine fibrillar twitching of general paresis and bulbar palsy, the tremor of alcoholism, the contortions of chorea, the lack of motility and atrophy in labioglossolaryngeal paralysis, and the deviation on protrusion in hemiplegia are positive signs of great value. Abnormalities of appetite for food, gastric and intestinal indigestion, constipation, and rectal conditions are significant in many ways. Attacks of colic, vomiting, diarrhea, and rectal tenesmus have special bearing on the condition of the reflex spinal centers. The condition of spleen and liver, as in acute and malarial infections and chronic alcoholism, may give important indications of constitutional and local states that have a relation to the nervous phenomena under investigation.

The Respiratory Organs.-In the nasal and pharyngeal spaces inflammations, new growths, or irritation zones may furnish the startingpoint for neurotic states of the most varying nature, as hysterical sneezing, spasmodic asthma, and pronounced neurasthenia. Laryngeal palsies and spasms require a careful topical examination. In the condition of the lungs and pleura we seek for local explanation of various symptoms, such as respiratory pain and oppression, costal neuralgia, continuous cough, or for the evidence of tubercular deposits, explanatory, perchance, of a cachexia that might otherwise be erroneously referred to nervous depression.

Circulatory Apparatus.-The condition of the heart is revealed only by a thorough physical examination of its position, size, action, and valvular competency. The condition of the arteries, patent to the eye in a tortuous temporal, to the finger by radial atheroma, should be still more extensively investigated in the femoral, brachial, carotid, and other superficial regions. The condition of the blood-pressure, as shown by arterial tension, on the two sides of the body, near the heart, and at a distance, is worthy of careful study. It enables one to draw analogical conclusions as to the circulatory apparatus of the central nerve-organs. The condition of the arteries is the best index of the real age of an individual. In them we often find evidence of a premature decay out of all relation to the years that have been lived. Sphygmographic tracings, as a method of record and precision, have their own value. The pulse, by its lack of rhythm, particularly by a tendency to great variation in its rate, depending upon slight exciting causes, often shows the unstable nerve-tone of the patient, or a general asthenia. Flushings, mottlings, local anemias and edemas are vivid expressions of angioneurotic disturbances. The blood must be examined for parasites, hemoglobin, and corpuscular conditions.

The temperature may be greatly modified by nervous diseases.

Organic brain-lesions may upset the balance between the thermotaxic and thermogenic centers, producing either a very high or a markedly subnormal body-heat. In hysteria a very high range of temperature is sometimes noted without the usual concomitants of fever. In cerebral hemorrhage and basilar meningitis the temperature is often below the normal. Early in cerebral hemorrhage the paralyzed side presents usually a disproportionate elevation of a degree or more of heat over the opposite half of the body, as is shown by axillary temperatures. The temperature of the paralyzed side later becomes subnormal. Slight variations of the central normal temperature, usually in an upward direction, are frequently observed in pure neurasthenic states, while the extremities are commonly cold.

The Integument. From the appearance and condition of the cutaneous expanse much is to be learned as to the general health of the individual and the activity of his physical functions. The skin may be greatly modified by nervous maladies. In some instances the dermal manifestations make up the major part of the disease, or the dermatosis may be an associated feature of other neurotic disturbance. All varieties of urticaria are of frequent occurrence among the neurotic. Dermographia and the tache cérébrale of meningitis demonstrate the vasomotor irregularities. Herpes and morphea, limited to the anatomical distribution of nerves or spinal segments, as in zoster on the face, trunk, or limbs, declare the nervous involvement. Neuralgias of long standing are frequently marked by dermal changes of increased or decreased nutrition, as witness the thickening of the skin of the face in neuralgia of the fifth cranial nerve and the subsequent blanching or the actual loss of the eyebrow and hair. The neuritides, if of a severe grade, show dermal dystrophy as well as muscular wasting. The epithelial structures involved may take on increased growth if vascular stasis favor increased nutrition, giving rise to scaliness of the skin and increased growth of the hair and nails. More frequently atrophic changes follow; the skin is thinned and glazed, the epithelium scant and poorly protective of the more highly organized subjacent tissue. The hair becomes dry, brittle, and sparse, and the nails rough-ridged and sometimes covered with overlapping scales. Pigmentary changes, swelling, and blue edema are not infrequent in hysteria. The enormous thickenings in myxedema and acromegalia are also due to perverted trophic control.

