Chapter 1
Olivia
Usually, I love stopping in at The Moon.
It’s a hip little bar one block from Main Street. A good place to hear live music, catch up on gossip and have a drink or two.
I’m a social person. Most of the time I like noise, a fun crowd, and a good gabfest.
But tonight’s an exception.
I’m tired.
My clothes are airplane-rumpled.
And no, washing my face at the Denver International Airport seven hours ago did not make me feel fresh. Hunching over that stainless steel sink only made me wish for a steamy hot shower, a pile of Dove body wash in my palm, and satin pajamas.
I just want to go home to my little apartment. Maybe stop in and see Gran, have a cup of chamomile tea, and then tuck myself in bed.
I grip the steering wheel and yawn.
That nap I took on Air Italia doesn’t count as a night’s sleep. I closed my eyes somewhere over the pink-tinted, snowy Alps. I’m not sure how long I was out. It was out long enough to feel disoriented when the stewardess woke me up, but not long enough to make me feel anywhere close to clear-headed.
That’s how I’d like my head to feel right now.
Clear.
That’s the best frame of mind for problem-solving, and right now I have a major problem to fix.
As I pass the Silver Creek welcome sign, a faint melody tinkles out from somewhere deep in my purse.
Probably Trent again. My brother is in panic mode.
I don’t blame him. I would be too, if I was in his shoes. In fact, the smartest thing my older brother Trent’s done in a long time is to freak out about the fact his fiancee, Maggie, left him.
I ignore the ringing. He’s probably calling to ask me how far out I am. Now that I’m only five minutes away it’ll be better to show up than to take yet another call from him.
In an effort to drown out his annoying ringtone, which I’ve heard way too often over these last two days, I turn up the podcast playing through my Mazda.
The topic is romantic relationships.
That’s the trickiest subject in the world, in my humble opinion.
Maybe that’s why I’m single.
To me, getting a real grip on how love works is tougher than deciphering a menu in Italian, when you don’t speak the language.
Or figuring out how to get from Terminal A to Terminal D at the Denver International Airport.
This whole romance thing, I think, is more complex than calculus, and I never got near that kind of math class in high school.
“...so you’re saying, Gemma, that when you make a match you’re focused on personality types?” “Oh, no, no, no.” Gemma Lafferty, a matchmaking expert, sighs. “I wish it was that simple, Andrea. But studies show that really good, solid, long-lasting couples— these couples who are truly in love and you can see it when they interact with each other— you know that kind of love?” “Oh, yes. One hundred percent. The Holy Grail for all of us single women.”
Sing it, sister.
I hang a right on Market Street.“Well, studies show that that kind of love is based on a very specific recipe, if I can call it that. It’s a mixture of personal histories, values, attachment styles, and, yes, personality traits. And even that barely scratches the surface. That’s why I like to really dive deep with each of my clients so that I can…” Up ahead, I spot the sign for The Moon.
The narrow, paved street is lined with cars. Out in front of the bar’s brick face, there’s the expected gathering of locals in a mix of fur, stylish felt hats, sleek leather cowboy boots, and designer suede. Silver Creek’s attracted a bunch of wealthy second-home owners lately, and working-class locals are few and far between. I squeeze the Mazda into the only available parking spot on the block that I can find. Come on, Gemma. Give me something I can work with.
I crank the volume dial to the max.
The host twitters over something witty Gemma said.
Gemma Lafferty remains serious. “I truly believe that this world would be a better place if we could get our relationships in order. We all have a Mr. or Mrs. Right out there. Why not really go after love, without holding back?” Well, dang.
That wasn’t the practical advice I was hoping for and I’m out of time.
Why couldn’t she say something about how to fix up a great couple that’s hit a bump in the road?
That’s what I need right now—advice on how to get Trent and Maggie back together.
They must get back together. They’re meant for each other, and their wedding’s only two weeks away. Since I set them up in the first place, I feel sort of responsible for seeing them through to the finish line.
Trent lucked out, big time when I scored him that first dinner date with my yoga instructor. I knew she was right for him. It was something about the fact that she loves stand-up comedy, fly fishing, and camping, just like Trent. They hit it off, and they’ve been together for five whole years. Five years that I’ve happily taken credit for.
And now… this?
According to Trent, Maggie packed up a suitcase and took off for her mother’s house two days ago and hasn’t picked up her phone since.
I step out into the cold, May-in-the-mountains air, trot across the street, and pull open The Moon’s door.
The place is busy and it takes me a minute to spot Trent, over by the bar. I see him, but he doesn’t see me.
So, when I position myself behind him and speak, his shoulders hitch up to his ears. “I can’t believe it. You let her go to her mother’s?”
“What the—!” The beer in his hands sloshes. “Olivia! Don’t sneak up on me like that.”
My brother’s buddy, Cole, is on the next barstool over. There’s an empty seat on his other side, but besides that, the bar’s packed. There must be a big basketball game on or something because most of the guys lining the tall table are in team colors that I recognize: sunny yellow, and midnight blue.
Cole’s shoulders rock as he gives a quick, silent laugh at my brother’s expense.
Nothing like a beer spill to get a lug-head laughing.
Trent flicks his hand and drops of beer spray outward.
Cole wipes his hand over his dark beard and shakes his head. He’s wearing a faded camo-printed ball cap pulled so low over his brow, I can barely see his dark eyes. His bulky, fur-lined canvas barn coat is smudged with grease and dirt like he worked in it all day.
For all I know, he did. He’s one of those rare unicorn, blue-collar types still left in this box canyon. He grew up out in the sticks on a ranch and still acts like he’s surrounded by cows, even though he’s lived here in town for years now. I can actually smell a mix of mud and engine oil wafting off of him. Lovely.
His voice is a low rumble. “Hey, Olivia.”
And that’s it.
No mention of Italy, where I’ve been for two weeks. No ‘nice to see you’ or ‘how was your flight?’.
Cole never says much to me, besides teasing me now and then.
And honestly, that’s fine. I don’t know anything about ranch work, fixing trucks, flying helicopters, or outdoorsy things. And as far as I can tell, given the hours and hours I’ve spent with him over the years, he doesn’t talk about much else.
“Hey yourself,” I say to him. “Can you move over one spot? I need to talk to this fool.”
Cole slides over, opening up the seat between him and Trent.
I settle in, feeling annoyed at the hubbub around me. On the bank of televisions above the liquor bottles, the basketball game is on display. A couple of dudes down the way are shouting about the referee’s unfair call.
“Why couldn’t you have met me at Gran’s like I asked?” I ask Trent, as I wave the bartender away. I don’t need a drink. I need a dark, quiet room and my soft pillow under my sleepy head.
“Grandma Georgia doesn’t keep beer in the fridge.”
“Yeah, well, that Coors in your hand isn’t going to help you get Maggie back, is it?”
Cole leans forward. “She’s got a point, there.”
I ignore him. I bet it was his idea to spend the evening at The Moon in the first place.
Cole’s always getting my brother into trouble. Like that time when they were seniors in high school, and Cole got Trent to skip class with him and climb Ajax Peak so they could ski down the next morning.
My grandmother grounded Trent for a month after that.
Smart lady, my gran.
