THE PHYSIOGNOMY OF DISEASE: WHAT A DOCTOR CAN TELL FROM APPEARANCES
It is our pride that medicine, from an art, and a pretty black one at
that, originally, is becoming a science. And the most powerful factor in
this development, its indispensable basis, in fact, has been the
invention of instruments of precision--the microscope, the fever
thermometer, the stethoscope, the ophthalmoscope, the test-tube, the
culture medium, the triumphs of the bacteriologist and of the chemist.
Any man who makes a final diagnosis in a serious case without resorting
to some or all of these means is regarded--and justly--as careless and
derelict in his duty to his patient.
At the same time, priceless and indispensable as are these laboratory
methods of investigation, they should not be allowed to make us too
scornful and neglectful of the evidence gained by the direct use of our
five senses. We should still avail ourselves of every particle of
information that can be gained by the trained eye, the educated ear, the
expert touch,--the _tactus eruditus_ of the medical classics,--and even
the sense of smell. There is, in fact, a general complaint among the
older members of the profession that the rising generation is being
trained to neglect and even despise the direct evidence of the senses,
and to accept no fact as a fact unless it has been seen through the
microscope or demonstrated by a reaction in the test-tube. As one of our
keenest observers and most philosophic thinkers expressed it a few
months ago:--
"I fear that certain physicians on their rounds are most careful to take
with them their stethoscope, their thermometer, their hemoglobin papers,
their sphygmomanometer, but leave their eyes and their brains at home."
And it is certain that the art of sight diagnosis, which seems like half
magic, possessed in such a wonderful degree by the older physicians of
the passing and past generations, has been almost lost by the new.
A healthful reaction has, however, set in; and while we certainly do not
love the Cæsar of laboratory methods and accuracy the less, we are
beginning to have a juster affection for the Rome of the rich harvest
that may be gained from the careful, painstaking, detective-like
exercise of our eye, ear, and hand.
As a matter of fact, the conflict between the two methods is only
apparent. Not only is each in its proper sphere indispensable, but they
are enormously helpful one to the other. Instead of our being able to
tell less by the careful, direct eye-and-hand examination of our
patients than the doctor of a century ago, we can tell three to five
times as much. Signs that he could interpret only by the slow and
painful method of two-thirds of a lifetime of plodding experience, or by
occasional flashes of half-inspired insight, we are now able to
interpret absolutely upon a physiological--yes, a chemical--basis from
the revelations of the microscope, the test-tube, and the culture
medium. His only way of determining the meaning of a particular tint of
the complexion, or line about the mouth, or eruption on the skin, was by
slowly and laboriously accumulating a long series of similar cases in
which that particular symptom was found always to occur, and deducing
its meaning. Now, we simply take a drop of our patient's blood, a
scraping from his throat, a portion of some one of his secretions, a
little slice of a tumor or growth, submit them to direct examination in
the laboratory, and get a prompt and decisive answer.
The observant physician begins to gather information about a patient
from the moment he enters the sick-room or the patient steps into his
consulting-room; and the value of the information obtained in the first
thirty seconds, before a word has been spoken, is sometimes
astonishingly great. While no intelligent man would dream of depending
upon this first _coup d'[oe]il_, "stroke of the eye" as the French so
graphically call it, for his final diagnosis, or accept its findings
until he had submitted them to the most ruthless cross-examination with
the stethoscope and in the laboratory, yet it will sometimes give him a
clew of almost priceless value. It is positively uncanny to see the
swift, intuitive manner in which an old, experienced, and thoughtful
physician will grasp the probable nature of a case in one keen look at a
patient. Often he can hardly explain to you himself how he does it, what
are the data that determine it; yet not infrequently, three times out
of five, your most elaborate and painstaking study of the case with all
the modern methods will bring you to the same conclusion as that sensed
within forty-five seconds by this keen-eyed old sleuth-hound of the
fever trails. Time and again, in my interne days, have I gone the rounds
of the wards or the out-patient departments with some kindly-faced,
keen-eyed old Sherlock Holmes of the profession, and seen him point to a
new case across the ward with the question: "When did that pneumonia
come in?" or pick out a pain-drawn, ashy mask in the waiting line, with
an abrupt, "Bring me that case of cancer of the stomach. He's in pain.
I'll take him first."
And, in later years, I have had colleagues with whom it was positively
painful to walk down a crowded street, from the gruesome habit that they
had of picking out, and condemning to lingering deaths, the cases of
cancer, of Bright's disease, or of locomotor ataxia, that we happened to
meet. Of course, they would be the first to admit that this was only
what they would term a "long shot," a guess; but it was a guess based
upon significant changes in the patient's countenance or gait, which
their trained eye picked out at once, and it was surprising how often
this snapshot diagnosis turned out to be correct.