Genito-urinary Tract. In the genito-urinary tract are found many conditions bearing an intimate relation, both causal and symptomatic, to nervous diseases. Some of them are overlooked or unknown to the patient, and others receive altogether too much attention at his hands. A thorough clinical examination of the urine, which should be quantitative as well as merely qualitative, is best made from a sample of a carefully measured twenty-four-hour collection. It shows at once the eliminative powers of the organism through the important excretion outlet of the kidneys. A lessened output of urea, or the presence of albumin or sugar, give important data as to the blood-state and may explain grave cerebral manifestations, such as convulsions and coma. A

very low specific gravity is noted after hysterical attacks. A large quantity of phosphates and oxalates is common to many neurasthenic conditions, and an ammoniacal urine is usual in paretic states of the detrusor urinæ. After an epileptic attack the specific gravity, toxicity, and solid constituents of the urine are increased.

The microscope, besides giving evidence of organic disease, such as nephritis, pyelitis, and cystitis, may show spermatozoa from a relaxed control of the outlets of the seminal vesicles, but more often demonstrates that the deposit considered seminal by the patient is devoid of testicular products.

Anuria in nephritis is of most serious import, though it may exist almost indefinitely in hysteria when associated with persistent emesis, whereby the uric products are vicariously ejected.

The state of the kidneys and ureters is made out largely by the investigation of the urinary secretion, but the bladder is open to more proximate methods. Its size, expulsive and retentive powers, its contents, and the condition of its mucous lining are, in suitable cases, to be investigated with precision. Loss of sphincteric control of the bladder in paraplegic and ataxic conditions is usual, while in meningitis, and in comatose states generally, retention of urine is to be expected and provided for.

The external genitals rarely give much information. In males preputial adhesions and accumulations or a long phimotic prepuce may be the source of irritation and the inciting cause of general nervous phenomena. Here, as elsewhere, any abnormal and correctable state should not escape appropriate attention. This is emphatically true of the deeper-lying generative organs in the female. Undoubtedly undue importance has attached to them and much ill-advised meddling has been bestowed, but a lack of integrity on their part should certainly engage methodical

treatment.

The genesic sense is usually blunted or completely destroyed in advanced locomotor ataxia and spinal lesions which cut off peripheral sensation. It is reduced in all depressed physical states, whether associated with marked nervous phenomena or not. On the other hand, the genital reflex may be accentuated in lateral sclerosis of the cord, and priapism, unattended by increased desire, may be a troublesome feature. In injuries to the cervical portion of the cord, priapism is likewise

common.

The question of sexual irritation and overindulgence calls for more than ordinary thought. Excess is a matter purely relative to the individual and his condition at the time of indulgence. Overuse of any organic function is shown by persistent fatigue and irritable prostration. This may here furnish us a working criterion, but we are to remember that matters have already gone too far when the great margin of natural reserve power has been overdrawn and even temporary debility produced. Thus, an amount of masturbation or sexual indulgence insignificant in a sturdy individual, is sufficient in the defective neurotic to induce a profound depression.

CHAPTER III.

THE MUSCULAR SYSTEM.

Motility. It is a rule with hardly an exception that nervous disorders are marked by errors of motility. These vary from a condition of slight general weakness, or paresis, to complete loss of muscular power, or paralysis, from slight tremor to rigid contractions. The character and distribution of the muscular difficulty is often of the first importance in diagnosis and in localizing limited lesions.