Trent lifts his long-necked bottle and takes a swig. He shakes his head as he slaps it back down on the coaster. “Maybe not, but there’s another thing. Grandma Georgia doesn't know yet.” I sigh. “Shoot. She doesn’t?”
It’s starting to hit me—how big this problem really is. My grandmother loves Maggie as much as Trent does. As much as I do. Heck, as much as anyone who’s ever met Maggie loves her. She’s one of those people who shines really bright, and we’ve all been basking in her warm glow for half a decade, counting on the fact that one day, she’d be part of the family. “The wedding is in fourteen days,” I say, as though my brother doesn’t know.
He knows. He helped me and Maggie address all those invitations, last spring.
He hired the band. He paid for the venue. He spent three days fly fishing for his bachelor party.
He knows.
Without much thought, I reach out for his bottle of Coors and take a swig.
This is bad. Really bad. Two weeks to the wedding, and he’s not even talking to his future bride.
Cole pipes up again. “Pretty sure you said Coors wouldn’t help the situation.” I swivel to him.
“You know what you just did? You offered to buy me a drink.”
He lifts the corner of his mouth in a smug grin.
“Thought I was pointing out a little hypocrisy.”
“That sure is a big word, coming from a guy who doesn’t even know how to be a Best Man... You’re supposed to give emotional support right up to the big day. How’d you let him mess up this bad?”
“Hey, did you come here straight from the airport?” My brother asks.
“Yes, and I’m exhausted, hungry, and cranky, so let’s get down to business.”
I can’t even believe I’m here, sleep-deprived and in pants so wrinkled they look like they’re fashioned out of crêpe.
“What we need is a plan.” I steal another sip of my brother’s beer. “I’m just having trouble wrapping my head around the fact that she actually packed up and left. Maggie has been by your side for five whole years, laughing at your jokes, cooking you pancakes, folding your underwear. She told me once that she feels like her life didn’t even start until she met you. She adores you.”
“Actually, I fold her underwear. I do the laundry, she—”
“That is not the point. The point is, when I left for Italy, you two were fine-tuning the seating chart. Since then, you managed, somehow, to do something to make her pack a suitcase and run away.” Trent’s shoulders slump.
Oops. Maybe I’m getting too worked up. He knows he messed up terribly, and he already feels bad enough about it.
I can tell he’s been busy beating himself up because of the two days of reddish stubble across his chin. The bags under his eyes are about as big as mine. I grab his hand and squeeze it.
“Hey. Sorry. I’m just fired up because… because she’s Maggie, and I love her like you do. I want her to be my sister-in-law. No—I want you to be happy. That’s what’s most important here.”
And the sister-in-law part.
Ever since Trent proposed and she said yes, I’ve been thinking of Maggie as the sister I never had.
I figured she’d be there at every Scott family holiday celebration, offering up that delicious cranberry sauce she always makes with the actual,
whole cranberries. Handing out plants as Christmas presents. Waving sparklers at the Fourth of July barbecue.
I thought we’d get to do sister-ish things, like go shopping for clothes together and plan family vacations and maybe share a room in a nursing home one day. Sisters do that, right?
“Everyone knows you guys make each other happy. We’re going to fix this.” I squeeze Trent’s hand. “I want this wedding to be the best day ever.”
“I do, too. I thought everything was good. How can I get her back, if she won’t even answer her phone?” He lifts his miserable eyes to meet mine. “I tried to drive out to her mom’s, but you know they have that gate across the driveway. I couldn’t even make it to the house.”
It sucks to see him so down.
So unshaven.
So un-Trent.
My big brother co-owns a successful ski-touring business with Cole. He drives a big, shiny new truck, owns a cute, tidy house and is typically so ontop of everything.
It’s unsettling, to see him at a loss like this.
Think, Olivia.
How am I going to make this better? How am I going to fix this crazy mess? The bartender passes, setting a bottle down in front of me as she goes. I see her pause in front of Cole to collect his credit card.
“Some women buy their own drinks,” Cole grumbles, as he sets his worn leather wallet on the bar. “It’s called equality.”
It’s our usual song and dance.
The last time I was here with Trent and Cole and some other friends, Cole made a big fuss about me buying his beer because of some bet I lost. The time before that, I got him to foot the bill for the two glasses of wine I had with dinner.
But right now, I have bigger things to worry about than squabbling with Cole...
“I left my card in the car,” I tell him with a dismissive wave out toward the street.
“Funny choice, seeing as everything in this place costs money.”
“Would you quit distracting me?” I lift the drink and take a sip. “I’m trying to think.” I turn to face Trent again. “Okay, let’s start from the beginning. She left Tuesday night, right?”
“Yeah. After dinner. I grilled.”
The bartender hands Cole back his card. He slips it in his wallet and leans to one hip to get his wallet into the back pocket of his snug black Levis.
“What’d you grill up?” he asks Trent.
As if that matters.
“I don’t think the menu’s the issue here,” I say. “We’re going to talk about actual emotions, as frightening as that might be to both of you.”
Trent leans forward to speak past me.
“Burgers. Cheeseburgers, with that good beef you gave us. Mine was medium-rare, I grilled hers up so it was well done. She hates seeing pink in the middle.”
“Can we focus, please?” I wave my hands to break up the meat-grilling chit-chat. “What’d she say, before she left? What was her emotional state? You know… crying, yelling, silent treatment…?”
I can’t imagine Maggie giving anyone the silent treatment.
Then again, we all behave badly under stress. I’ve seen myself act like a two-year-old under the perfect storm of circumstances, so for all I know sweet Maggie threw a temper tantrum and rolled on Trent’s kitchen floor, balled up fists, screaming and all, before she scooted out of town.
“She was sort of sad,” Trent mumbles.
I arch a brow and deliver a disappointed teacher look at my brother. He’s a year and a half older than me, but sometimes I feel about a thousand times wiser.
“Sort of sad? You’re going to have to do a lot better than that if we’re going to get to the bottom of this mess.”
“Okay… she was sad, like, disappointed in me or something. And I think she cried, but not in front of me. Her eyes were puffy and red when she came out onto the deck to say she needed some time to herself. She already had her suitcase packed.”
“Not good. Not good.” I swipe my bangs from my eyes and try to use those two barely helpful pieces of information to see things from Maggie’s point of view. It’s two weeks before her wedding. She’s disappointed enough to cry… about what?
“Man,” Cole says, “Did you use the new gas grill or that old charcoal one?”
Really? I peer his way long enough to shoot a glare that I hope reaches him under the brim of his camo hat.
He holds a hand up. “Sorry! I was curious.”
“Yeah, but you’re not helping.”
“Okay—how’s this.” He takes a swig of beer. The fur-lined canvas bar coat opens up enough to show the black t-shirt pulled taut across his chest and the silver chain necklace with some sort of saint medallion that rests on his strong pecs. “Trent, how about that time back around Christmas, when she was talkin’ about the yoga thing?”
Trent speaks past me again, like I’m not even sitting right here.
“What yoga thing?”
“You know… the yoga thing.”
I pinch the bridge of my nose.
I’m too tired for this.
Too jet-lagged.
Too smart, with too much estrogen simmering in my body.
“If you two meat-heads could try using your words, that’d be wonderful. I’d like to make some progress before the bar closes.”
Trent ignores me. “You mean that woo-woo couples camping thing in the desert she wanted to go to?” he asks Cole.