The first thing that a medical student has to learn is that appearances
are _not_ deceptive--except to fools. Every line of the human figure,
every proportion of a limb, every detail of size, shape, or relation in
an organ, _means_ something. Not a line upon any bone in the skeleton
which was not made by the hand-grip or thumbprint of some muscle,
tendon, or ligament; no bump or knuckle which is not a lever or
hand-hold for the grip of some muscle; not a line or a curve or an
opening in that Chinese puzzle, the skull, which was not made to protect
the brain, to accommodate an eye, to transmit a blood-vessel, or to
allow the escape of a nerve. Every minutest detail of structure means
something to the man who will take the pains to puzzle it out. And if
this is true of the foundation structure of the body, is it to be
expected that the law ceases to run upon the surface?
Not a line, not a tint, not a hollow of that living picture, the face,
but means something, if we will take the time and labor to interpret it.
Even coming events cast their shadows before upon that most exquisitely
responsive surface--half mirror, half sensitive plate--the human
countenance. The place where the moving finger of disease writes its
clearest and most unmistakable message is the one to which we must
naturally turn, the face; not merely for the infantile tenth part of a
reason which we often hear alleged, that it is the only part of the
body, except the hand, which is habitually exposed, and hence open to
observation, but because here are grouped the indicators and registers
of almost every important organ and system in the body.
What, of course, originally made the face the face, and, for the matter
of that, the head the head, was the intake opening of the food-canal,
the mouth. Around this necessarily grouped themselves the outlook
departments, the special senses, the nose, the eyes, and ears; while
later, by an exceedingly clumsy device of nature, part of the mouth was
split off for the intake of a new ventilating system. So that when we
glance at the face we are looking first at the automatically controlled
intake openings of the two most important systems in the body, the
alimentary and the respiratory, whose muscles contract and relax, ripple
in comfort or knot in agony, in response to every important change that
takes place throughout the entire extent of both.
Second, at the apertures of the two most important members of the
outlook corps, the senses of sight and of smell. These are not only
sharply alert to every external indication of danger, but by a curious
reversal, which we will consider more carefully later, reflect signals
of distress or discomfort from within. Last, but not least, the
translucent tissues, the semi-transparent skin, barely veiling the
pulsating mesh of myriad blood-vessels, is a superb color index,
painting in vivid tints--"yellow, and ashy pale, and hectic red"--the
living, ever changing, moving picture of the vigor of the life-centre,
the blood-pump, and the richness of its crimson stream. Small wonder
that the shrewd advice of a veteran physician to the medical student
should be: "The first step in the examination is to look at your
patient; the second is to look again, and the third to take another look
at him; and keep on looking all through the examination."
It is no uncommon thing for an expert diagnostician deliberately to lead
the patient into conversation upon some utterly irrelevant subjects,
like the weather, the crops, or the incidents of his journey to the
city, simply for the purpose of taking his mind off himself, putting
him at his ease, and meanwhile quietly deciphering the unmistakable
cuneiform inscription, often twice palimpsest, written by the finger of
disease upon his face. It takes time and infinite pains. In no other
realm does genius come nearer to Buffon's famous description, "the
capacity for taking pains," but it is well worth the while. And with all
our boasted and really marvelous progress in precise knowledge of
disease, accomplished through the microscope in the laboratory, it
remains a fact of experience that so careful and so trustworthy is this
face-picture when analyzed, that our best and most depended upon
impressions as to the actual condition of patients, are still obtained
from this source. Many and many a time have I heard the expression from
a grizzled consultant in a desperate case, "Well, the last blood-count
was better," or, "The fever is lower," or, "There is less albumen,--but
I don't like the look of him a bit"; and within twenty-four hours you
might be called in haste to find your patient down with a hemorrhage, or
in a fatal chill, or sinking into the last coma.
It would really be difficult to say just what that careful and loving
student of the _genus humanum_ known as a doctor looks at first in the
face of a patient. Indeed, he could probably hardly tell you himself,
and after he has spent fifteen or twenty years at it, it has become such
a second nature, such a matter of instinct with him, that he will often
put together all the signs at once, note their relations, and come to a
conclusion almost in the "stroke of an eye," as if by instinct, just as
a weather-wise old salt will tell you by a single glance at the sky
when and from what quarter a storm is coming.
I shall never forget the remark of my greatest and most revered teacher,
when he called me into his consultation-room to show me a case of
typical locomotor ataxia, gave me a brief but significant history, put
the patient through his paces, and asked for a diagnosis. I hesitated,
blundered through a number of further unnecessary questions, and finally
stumbled upon it. After the patient had left the room, I, feeling rather
proud of myself, expected his commendation, but I didn't get it. "My
boy," he said, "you are not up to the mark yet. You should be able to
recognize a disease like that just as you know the face of an
acquaintance on the street." A positive and full-blown diagnosis of this
sort can, of course, only be made in two or three cases out of ten. But
the method is both logical and scientific, and will give information of
priceless value in ninety-nine cases out of a hundred.
