which requires nothing so much as a change of surroundings or more exercise in the open. And this is neither the need nor the prerogative of the rich man alone.

DRUGS. AS in the case of alcohol, so with drugs, the physician should exercise no foolish reserve in putting direct questions. In many cases, mere observation of the patient-his approach, his speech, etc.-tells the whole story, rendering questions almost unnecessary. Opium, and its many derivatives, and cocain, are in the great majority of instances the drugs employed, in the sense of drug addiction. Morbid conditions may, however, not infrequently be traced to the regular use, even in moderation, of such substances as aspirin, antipyrin, acetanilid, etc.

SLEEP. There is no hard and fast rule as to the time the average normal person requires for sleep. Eight hours may be regarded as sufficient for the majority of mature individuals. However, some require nine hours or even more to feel "fit," and others are satisfied with six or less. In many, if not most, cases as an individual gets along in years he finds that he needs much less sleep than the young adult. Also, toward middle life, many persons find that they have acquired the habit of awaking very early in the morning and that they are ready to begin the day's work, irrespective of the hour at which they may have retired the night before.

Bearing these facts in mind, the examiner should inquire into the patient's sleeping régime-how long and how well he sleeps, and whether he awakens refreshed. One should inquire, finally, as to the conditions of temperature and ventilation under which the patient sleeps.

TEETH. In view of the established importance of the condition of the teeth in the state of the patient's health, questions bearing upon the daily care of the teeth and the regularity with which the individual consults his dentist should form part of the routine in every case.

TOBACCO. This item should be as carefully investigated as is the subject of alcohol, because of the many injurious effects of smoking upon the predisposed individual. Conditions of vascular spasm (angina pectoris, intermittent claudication), gastric disorders, insomnia, nervous disorders, involvement of the optic nerve, and cardiac irregularities are a few of the more important disturbances more or less directly attributable to the use of tobacco in excess or to the use of tobacco in any amount by hypersusceptible individuals.

OTHER FACTORS.-Finally, in certain cases, it becomes necessary to go into the matter of the patient's clothing, his sexual habits, his business or family worries and other details of his routine life.

Venereal History.-Syphilis and gonorrhea are the two venereal diseases concerning which specific questions are to be put. Different courses must be pursued, depending upon the sex of the patient. A man will as a rule admit readily enough that he has had one or more attacks of gonorrhea, especially if it be spoken of as "clap." It is more difficult, as a rule, to obtain a history of syphilis. This is not so much a matter of concealment on the part of the patients, who fortunately have learned much through the medical propaganda of recent years concern

ing the by-products of the disease, and are generally willing and even eager to give the physician all the information they can. It is rather due to ignorance either of the meaning of the term or of the fact that they have been infected.

It happens not at all infrequently, for example, that the chancre was intra-urethral and associated with a neisserian infection, and that the secondary manifestations were transient or practically absent. Many patients are perfectly honest and correct in their statements that they have never observed cutaneous manifestations; others have seen no reason to distinguish between a syphilitic sore-throat and other anginas which they may have had from time to time. Extragenital chancres, and especially syphilis insontium, very frequently remain unrecognized. The venereal history of the married male also includes information as to the health of the patient's children and as to any miscarriages which his wife may have had.

Syphilis is widespread and its sequelæ are extremely important. It is therefore fortunate that the case upon which the history throws an inadequate etiological light can be illuminated in still other ways. The author refers to the several laboratory methods of the last decade, namely the Wassermann reaction in the blood and in the spinal fluid-with a provocative salvarsan injection, if necessary-the luetin cutaneous reaction, and the study of the cerebrospinal fluid.

In the case of women patients direct questions as to syphilis and gonorrhea are generally omitted. Circumlocution is usually satisfactory. Thus, if the present complaint, reënforced by the local examination, indicates a salpingitis, the patient may be questioned as to a previous vaginal discharge-its color, thickness, duration, effect on the act of urination, etc. If syphilis is suggested by the history already taken, she may be questioned as to the occurrence of sore throat, exanthem, loss of hair, headache, and other manifestations of the secondary period. A woman rarely has knowledge of the primary lesion. The most important information, however, is obtained from the menstrual history, which includes questions concerning miscarriages (see p. 587). Finally, as in the case of the male, if all of these leads yield nothing, the laboratory is the decisive recourse.