“Yeah… yeah, that.” Cole does another one of those slow nods. “Glamping. Some hippy lady...”
I throw a hand up.
“Am I invisible? Someone talk to me!”
OceanofPDF.com
Chapter 3
Olivia
There are perks that come with being a travel blogger.
I get all sorts of things paid for, for one thing. Airplane tickets, cruise vacations, week-long stays at luxury hotels.
Gourmet meals, visits to spas, even an African Safari, once. That particular trip wasn’t that much fun. As in, it was terrible. The Jeep didn’t have windows. Rhinoceros might look interesting and harmless enough on wall calendars, but they’re actually terrifying to see in person.
Lions? Forget about it.
I peed my pants a tiny bit when the tour guide pointed a pair of them out, I was so scared. I had to tie my sweater around my waist and avoid the other guests for hours until I could change. That detail certainly didn’t go in the articles I wrote about the trip.
In addition to all the paid-for trips, I also get to meet amazing people in the industry.
And if I’ve learned one thing about relationships, it’s that everyone on this earth likes a win-win situation. I’m really hoping that Skye Solei, the
yoga teacher in charge of the Couples in Crisis retreat, will see that if she helps me out, I’ll help her. Big time. This woman’s website is in shambles, and I’m the perfect girl to jazz it up for her with some stellar content.
I prop my fuzzy slippers up on the coffee table and scan her clunky, outdated website, looking for her phone number. I already sent her an email, but I’m worried that’s not enough. Because somewhere between chowing down a bagel this morning and drinking my second cup of coffee, I realized that the couples retreat my brother so stupidly refused to attend is actually starting tomorrow.
Not only that but it’s totally booked up, according to this sparse website.
I sip more hazelnut-laced coffee and listen to her phone ring.
Outside the single window in my studio apartment, I can see down into my grandparent’s backyard. My Grandpa Ray’s out there, kneeling in front of a muddy garden bed. I haven’t even seen him or Grandma Georgia since I got home, and it takes some major self-discipline to stay focused on the phone call I’m making instead of hanging up and running down there to give him a hug.
When Skye finally picks up, I’m mid-sip.
I hurry up and swallow. “I’m so glad to get in touch with you!” I gush, after introducing myself. “I’m a writer in the travel industry niche. I have a question for you about your upcoming retreat.”
I flick my eyes to the photo of steep, reddish canyon walls on her website. “The one in Desolation Valley…?”
“Of course. Heart-centered yoga for couples in—”
“In crisis. Right.” I didn’t mean to cut her off, but here we are.
I blame my nerves.
This has to work.
It’s the only idea I have for fixing whatever’s going on with my brother and Maggie. I bite my lower lip.
Please say yes.
“I have an offer for you, and I’m really hoping you’ll be interested. See, my brother and his fiancee thought about registering for it. But he was stubborn and refused, and now they’re in a big fight and the only thing I can think of to get her talking to him again is a stay at your…”
I glance back at the website, so I’m sure to get the name right, “Sunrise Ranch. Great name, by the way. I could write for you, in exchange.”
“How nice of you to call.” She’s got one of those whispery, melodic voices. It’s like she’s singing a lullaby in my ear.
“A writer, you say? It’s so wonderful, isn't it, how the universe arranges these things?”
“Sure is. I actually specialize in marketing writing. It can be great for places like yours, where potential visitors pop into a website before booking a stay. And speaking of your website, I’ve been checking it out. The last article you have published is dated seven years ago.”
“I do neglect that aspect of my work. I haven’t looked in on that website since the winter solstice when I set the intention of nurturing my business. As I’m sure you know, intentions come to fruition in unexpected ways. We don’t dictate the ‘how’. That would be quite arrogant, wouldn’t it? We let guidance come through. Our Sankalpa reaches to the heart’s deepest desire and then things fall into place.”
“Erm…”
I do attend yoga classes regularly when I’m not traveling.
But picking up a few terms in Sanskrit is about as far as I’ve gotten with the actual philosophy behind all those pretzel-bendy exercises. Shavasana is my favorite word because it means lie down and relax all your muscles until you’re nearly falling asleep.
And sometimes when a yoga teacher puts us in that pose, I actually do blackout for a few seconds. Who doesn’t like a good power nap?
Skye goes on in her whispery way. “At first, I thought I should spend time focused on that old website, but whenever I sat down to do it, I couldn’t muster the energy. As it turned out I was much more inclined to work on my shoulder stands than stress at the computer.”
“Maybe I can help you out,” I suggest. “I could produce some content for you about your retreats, and your ranch. I’d love it if you could find room for my brother and his fiancée. I know it’s last-minute…” I pace to the window, look down on the lawn, and then actually cross my fingers.
It’s a weird superstition, this crossing-of-fingers thing. Like if I twist one digit over the other, this woman miles away is going to give me the answer I want.
I think I’m holding my breath, too. At least, I feel it come out in a whoosh when I hear her say, “Yes, I do believe I could fit them in.”
“Really? Oh, my goodness, that’s great!”
As far as I’m concerned, this is a victory.
Epic shopping trips with Maggie, here I come!
She will be a Scott. I’m going to see to that.
“I had one cancellation come through just this morning,” Skye says. “That’s to be expected. When it comes to doing this deep work, some people just aren’t ready, and their resistance is sure to surface as the event draws near. We must be warriors of the soul to delve into uncharted territory and do what it takes to do the real work of opening the heart. And then, there was the DeMarsico cancellation that came through three weeks back. They can’t make it because of a dead uncle. Funeral, or something.” I expect her to say something poetic about death. She surprises me by falling silent.
“Um… so, you have openings? That really is fantastic. My brother’s name is Trent Scott, and his fiancée is Maggie Thompson. And I’m Olivia Scott. I’d be happy to stay for the five days so that I can write about your place and your teaching style, or whatever else you want me to cover. And if you need payment, too, my brother can take care of that.”
This is his wedding I’m saving, after all. He can foot the bill.
“I think the articles will be plenty of payment. You tell your brother and his fiancee that I’ll be more than happy to work with them. And I’ll look forward to going on this journey of discovery and healing with you and your partner as well, Olivia. I’ll book the Starry Sky as well as the Milky Way yurt. The opening ceremony begins tomorrow at five, but I do advise guests to arrive a few hours before then, so they have time to get settled in before the real work begins.”
Below, my grandpa takes off his hat and swipes the back of his hand over his brow. He looks up, catches sight of me in the window, and waves.
I wave back, though now I’m distracted. “Thanks—but I’ll be on my own. Better that way, so I can observe and do research for the articles.”
“Alone…? Oh, no. That won’t do.”
That won’t do? What does she think, I have a choice about being single? She goes on.
“I’d much prefer it if you bring your partner along. This is a couples retreat, dear. It requires vulnerability and authenticity. I don’t think the other participants will much appreciate a reporter there, observing. Better if you’re part of the experience, documenting your own journey on the ranch.”
“I—” I don’t have a boyfriend.
I stop myself before completing the sentence aloud.
What if she takes back her offer? She sounds dead set against having me there on my own.
I’m going to regret this, I think, as I close my eyes.
“I—I’ll be sure to bring along my partner, then. I’ll… um… see if he can get the… uh… time off from work.”