The station, attitude, and gait of the patient, depending as they do largely on muscular force, control, and activity, often furnish most important information. The contractured, semiflexed position of the upper extremity and the rigid lower limb, swung en masse from the pelvis with dragging toe, mark the hemiplegic. The bowed and trotting

De

Fig. 1.-Mathieu's hand-dynamometer fitted with detachable handles.

gait of paralysis agitans; the stamping and sprawling of tabes dorsalis ; the steppage or high knee-action with dangling feet that results from multiple neuritis; the spastic, rigid, and trembling legs of paraplegia ; the dangle-leg of anterior poliomyelitis, and the cerebellar stagger tell their own story. Minor peculiarities are no less, but rather more, important. The spinal rigidity and constant guarding against jars that dominate the attitudes and gait of the subjects of spinal injuries; the distorted features of cranial-nerve palsies, athetoid movements, choreic twitchings, restlessness, slight limps, awkwardness, attitudes of limbs, trunk, or head long or customarily maintained, have one and all a significance that can not be overestimated.

Reduced Motility. For testing muscular strength numerous recording instruments are available. In the hand-dynamometer of Mathieu we have a simple means of testing the grasp, and by fitting it with light handles attached at either end it can be employed in various ways to test the muscular groups of the upper and lower extremities. The examiner always has in his own person a check upon the records of the patient. When one handle is attached to a hook in the floor, the

lifting power of the back, the legs, or the arms is readily ascertained. Readings on such an instrument are of the greatest value for clinical records and as a means of comparison at future times.

But without any such instrument the physician can roughly test every group of muscles by opposing the efforts of the patient. To examine flexor and extensor muscles of the wrist, elbow, and shoulder, instruct the patient to resist your efforts to communicate motion to the respective joints. The same can be done in the lower extremity with the ankle and the knee. The hip is tested by having the patient mount a chair, ascend stairs, and raise the limb to a horizontal position. Both hands of the examiner grasped by those of the patient as vigorously as possible enables the physician to compare their strength.

In hysterics and malingerers it is sometimes difficult to feel that full efforts have been put forth, and in other instances muscular exertion is inhibited by pain or tenderness. In these cases particularly, the muscular tests may be advantageously varied and repeated by securing a large number of movements, such as having the patient stand on one foot, rise on the toes, stoop, crouch, lift chairs, and execute other tasks when he is not conscious of the purpose in view. Small movements of the fingers are very clearly studied as the patient buttons his clothing or handles different objects, which may, with design, be placed in his way.

Where the degree of feebleness is slight, it perhaps is manifest simply as fatigue after exertion or in walking a comparatively short distance. In some cases muscles which at first register considerable strength are rapidly exhausted by a few full contractions. In others initial efforts are weak, but quickly increase to a normal power, making it needful to always take an average of several tests.

The limits of the paralysis or paresis must be precisely noted, whether confined to a single muscle or muscle group, to the distribution of a single nerve or group of nerves, to a single limb, to the face, to one side of the body or to more. If the involvement is wide-spread, it will probably vary in degree in different regions, and this is also of importance. The terms monoplegia, hemiplegia, paraplegia, and diplegia are employed respectively as the face or a single extremity, the lateral body-half, both lower extremities, or both sides of the body are involved.

Not only is it necessary to record the strength of the muscles under examination, but also the manner in which they perform. For all precise movements, complete balance of muscular action-synergy-is a prerequisite. If the flexors of a joint are weakened, the extensors not only fail to execute their function with exactness, but their strength is also diminished and the resulting volitional movement is weak or clumsy in consequence. In conditions marked by errors of sensation, especially by impairment of the muscular sense which gives a knowledge of the position of our members and enables us to estimate weight, movements become uncertain. This uncertainty is generally exaggerated if the movements are not guided by the eye. Incoordination of movement results. This is sought for, and, if present, is demonstrated by having the patient, with closed eyes, touch given points, either on his own person or elsewhere, as by bringing the index tips of both hands together,