Menstrual History. In the case of patients presenting themselves with a distinctly gynecologic complaint, the present and past details (including operations) bearing upon that complaint should be analyzed under the subdivision: Present Complaint (p. 572); in the remainder of the cases, all illnesses of pelvic origin are to be considered in the subdivision under discussion.

The following questionnaire applies to the menstrual function:

(1) The age at which the monthly periods began, the time which elapsed before the menses became regular, and the symptoms, if any, which marked the period of adolescence.

(2) The type of menstruation, i.e., twenty-eight-day type, thirty-day type, etc.

(3) The regularity of the menstrual flow. (4) The amount of flow.

(5) The duration of flow.

(6) The symptoms present during the period.

(7) If the climacteric has taken place, the age at which it occurred, the symptoms of the transition, and the manifestations, if any, which have appeared since the change.

(8) The number of children born, if any, their ages and state of health; the number of children who may have died and the causes of their death; the number of miscarriages and their time relation to full term deliveries.

As has already been stated, important light as regards syphilis in the patient's anamnesis is thrown by the history of miscarriages. Following marriage, if one pregnancy after another results in a miscarriage, each of which occurs at a time somewhat later than its predecessor, one child being delivered dead at term and the next living only a short time, the evidence is practically complete that the mother has syphilis. Less marked variations of this sequence possess a significance only less important. One or more miscarriages scattered irregularly among full term deliveries of children who have survived and remained healthy have relatively little significance, so far as lues is concerned.

In the majority of cases, local conditions are naturally at the basis of abnormalities revealed by the menstrual history. Many general states, however, are suggested by such anomalies, especially in the case of women. in whom the menstrual function has previously been normal and who have not reached the age of the menopause. A few such general conditions may be cited, namely, tuberculosis, chlorosis, Graves' disease, myxedema and hypophysial disorders (acromegaly).

SYMPTOMS WHICH MAY BE NOTED BY THE EXAMINER WHILE HE IS WRITING THE HISTORY AND BEFORE HE HAS BEGUN THE EXAMINATION PROPER

At this point we shall consider, very briefly, certain matters which belong properly in the province of the physical examination and not in a chapter devoted to the writing of histories. However, the author has thought it advisable to risk the criticism of encroaching upon the field of physical diagnosis in order to emphasize the preeminent importance of the education of the physician's sense of observation. Although it is no doubt true that the power to see manifestations in the patient is to some extent a gift not possessed by all, it is equally true that the man who tends to overlook what is obvious to another can educate his undeveloped or neglected sense of observation to no small degree.

Perhaps by this repetition the author can assist in correcting another failing all too common among practitioners, namely, that of resorting at once to palpation, percussion or auscultation, before the eyes have been given a chance to observe.

The following are among the more important points of information (the list is by no means an exhaustive one) which the physician may have been able to gather upon meeting the patient and during the preparation of the history, before he has begun the actual physical examination.

Mental State.-A very fair idea of the patient's mental condition should have been gained by the time the history has been written, provided, of course, his sensorium is such that he can answer questions. Indeed, the diagnosis of the psychoses and neuroses must, in great part, rest upon what the patient says and his way of saying it, supplemented, if need be, by the statements of relatives and friends.

Insanity, aside from quiescent periods which may be part and parcel of certain types, is usually easily recognized as such. The emotional side of hysteria will scarcely be held in complete abeyance while the individual is being questioned. There may be attacks of weeping, crying, laughing, perhaps cries which mimic the sounds produced by animals, as barking, mewing, etc., or even a characteristic convulsive seizure especially staged for the physician. The neurasthenic generally betrays himself by his low-spirited and despondent mien, which is apt to be reflected in his mode of approach and even in his dress; while as the recital of the history progresses, his all-embracing symptom-complex, his anxieties, his phobias, etc., confirm what observation alone has suggested. However, the author cannot refrain from digressing to emphasize that if the examiner wishes to avoid serious error he must not make his final diagnosis of hysteria or neurasthenia until the routine examination has been completed, for it not infrequently happens that one or the other of these conditions is superimposed upon the basis of an organic process.