“Wonderful. I’ll see you all tomorrow afternoon.”
I hang up and listen to the clomp, clomp, clomp of my grandfather hiking up the stairs from the garage.
When I open the door, he peers at me, his bushy white brows knit together with concern.
“What is it, Love Bug? You look like you’re sick to your stomach. Did you get bad airplane food again?”
“Nope. It’s…er.”
It’s my life. My freaking life.
I try to fix one problem, and I make another.
“It’s… nothing, Grandpa.”
“Good, I hate the thought of you feeling ill, with the wedding coming up. Goodness, it was quiet around here while you were gone. We missed you. What do you say to some tea? We can’t wait to hear about that trip of yours, and Gigi made those pistachio muffins you like.”
Gigi, of course, is my Grandmother Georgia. Her muffins are out-ofthis-world good, and I want to tell her all about my two weeks in Italy, too.
“Maybe I could swing by in a couple of hours? I have something to deal with, first. It’s sort of urgent.”
Finding a fake boyfriend so you can save your brother’s wedding counts as ‘urgent’, right? My grandfather seems to be satisfied.
“You bet, Love Bug. The doors always open and I’ll try my darndest not to eat all the muffins.” He laughs and pecks my cheek.
I walk with him down to the garage and then take down a list of groceries that he and Gigi need me to pick up when I’m out.
Back up in my apartment, I kick off my slippers.
It’s time to get out of these PJs and into some actual clothes. I wanted to knock out another segment of my Ultimate Guide to Touring Italy’s Best Cities on Foot article, but that’s going to have to wait. So is eating a tender, fluffy, nutty muffin.
How am I going to find a guy willing to go play the part of my boyfriend for five whole days?
I pull on jeans, tug a sweater over my head and then primp my curls back into place. I can figure this out. I have to.
Trent’s counting on me.
As I jog down the apartment steps, I dial Maggie. She may not be talking to my block-headed brother, but maybe, just maybe, she’ll talk to me.
Chapter 4
Cole
I’m paying for the three beers I drank last night.
And for getting up before the sun, so I could drive out to my family’s ranch in Farmdale. The freaking tractor tanked again. I keep telling Dad he should buy a new one, but he keeps insisting the one he’s got is fine.
I smacked my head on the axle and jammed my thumb trying to get a lug-nut loose. Then I drove the hour back here to Silver Creek as the sun rose above the ridges. Had to wait in line for coffee at the window down on Market Street for a full twenty minutes, while every diva and mountain-guy wanna-be in town bought themselves some sort of fancy caffeinated beverage.
What’s the big deal about these lattes and cappuccinos, anyway?
What’s wrong with good old, simple, get-the-job-done black coffee?
Nothing.
Nothing’s wrong with black coffee.
I bet half the people in that line didn’t even have jobs to go to today. Seems to me like most people in this town have plenty of time to stand
around and trade compliments about whatever purebred dog they’re yanking around, and very little time for actual work.
But I have a business to run.
Might not be ranching, like my dad and brothers expected, but it’s still honest work.
Even if I have a headache ‘cause I stayed out too late keeping Trent company, I’m still gonna do it.
I lean back in my chair and listen to yet another aviation leasing specialist jabber on about what he’s got on offer.
I know he’s trying to upsell me. I’m not interested.
“Mike, man, I hear you,” I tell the guy. “I’m sure that bird’s sweet, but our clients don’t expect leather upholstery. They want to get up into the mountains so they can make powder turns. I’m more interested in that M44 model you told me about yesterday.”
“But—but—Versace leather!” He sighs. I’m a big old disappointment to him, obviously. “You do charge high dollar for your ski tours, right? Thousands of bucks a day? These executive-suite touches will add value—”
“No, man.” I swivel to face Trent and shake my head at him. He knows how much I hate dealing with these salesy types.
Trent wags his head empathetically, though his heart’s not in the gesture.
Poor guy’s gray-faced, with dark smudges under his eyes. He hasn’t touched the breakfast sandwich I brought him again.
“I told you, we’re after functional. Practical. No frills. Safe. Yeah, we charge high dollar, but that’s for getting these people up to the mountains and back in one piece, with a good experience under their belt. I want to know more about the M44.”
“The M44’s cockpit is outdated,” my sales rep friend argues.
“I learned on an old machine. That doesn’t scare me. I don’t need digital. So how about we move past this executive-model crap and get down to it about the basic model. We’d need her for five months, December through April.” He protests some more but eventually agrees to check on availability and pricing. He promises to get back to me and I hang up feeling frustrated.
I cross the company name off my list.
“That should’ve taken me five minutes. Instead, I had to listen to his crap for twenty.”
“Mike again?”
“The guy’s going for salesman of the year or something. I don’t think he’s going to come through on the M44, either. They always get booked up first.”
Trent swears into his coffee cup before taking a sip. Then he goes back to studying his laptop screen. He’s made a good show of working this morning, though I’m not sure he’s actually getting much done. He’s supposed to be reaching out to previous clients, but I’ve barely heard him type a dozen words if that.
He keeps reaching for his phone and then chucking it back on the desk like it bit him.
“Has she called you back yet?” I ask, meaning Maggie.
“No. I’ve left her five messages so far this morning.”
“Sorry, dude. Wish I had some advice for you, but… you know.”
What do I know about women? The woman I’ve been after for a while now, Danielle, turned me down again this morning.
I saw her in that long line for coffee. She was one of the few people there actually on her way to a job. Her Wild Chicks catering van was parked not far away.
Trent knows me well, and he guesses what’s on my mind. “You seen Danielle around lately, or what?”
“She was down on Market Street at the window. Man, that line gets long. Drives me crazy, just waiting.”
“You talk to her?”
“Yeah. Asked her to the wedding.”
“Aagh. If it happens,” Trent says with a groan. He reaches his hands up and rakes both through his hair, clawing at his scalp.
“Why won’t she call me back?”
“She’s mad, I guess. Or sad. Or whatever you talked to Olivia about last night.”
At that moment, the front office door swings open, and Olivia saunters in. She looks more bright-eyed than me and Trent, and she’s smiling.
She takes one look at the two of us and laughs.
“Yikes. It’s like walking under a big dark storm cloud, stepping in here. Can’t either of you smile once in a while?”
“Why should I smile?” Trent grumbles. “Maggie still hasn’t called me.”
“I know.” She walks over to his desk. “I just got off the phone with her a few minutes ago. Here, eat something for heaven’s sake.” She sets a wrapped foil package down on his desk, next to the one already there.
Trent points to the first. “Cole brought me one, too.”
She glances over at me, but not for long. I’ve never kept her attention. I’ve tried to talk to her over the years. Real, actual conversations, not just kid stuff like what channel to watch or whether there’s any lemonade in the fridge. She and Trent were raised by their grandparents, and I spent a ton of time over at that house from the time I was seventeen.
But whenever I tried to talk to her, she’d get to looking bored.
So, lately, I don’t try. Women like Olivia go for flashy guys, the sort with degrees, book smarts, and loud opinions.
Soon she’s back to fussing over her brother. She unwraps the foil around the sandwich so it’s like a plate under the greasy English muffin, and then slides the whole bundle on top of his paperwork.
“Seriously, eat. You look like you’re about to faint. I need you to be in at least decent shape when you see her.”