Probably the first, if not the most important, character that catches
the physician's eye when it first falls upon a patient is his
expression. This, of course, is a complex of a number of different
markings, but chiefly determined by certain lines and alterations of
position of the skin of the face, which give to it, as we frequently
hear it expressed, an air of cheerfulness or depression, comfort or
discomfort, hope or despair. These lines, whether temporary or
permanent, are made by the contractions of certain muscles passing from
one part of the skin to another or from the underlying bones to the
skin. These are known in our anatomical textbooks by the natural but
absurd name of "muscles of expression."
Their play, it is true, does make up about two-thirds of the wonderful
shifting of relations, which makes the human countenance the most
expressive thing in the world; but their original business is something
totally different. Primarily considered, they are solely for the purpose
of opening or closing, contracting or expanding, the different orifices
which, as we have seen, appear upon the surface of the face. This
naturally throws them into three great groups: those about and
controlling the orifice of the alimentary canal, the mouth; those
surrounding the joint openings of the air-tube and organ of smell, and
those surrounding the eyes.
As there are some twenty-four pairs of these in an area only slightly
greater than that of the outspread hand, and as they are capable of
acting with every imaginable grade of vigor and in every possible
combination, it can readily be seen what an infinite and complicated
series of expressions--or, in other words, indications of the state of
affairs within those different orifices--they are capable of. Only the
barest and rudest outlines of their meaning and principles of
interpretation can be attempted. To put it very roughly, the main
underlying principle of interpretation is that we make our first
instinctive judgment of the site of the disease from noting which of the
three great orifices is distorted furthest from its normal condition.
Then by constructing a parallel upon the similarity or the difference of
the lines about the other two openings, we get what a surveyor would
call our "lines of triangulation," and by following these to their
converging point can often arrive at a fairly accurate localization.
The greatest difficulty in the method, though at times our greatest
help, is the extraordinary and intimate sympathy which exists between
all three of these groups. If pain, no matter where located, once
becomes intense enough, its manifestations will travel over the
face-dial, overflowing the organ or system in which it occurs, and eyes,
nostrils, and mouth will alike reveal its presence. Here, of course, is
where our second great process, so well known in all clew-following,
elimination, comes in.
A patient comes in with pain-lines written all over his face. To put it
very roughly--has he cancer of the stomach? Pneumonia? Brain tumor? If
there be no play of the muscles distending and contracting the nostrils
with each expiration, no increased rapidity of breathing, no gasp when a
full breath is drawn, and no deep red fever blush on the cheeks, we
mentally eliminate pneumonia. The absence of these nasal signs throws us
back toward cancer or some other painful affection of the alimentary
canal. If the pain-lines about the mouth are of recent formation, and
have not graved themselves into the furrows of the forehead above and
between the eyebrows; if the color, instead of ashy, be clear and red,
we throw out cancer and think of colic, ulcer, hyperacidity, or some
milder form of alimentary disease.
If, on the other hand, the pain-lines are heaviest about the brows, the
eyes, and the forehead, with only a sympathetic droop or twist of the
corners of the mouth, if the nostrils are not at all distorted or too
movable, if there is no fever flush and little wasting, and on turning
to the eyes we find a difference between the pupils, or a wide
distention or pin-point-like contraction of both or a slight squint, the
picture of brain tumor would rise in the mind. Once started upon any one
of these clews, then a hundred other data would be quickly looked for
and asked after, and ultimately, assisted by a thorough and exhaustive
examination with the instruments of precision and the tests in the
laboratory, a conclusion is arrived at. This, of course, is but the
roughest and crudest outline suggestive of the method of procedure.
Probably not more than once in three times will the first clew that we
start on prove to be the right one; but the moment that we find this
barred, we take up the next most probable, and in this manner hit upon
the true scent.
As to the cause and rationale of these pain-lines, only the barest
outlines can be given. Take the mouth for an example. When all is going
well in the alimentary canal, without pain, without hunger, and both
absorption of food and elimination of waste are proceeding normally, the
tissues about the mouth, like those of the rest of the body, are apt to
be plump and full; the muscles which open the aperture, having fulfilled
their duty and received their regular wages, are quietly at rest; those
that close the opening, having neither anticipation of an early call for
the admission of necessary nutriment, nor an instinctive desire to shut
out anything that may be indigestible or undesirable, are now in their
normal condition of peaceful, moderate contraction; the face has a
comfortable, well-fed, wholesome look. On the other hand, let the
digestive juices fail to do their duty properly, or the swarms of
bacteria pets which we keep in our food-canals get beyond control; or if
for any other reason the tissues be kept from getting their proper
supply of nourishment from the food-canal, the state of affairs is
quickly revealed in the mouth mirror. Those muscles which open the
mouth, instead of resting peacefully in the consciousness of duty well
done, are in a state of perpetual fidget, twitching, pulling, wondering
whether they ought not to open the portal for the entrance of new
supplies of material, since the tissues are crying for food.