As regards the patient's sensorium we either recognize the individual to be in full control of his mental faculties, or, on the contrary, we note the presence of such deviations from the normal as coma, which may be of different degrees, varying from the form in which the patient may easily be aroused to that in which unconsciousness is absolute; delirium, which may be quiet, noisy or mixed; or stupor, such as results from alcohol or opiates.

Mode of Approach. Such information as may be derived from observation of the bedridden individual will be discussed below. The ambulatory patient cannot fail to make a very definite impression upon the physician, merely by his mode of approach. An erect carriage and an energetic gait point generally to some illness of a minor nature; a bent figure and a slow, calculated walk, to a serious illness or perhaps to mental depression. An unusual gait may clinch the diagnosis-or a portion of it, at least-at a glance (tabes dorsalis, hip-joint disease, hemiplegia, paralysis agitans, etc.).

Facial Expression. Data of great diagnostic value may be derived from a close observation of the patient's facial expression. First of all, conclusions as to his mental state (see above) are based not only upon the content, mode of recital and coherence of his story, but also in great part upon the impression conveyed to the examiner by the play

of his facial muscles. Intelligence and the varying degrees of lack of intelligence quickly reveal themselves by subtleties of expression. The hysterical grimace or purposeless smile are unmistakable, as are also the depressed mien of the neurasthenic.

The expression conveys also such subjective states as pain, anxiety, agitation, uneasiness and care, and gives one a very fair idea of the severity of the patient's illness. The face is furthermore a good index. of the presence of fever, which is recognized by a characteristic luster of the eyes and a redness and turgidity of the skin; while the sick individual may in some cases appear peculiarly animated and in others extremely depressed and dull.

Also characteristic are the distress and anxiety of dyspneic patients, the hunted expression in the more advanced stages of pulmonary tuberculosis, the facies hippocratica of peritonitis, the mask-like face of Parkinson's disease, the risus sardonicus of tetanus, the adenoid facies, the acromegalic face (large features, prognathous jaw), and the absent play of the facial muscles in Bell's palsy.

Position in Bed.-Many diseases may be characteristically indicated by the position assumed by the bed-ridden individual. This is illustrated by the case of the typhoid patient, for example. After the nurse has given him his morning care, he will remain until disturbed in the position in which he is left, namely, flat on his back in the middle of the bed. The resemblance of one case of typhoid to another is truly remarkable. The individual with disease of the thoracic organs, on the contrary, generally prefers to lie upon his side. Such a condition may properly be assumed to exist if the patient maintains the lateral posture when the physician enters the sick room and even when he is addressed. If pain dominates the picture, the sick man generally prefers to lie upon the unaffected side, as the weight of the body tends to increase the distress. If, on the contrary, the pulmonary function is limited (in pneumonia, fluid or air causing collapse of one lung), lying upon the involved side is preferable, as the healthy-or relatively healthy-side is unimpeded and can better do the work of both. In some cases, however, in which the pain and restrained breathing are more or less dependent one upon the other, the patient is likely to lie upon the side in which the pathology is located, as the body weight tends to act as a splint and thus limits the painful excursions.

In cardiac disease the patient may assume any of several positions, the comfortable one in the particular case being that in which the heart can best work under the disadvantages present.

In the severest grade of dyspnea-orthopnea-the patient can find a fair degree of comfort only by assuming the upright position, in a chair or propped up in bed, a position which gives the accessory muscles of respiration the freest play and allows the diaphragm to descend more readily, if fluid is present in the abdomen.

In meningitis, owing to muscular rigidity, certain constrained positions are common-opisthotonos, and more frequently, orthotonus. In conditions of peritoneal irritation, one or both thighs may be flexed to