“See her?” For the first time in days, Trent actually sits up straight. He reaches for the sandwich. “What do you mean?”
Then he digs in like he’s starving.
I’m sure he is. You can’t live on beer and mint Tic Tacs, even though he’s given that menu his best shot these past two days.
It’s probably a good thing Olivia’s home.
Though, that’s a hard truth to keep in mind when she plops down on my desk.
Right on top of it, with her back to me. Without even clearing a space. She always does this, too. And every time, I think how we should get at least one chair in this little closet-like office space. Olivia hangs out here a lot when she’s between trips, and even though her backside’s not bad to look at—not at all bad—it’s hard for me to get work done when she’s using my desk as bench seating.
“Hey, Olivia.”
She doesn’t even look back at me. Just gives that sassy response she always gives me when I say hello. “Hey, yourself.”
Hey yourself.
She’s said that to me probably ten thousand times over the years.
Would it kill her to give me a decent greeting? Say my name, maybe? Ask me how I’m doing?
That’s too much to ask, clearly. She goes right on talking to Trent. “I got you and Maggie into the Couples in Crisis retreat! Yay!” She claps her hands. “Maggie actually sounded hopeful about it. She sure was tightlipped about what’s going on between you two, but she did say that it means a lot to her that you’re willing to do this with her. And you are willing, aren’t you?”
“Yes. A hundred percent,” Trent agrees.
I get the feeling that he’s not just giving his bossy sister the answer she’s fishing for. He really sounds ready to do this retreat thing.
And that says a lot, as far as his relationship with his girl goes.
Trent hates touchy-feely things. He’s like me. We like action, not sitting around hashing out who said what and whose feelings were hurt.
It’s crazy how sometimes the two of us go hours without saying even one word. Once we went on an entire camping trip without talking about much more than what kind of fish were biting.
But the guy has a big heart, and I know he’s bent up about Maggie and ready to do whatever it takes to get her back.
In that respect, he’s a better man than me.
If it was me? I wouldn’t be caught dead at a yoga retreat.
Even if it was to win back a woman, I was head over heels for. Maybe I’ve just never been that head over heels for anyone.
I’ve had crushes, sure.
Heck, I even once had a thing for the woman sitting on my desk right now. I had the hots for Olivia way back in high school, and she sure shut that down really fast.
I moved on and liked other women, and even dated some. But I’ve never met one I’d suffer for like I’m sure Trent’s about to suffer.
Five days in some remote desert, stuck with a bunch of other couples on the rocks?
Shoot me.
Olivia leans back, nearly knocking my travel mug over with her hand. She’s swinging her legs, and the desk creaks under her weight.
“The lady who's running the retreat sounds sweet, in a yoga-teacher kinda way. She was up for my idea of trading articles for retreat spots, so you don’t owe her any money. You owe me, though. Big time.”
She pokes a cherry-red nail her brother’s way.
“I accept gift certificates, cashmere sweaters, or boxes of chocolate. Oh, and she wants me to go to the retreat, too. Like, immerse myself in it. Participate. Which is going to be a challenge since it’s a couples retreat and I’m not seeing anyone.”
I’m barely listening to her.
Instead, my mind’s on Mike. What he’s finding out from management about the M44?
Man, we really have to get a chopper booked for next winter. Soon. The company Trent and I have used since starting up this business together recently went bankrupt.
Of all the things I have to do today, pursuing a new helicopter is the most important.
But I guess my calls will have to wait.
Olivia’s booty’s pinning down the list of aviation leasing companies that I’m working through.
I sigh with frustration and sip the coffee that I managed to save from destruction.
She’s definitely back to her cheerful self now that she’s not so travelweary anymore. If she was feeling moody, she’d harp on me for sighing like that.
I try again.
I want her to get the point—that I need her to move.
She glances over her shoulder at me. “What, are you going through menopause or something? Having a hot flash? What?” I snort.
I have to hand it to her. She can make me laugh.
“Maybe you should go get some fresh air or something. It’s super nice outside.” She pulls out her phone and starts scrolling through. “All I have to do is find a guy to go with me and pretend to be my boyfriend.”
“Shouldn’t be too hard,” I mumble, more to myself than anything. “Bunch of bickering couples sitting around, getting in touch with their feelings…? That’s every guy’s dream vacation.”
She ignores my sarcasm.
I catch a whiff of her shampoo as she flicks her curls back and presses her phone to her ear. I do my best to tune her out as she jokes around with a guy named Sam, who I remember from high school. Then Randy, who runs
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muscular atrophy (as in progressive muscular atrophy) the loss of faradic contractility is only demonstrable in the affected fasciculi, good contractions being obtained in adjacent healthy fasciculi of the same muscle. The amount or extent of contraction varies pari passu with the progress of the atrophy. The galvanic reactions of this form of muscular atrophy are not yet well established. Muscles and muscular groups in a condition of impaired nutrition exhibit at an early period an interesting condition—viz. that they no longer contract by reflex excitation. Thus in a case of infantile poliomyelitis with paralysis of the muscles of the leg, these muscles no longer contract when the sole of the foot is tickled, and if the thigh-muscles are affected even so slightly as to appear of normal size and consistence, the patellar reflex is found wanting. In these and in traumatic cases the reflex act is prevented by lesion of the centrifugal motor nervous apparatus, and perhaps also by the associated muscular trophic alterations.
6 Conveniently expressed by the symbol De R.
Histological changes in atrophied muscles vary somewhat in character in different diseases, and vary much in degree at different periods of the atrophy. An early appearance is the presence of proteinaceous and of fatty granules or molecules in the sarcous substance. Later, the muscular fibres become reduced in size, lose their striation, and show inequalities; the interstitial connective tissue becomes active and increases in amount, at the same time that fat is deposited. The fatty change in some cases, in others the granular or proteinaceous transformation, ultimately completely destroys the muscular substance, so that in the place of a muscle we find abnormal connective and fatty tissues, blood-vessels, fatty and proteinaceous débris, the whole presenting a pale yellowish-white aspect. It is in this final stage of degenerative atrophy that all electrical reactions are lost. In the pseudo-hypertrophic state the interfibrillary and interfascicular connective-tissue growth is much more active, and the wasting muscular fibres are buried in masses of wavy and fatty connective tissue. In this condition also electrical reactions may be wholly absent.
(b) Atrophy due to defective innervation sometimes affects the skin and bones. In the former, after nerve-injuries more especially, we observe loss of thickness, glossiness, and perverted circulation and secretion; the hairs may fall out or grow abnormally; the nails are slow of growth, thick, rugose, incurvated, and brittle. In other cases, as in cerebral and spinal paralyses, the skin of the paralyzed part is abnormally dry, rough, and furfuraceous, and it loses its elasticity. In some varieties of so-called skin diseases the patches of altered nutrition (eczema, bullæ, herpes, psoriasis, leucoderma, scleroderma, etc.) are often, probably, dependent upon nervous lesions.
In the very rare disease known as progressive facial atrophy the skin, subcutaneous areolar tissue, and the bones undergo extreme atrophy. The initial lesion is usually a patch of scleroderma with or without neuralgic phenomena; the skin is thin, darker and smoother than normal; it soon adheres to the subjacent bone (maxilla or zygoma), which itself steadily diminishes in size. Almost the entire half of the face (including the palate and tongue) may ultimately show the atrophic changes. We are not yet prepared to state the causal nerve-lesion in this disease.
The bones are abnormally fragile (fragilitas ossium) in some nervous diseases, more especially in dementia paralytica and posterior spinal sclerosis; but whether this condition is due directly to the nervous disease or is the expression of more general malnutrition is now undecided.
The complex lesions of joints observed in the course of posterior spinal sclerosis, the spinal arthropathies of Charcot, probably belong to this category. The affected joint (knee, shoulder, or ankle) rather suddenly swells, and the swelling usually invades the rest of the member or extends to the next distal joint; it is a hard, semi-elastic swelling unlike common œdema. After its gradual subsidence it is found that changes have taken place in the articulation itself, and later distinct evidences of destructive disease, such as erosion of cartilages, relaxation of ligaments, swelling, are observed. In many
cases extra-articular lesions appear in the shape of osteophitic formations from the adjacent bones. The hydrarthrosis may persist or disappear. So complete may be the destruction of the joint that— for example, in a case of arthropathy of the knee—the leg may be twisted about in all directions, and even over-extended so as to lie upon the anterior surface of the thigh. Examination of the joint postmortem reveals non-suppurative destruction of all its component parts, cartilages, ligaments, and epiphyses; the eroded, deformed ends of the bones rub against one another in a false joint-cavity formed of the skin, connective tissue, tendons, and remains of ligaments. The absence of pain and tenderness in the course of arthropathies is a striking feature—so much so that when, in an adult patient, it is observed that manipulation or puncture of a diseased joint is painless, special inquiry should be made for symptoms of posterior spinal sclerosis.7
7 We have known one case in which the diagnosis of tabes dorsalis was made (and verified after death) in this way, after the surgeon in charge of the patient had mentioned the fact that puncturing a swollen diseased knee-joint was painless.
(c) Under the head of degenerative atrophies should be included the secondary changes which affect certain nerve-tracts within the nervous system itself. It is impossible in this introduction to treat fully of this interesting category of trophic changes; the following summary must suffice: (1) When the cerebral motor cortex or any part of the associated pyramidal (or motor) tract is destructively injured, there occurs, in from three to six weeks, a degeneration of the whole tract caudad of (below) the brain. The myeline becomes granular and disappears, the cylinder-axes are broken up and vanish, the connective tissue (neuroglia) increases in amount; the atrophied and degenerated area appears in a transection rather translucent in contrast to the pearly white of the normal medullary tissue, and when the preparation is stained with carmine the patch takes up an abnormal amount of pigment. This is the so-called descending degeneration, or centrifugal atrophy of the central nervous system. (2) After total transverse lesions of the spinal cord, besides the above-described centrifugal degeneration caudad of the
lesion, we observe frontad of (above) it similar changes in the posterior median columns, and in the direct cerebellar tracts— centripetal degeneration. At present we have no knowledge of centripetal (ascending) degenerations in the cerebrum and in nervetrunks; and if the results of von Gudden's experimental method be cited against this statement, it must be replied that its effects are best seen in newly-born animals, and that its pathology is yet unknown. (3) Lesions of the anterior gray matter (ventral cornua) of the spinal cord, and of mixed nerve-trunks produce only centrifugal or descending degeneration. All the nerve-fibres deriving their innervation from the injured area in the cord, or in case of nerves all fibres below the injury, perish—i.e. their myeline breaks up and undergoes granular and fatty degeneration, their cylinder-axes are segmented and disappear, while at the same time the connective tissue of the nerve becomes abnormally active and increases. Furthermore, in cases of this category there are, inevitably, degenerative and atrophic changes in the attached muscles, and peculiar electro-muscular reactions (vide supra). All these central and peripheral nervous degenerations, due to a local lesion, are conveniently grouped under the name of Wallerian degeneration.
2. ERUPTIONS AND ULCERATIONS.—(a) The cutaneous eruption about whose nervous origin there is the least doubt is that known as herpes or zona. This manifests itself, with or without paræsthesiæ (pain, itching, formication, etc.), as vesicles upon deeply-inflamed spots of skin distributed in the territory of one or more sensory nerves, and almost always unilaterally. The destructive process in the derma is so profound as to leave scars which are indelible as a rule. In general terms it might be stated that herpes may occur in the range of any sensory nerve distributed to the skin or mucous membranes. The neuralgia attending its development may be severe, and in some cases lasts for years after the healing of the eruption. The pathology of this affection appears to be inflammation of the ganglion of the posterior root of one or more spinal nerves (including the trigeminus and glosso-pharyngeal) or of their trunks. Herpes may appear in the course of spontaneous and traumatic neuritis; and in the last-named conditions a variety of eruptions have
been observed in the area supplied by affected nerves, such as eczema, bullæ, etc.
(b) That ulceration may result directly from a nervous lesion is shown by the history of herpes, where a destructive process takes place in the derma under such conditions as to exclude the action of external agencies. But the same cannot be said of the ordinary ulcerations and gangrenous lesions observed in a number of nervous diseases, as the bed-sores of myelitis or of spinal injuries, the ulceration of the cornea in trigeminal anæsthesia, the digital ulcers and gangrene of lepra, asphyxia of the extremities, and nerve-injuries. As regards all these, the proper explanation is, it seems to us, that the anæsthesia existing as a predisposing cause (leading to imperfect protection of the part), the ulceration itself, is directly, actively caused by external agencies. Let me briefly cite a few instructive experimental and pathological facts bearing on this question.
It is well known that in animals and man lesions of the trigeminus nerve sufficient to produce anæsthesia (of its first branch more especially) are frequently, if not invariably, followed by ulceration and perforation of the cornea and phthisis bulbi. These were long held to be true dystropic changes, but about thirty and twenty years ago Snellen and von Gudden demonstrated independently and by different methods that these ocular lesions could be entirely prevented by absolute closure (perfect protection) of the eyelids prior to the experiment on the trigeminus. Not long afterward BrownSéquard showed that the sloughing ulcers which occur about the foot of an animal whose sciatic nerve has been cut may be entirely prevented by care, cleanliness, and soft bedding. The conclusion to be drawn from these observations is that in almost all cases the ulcerations and sloughing observed in man during the course of a nervous disease sufficient to produce anæsthesia, such as traumatic neuritis, lepra anæsthetica, traumatic or simple myelitis transversa, disease of the trigeminal nerve, etc., are in reality produced by external agencies, injuries to the cuticle, action of filth, and, we think, the entrance of bacteria, which are well known to possess extraordinary powers of penetration into tissues whose protecting
epithelial layer is removed. Clinical observation corroborates this view, for, with strict antiseptic treatment and under sealed dressings (collodion to ulcerated finger-tips), these ulcerations heal rapidly and completely, while the anæsthesia remains unchanged and the nervous lesions may even progress. At the same time, while we believe the above to be the pathology of so-called trophic ulcers, we would admit the possibility of spontaneous neuritic ulceration and gangrene, as shown more especially in herpes.
3. ALTERED SECRETIONS
.—Under the influence of disordered innervation secretions may be altered in quantity and in quality Symptoms of this class may be caused by neural or by central lesions, and the mechanism of their action may be direct or reflex.
(
a) After section or lesion by disease of the cervical sympathetic nerve we observe increased activity of the entire skin in the affected area of the head and face: there is more perspiration, lachrymation, and more cerumen is found in the ear. In cases of lesions of a certain part of the oblongata we find one result to be polyuria. In many cases of nerve-injuries the sweat-glands and hair-follicles of the parts supplied by the affected nerve appear to be sometimes abnormally active, or in other cases inactive. In some rare cases of insanity profuse salivation and extraordinary growth of hair are striking symptoms. Lastly, in some functional nervous affections the various secretions and excretions may be altered to extraordinary extremes (e.g. the polyuria and anuria of hysteria).
(b) Qualitative modifications of secretions also occur, as exhibited in the many variations in the composition of the urine in various neuritic conditions, the watery urine of hysteria, the phosphatic urine of neurasthenia. Injuries of a part of the floor of the oblongata (and very probably other lesions of the nervous system) give rise to the appearance of sugar, and sometimes of albumen, in the urine. Under the influence of disease or of an emotion the breast-milk may become toxic to the nursing child, causing diarrhœa, convulsions, etc. In some forms of nervous dyspepsia large quantities of acid or of alkaline fluid may be rapidly poured out into the stomach as a result
of disturbed glandular and vaso-motor action. In a few cases of neurosis malodorous or perfumed perspiration has been observed.
In a general way it may be stated that, inasmuch as the normal function of glands is largely, if not exclusively, under direct and reflex nervous control, their secretions may be quickly altered in quantity or quality by rapid nervous disease or by functional disorders. It is probable that much of our future progress in the semeiology of nervous diseases will be in this direction by the aid of improved medical chemistry.
4. ASSIMILATION, METAMORPHOSIS OF FOOD, TISSUE-LIFE, and BLOODMAKING are probably under nervous control to a certain extent, but our knowledge is not now in a state to speak positively and definitely of alterations in these processes as symptoms of nervous disease.
THE PRINCIPLES OF DIAGNOSIS.
Having in the preceding pages surveyed the field of neurological semeiology in an analytical way, it remains to briefly indicate how far and in what manner these data can be best utilized for logical diagnosis in the present state of science. If we may be allowed an illustration, we would say that the foregoing sections contain a nearly complete vocabulary of the language of nervous diseases, and that the following pages express an attempt at formulating its grammar.
In the first place, it is important to classify the symptoms observed according to their probable immediate cause in the nervous organs, whether they are due to irritation or to the destruction of parts. The extreme value of such a distinction in practice was first emphatically brought forward by Brown-Séquard in his famous Lectures on the Physiology and Pathology of the Central Nervous System (Philada.,
1860); and to the observance of this law of genesis of symptoms we believe that a large part of the subsequent extraordinary progress of neurological science is due.
The symptoms produced by irritation of nervous organs are usually hyperkineses or paræsthesiæ in their various forms. The symptoms, spasm, pain, or numbness, are usually, though by no means always, intermittent. That paralysis and anæsthesia may occur from irritation, by an inhibitory process, is not to be denied, yet we must maintain the extreme rarity of such a mechanism. The phenomena of inhibition are so prominent in the normal nervous system that a physician who looks at nervous diseases from the standpoint of the physiologist may well be excused for seeing morbid inhibitory processes where others do not.
The symptoms due to destructive lesions—i.e. those indicating destruction of parts of the nervous system—are paralysis, hyperkinesis, and anæsthesia, of absolutely or relatively constant presence. Thus, for example, the paralysis of common hemiplegia due to destruction of the motor part of the internal capsule is constant and permanent, while the accompanying tonic spasm (late contracture), which is considered an even more positive sign of serious destructive injury to the cerebral motor tract, is permanent, but intermittent—i.e. it is absent in profound sleep, and reappears as soon as the patient awakes.
The association of symptoms of irritation and those of destruction is frequent but variable. In many cases, as in cerebral tremor and posterior spinal sclerosis, spasm and paræsthesiæ precede paralysis, anæsthesia, and ataxia. In other cases (in many at a certain period) they coexist. In a small group of cases the irritative symptoms follow those indicating destruction, sometimes occurring years afterward, as in post-hemiplegic epilepsy and neuralgia due to cicatrices. We would repeat that very often, more especially in organic nervous affections, much light is thrown on the diagnosis by careful noting of the topographic distribution and chronological order of appearance of the symptoms.
In the second place, it is necessary to group the symptoms of disease of the nervous system in two great classes—viz. those representing demonstrable lesions, macro- or microscopic, and those dependent upon perverted functions or molecular malnutrition of the nervous organs or elements. The first group is designated as organic diseases; the second as functional affections. Mental diseases, so called, can also be classified, according to their symptoms, in either of these groups.
The symptoms of the first group, that of organic nervous diseases, are characterized by definiteness of distribution, by permanency, by relative invariability, and by the predominance of objective signs.
Another important characteristic of organic diseases is their progressive or fatal tendency, either with reference to life in general or to that of parts or organs. A third peculiarity of these diseases is that they do not occupy the patient's attention as strongly or as constantly as neuroses: in other words, the Ego is less involved.
The symptoms of the second group, that of functional nervous affections (neuroses and psychoses), are characterized by generality and indefiniteness of distribution, by relative variability, by easy removal or spontaneous disappearance, and by the preponderance of subjective symptoms. The affection may endure for many years or for a lifetime without fatal result and without special aggravation. The Ego is very strongly and deeply affected, fear, depression, and constant dwelling upon the symptoms being prominent features.
These are general statements intended to serve as guides for the preliminary study of a case. It must be remembered that they are all liable to exceptions, and that each patient must be separately considered. It should be borne in mind that what to-day appears as a functional affection, chiefly indicated by subjective symptoms, may in a few months present distinct signs of organic changes in the nervous system. Also, it must be added that in the present state of knowledge we sometimes are not sure as to the presence or absence of organic changes even after careful study of a case; as, for example, in some epilepsies and neuralgias.
Furthermore, allowance must be made for the following sources of error:
Anatomical variability; as, for example, in the distribution of peripheral nerves and in the amount of decussation of fibres of the pyramids;
The coincidence of diseases and multiplicity of lesions;
The toxic effects of drugs taken by the patient previous to our examination; as, for example, bromism.
I. The Diagnosis of Organic Diseases of the Nervous System.
This should invariably consist, in the observer's mind at least, of three separate diagnoses, each formed by the application of widely different sources of knowledge, and each requiring a different logical process. One diagnosis forms the indispensable preliminary to the others, and the last one, when correct, demonstrates that the neurologist is a physician as well as a specialist. A further utility of this procedure by the method of the threefold diagnosis is, in our opinion, that it constitutes the sure inductive reasoning to be employed in the search after the pathology of new diseases, and must prove of help in the future growth of neurological medicine.
These diagnoses are—
The diagnosis of the symptoms or symptom-group;
The diagnosis of the location of the lesion;
The diagnosis of the nature of the lesion or of the functional disorder.
1. The diagnosis of the symptom or symptom-group is to be made by —(a) careful inquiry into the manner of appearance, development, and chronological order of the symptoms as related by the patient or
by his friends, and more especially by (b) an exact, and in some directions minute, determination of the symptoms, obvious or latent, present in the patient. This valuable method of exact observation is sometimes, no doubt, carried to a ridiculous extreme, entailing much loss of time without corresponding results; but in medical practice, as in all forms of professional work, there enters a sort of genius, partly innate, but largely developed by cultivation, which enables the observer to seize at once, apparently by intuition or in the course of a few minutes of study, the really valuable and suggestive phenomena; and it is in this line, the line of important and correlated facts, that observation cannot be too minute and exact. In following this method technical terms must be correctly used and definitions rigidly adhered to, as superficial and loose records nearly always mislead. Sometimes in the course of the examination a symptom is discovered or a hint is thrown out by the patient which suggests new lines of inquiry, and occasionally necessitates an entire rearrangement of the data obtained. Consequently, it is important that the observer should approach a case tabula rasa, and should, as far as possible, prevent his being biassed by anticipations of, and immature guesses at, the third or final diagnosis.
Besides exactness of observation, it is necessary that the physician should have a thorough knowledge of nervous nosology in order to complete the first diagnosis: he must be acquainted by book-study and by personal observation with the numerous types of symptomgroups which fill up our present classification of diseases, so that he can at once say, approximately at least, in what category the case before him belongs.
2. The second diagnosis, that of the location of the lesions, is to be arrived at by the application of the observer's knowledge of the anatomy and physiology of the nervous system; and therefore it is here that special training is of the greatest advantage. The anatomy and physiology of use in this connection are not the bare sciences as taught in ordinary text-books, but a higher sort of knowledge, corrected and extended by the teachings of pathology and pathological anatomy. The physician must be well versed in the
recent revelations of experimentation and of autopsies bearing upon the architecture and functions of the central nervous system, and should be able to apply this knowledge deductively to the case in hand. In this manner the now abundant material grouped under the term Localization of Cerebral and Spinal Diseases (vide the next article) can be made of the greatest utility in every-day practice. The solution of the problem of localization of the lesion is much simplified if it be first accurately determined whether the lesion is peripheral, spinal, or cerebral.
3. The final diagnosis is with respect to the nature of the lesion. While the second diagnosis may be said to possess the greater scientific interest, this one must be admitted to possess paramount practical importance, as from it we derive the indications for rational treatment and the data of prognosis. The third diagnosis is to be made by the application of the observer's knowledge of general pathology and etiology; hence it is in this field that the best-trained physician succeeds—where the experienced practitioner may sometimes eclipse the brilliant specialist. The truth of this is maintained by those who hold, as we do, that it is unwise to embark in specialism without having had good hospital advantages and extensive general practice.
In order to arrive at the diagnosis of the nature of the lesion we must consider the family history, trace out predispositions, study the various causes of disease to which the patient has been exposed, and by a thorough examination of the various functions and the objective condition of the patient ascertain what pathological processes are active in him. Often the clue to the diagnosis is found in signs afforded by non-nervous organs, as nervous syphilis by nodes and cutaneous cicatrices, cerebral hemorrhage by renal disease and increased arterial tension, cerebral tuberculosis by pulmonary lesions, etc.
A purely empirical form of knowledge of some utility in proving the pathological diagnosis is that of the relative frequency of certain lesions in the two sexes, at different ages, in various professions,
etc.—a statistical knowledge which is to be applied deductively to the case under study.
Considerable uncertainty sometimes remains even after the most careful analysis of a case, and often, after stating the first and second diagnoses quite positively, scientific caution and due regard for truth compel us to state the third diagnosis in alternative propositions or as a diagnosis of probability, to be finally settled by the appearance of new symptoms, or in some rare cases only by a post-mortem examination.
II. The Diagnosis of Functional Nervous Affections (Neuroses and Psychoses).
In some diseases of this class—as, for example, epilepsy—it is desirable to make the triple diagnosis as stated supra, but usually the two problems to be solved are—What is the symptom-group? and what is the pathology of the affection? The question of localization is less important and less easy of solution, as the symptoms are more usually generalized, often vague, and sometimes purely subjective.
1. The first diagnosis is to be made in the same manner as already stated, but besides, in many cases, a close psychological analysis is required to ascertain the emotional and mental state of the patient. Not only is this indispensable in cases of insanity, but it is often of great utility in other conditions, as hysteria, hypochondriasis, and simulation. In the course of this study we are frequently brought face to face with a most difficult problem—viz. the correct estimation of the degree of pain experienced by a patient. Is it a quasi-objective, correctly-portrayed sensation? is it magnified by abnormal sensitiveness or by true exaggeration? or is it simulated for a purpose? These questions demand the greatest freedom from prejudice and most delicate tact for their solution, and occasionally the most experienced physician is deceived. More especially are caution and scientific doubt to be exercised when this symptom
(pain) stands alone or nearly so, as in some medico-legal cases and in certain hypochondriacal states where self-delusion seems to constitute the only real disease.
2. The diagnosis of the pathological nature of the functional disturbance (functional lesion) is to be made only by an exhaustive study of the patient's personal and family history and of his general condition. The following are the principal lines of inquiry to be followed:
(a) As to hereditary predisposition: direct or indirect inheritance of neurotic tendencies, of psychic peculiarities, and as to the presence of the various psychic and physical signs grouped under the term psychic degeneration.
(b) As to personal habits: overwork, masturbation, the abuse of tobacco, alcohol, or coitus, injudicious diet, abnormal postures, injurious avocations, etc.
(c) As to dyscrasic and hæmic conditions: uræmia, lithæmia, anæmia, malarial and syphilitic infection, etc.
(d) As to the condition of important organs: of the eye in connection with headaches and vertigo; of the ear in relation to vertigo and epileptiform attacks; of the heart (and arterial tension) in various head-symptoms; of the sexual organs in hysteria, hypochondriasis, epilepsy, etc.
A serious stumbling-block in this last line of inquiry is the everrecurring question as to the causal relation between the symptoms observed. Is the asthenopia the cause of the headache, or does the neurasthenia, giving rise to the headache, cause the asthenopia? Does the extremely slow action of the heart in a given case produce the epileptoid attacks, or are both due to a lesion of the medulla? Does ovarian hyperæsthesia and neuralgia (with or without organic changes) cause the hystero-epilepsy, or is the ovaria one of the numerous peripherally projected sensory symptoms of the hysteric state? Does the lithæmia, oxaluria, azoturia, or phosphaturia found
in a patient give rise to the nervous symptoms complained of, or are they (the morbid excretions) the result of defective innervation? The candid neurologist, looking at his cases from the standpoint of the general physician rather than from the loophole of narrow specialism, must admit that these questions vex him daily, and that they are often not to be resolved in the present state of knowledge except by a recurrence to the therapeutic test.
For this extremely difficult diagnosis of the pathology of functional nervous affections we would obtain much immediate assistance if observers had the courage to publish their cases in continuous series, instead of giving us successful cases, which often only serve to mislead. For example, how greatly would the question of the relation between ovarian symptoms and epilepsy (also hysteroepilepsy) be advanced if we had the final results of all cases of removal of the ovaries for these diseases at a period not less than one year after the operation! And so with the attempts made to cure headaches by the correction of errors of refraction and weakness of the interni. The profession has a right to demand a frank and full report of the experience of those who practice and teach in these directions.