As the strongest of these are those which pull the corners of the mouth
outward and downward, the resultant expression is one of depression,
with downward-curving angles to the mouth. The eyes, and even the
nostrils, sympathetically follow suit, and we have that countenance
which, by the cartoonist's well-known trick, can be produced by the
alteration of one pair of lines, those at the angles of the mouth,
turning a smiling countenance into a weeping one. On the other hand, if
all these processes of nutrition and absorption are proceeding as they
should, they are accompanied by mild sensations of comfort which,
although they no longer reach our consciousness, reveal themselves in
the mouth-opening muscles, and they gently contract upward and outward,
in pleasurable anticipation of the next intake, and we get the grin or
the smile.
If, on the other hand, these digestive disturbances be accompanied by
pain, then another shading appears on our magic mirror, and that is a
curious contraction of the mouth, with distortion of the lines
surrounding it, so violent in some cases as positively to whiten the
lips or produce lines of paleness along the course of the muscles. This
is the set or twisted mouth of agony, and is due to a curious
transference and reflex on this order: that inasmuch as the last food
which entered the alimentary canal seems to have caused this disturbance
and pain, no more will be allowed to enter it at present under any
conditions. And as our alimentary instincts are the most fundamental of
all, by a due process of transference, mental agony calls into action
this same set of muscles, to shut out any possible addition to the agony
already present.
The lines of determination, similarly, about the mouth, are those of the
individual who has the courage to say "No" to the tempting morsel when
he doesn't need it; and the lines of weakness and irresolution are those
of the nature which cannot resist either gastronomic or other
temptation. Similarly, the well-known lines of disgust or of discontent
about the corners of the mouth are the unconscious contractions
accompanying nausea, and preparations to expel the offending morsel
whether from stomach or mouth.
If, on the other hand, our first glance shows us that the deepest
pain-lines are those about the nostrils and upper lip, especially if the
wings of the nostrils can be seen to dilate with each breath, and
breathing be faster than normal, our clew points in the direction of
some disease of the great organs above the diaphragm--that is, the
lungs or heart.
Signs in this region might refer to either of these, for the reason
that, although a sufficient intake of air is one of the necessary
conditions of proper oxygenation, a free and abundant circulation of the
blood through the air-cells is equally essential. In fact, that common
phenomenon known as "shortness of breath" is more frequently due to
disturbances of the heart and circulation than it is to the lungs,
especially in patients who are able to be up and about. If, in addition
to the danger signal of the rise and fall of the nostrils with each
breath, we have a pale, translucent skin, with a light, hectic flush
showing just below the knife-like lower edge of the cheekbone, a widely
open, shining eye, and a clustering abundance of hair of a glossiness
bordering on dampness, red lips slightly parted, showing the teeth
between, a painfully strong suspicion of consumption would arise
unbidden.
This pathetic type of face has that fatal gift which the French
clinicians, with their usual happiness of phrase, term _La beauté du
diable_. The eager eyes, dilated nostrils, parted lips, give that weird
air of exaltation which, when it occurs, as it occasionally does in the
dying, is interpreted as the result of glimpses into a spirit world.
When to this is added the mild delirium of fever, when memories of
happier days and of those who have passed before rise unbidden and
babble themselves from the tongue, one can hardly wonder at this
interpretation.
The last group of lines to be noted is that about the eyes and
forehead. These are less reliable than either of the other two, for the
reason that they are so sympathetic as almost invariably to be present
in addition, whenever the lower dial-plates of the face are disturbed.
It is only when they appear alone that they are significant; then they
may be interpreted as one of three things: first, and commonest, eye
strain; second, disease in some part of the nervous system or muscular
system, not connected with the organs of the chest or abdomen; and
third, mental disturbances.
This last relation, of course, makes them in many respects the least
reliable of all the face indices, because--as is household
knowledge--they indicate mental conditions and operations, as well as
bodily. "The wrinkled brow of thought," the "deep lines of perplexity,"
etc., are in the vocabulary of the grammar grades. They are, however, a
valuable check upon the other two groups. They are not apt to be present
in consumption and in other forms of serious disease, attended by fever,
on account of the curious effect produced by the toxins of the disease,
which is often not only stimulating, but even of an exhilarating nature,
or will produce a slight stupor or lethargy, such as is typical of
typhoid.
One of the most singular transformations in the sick-room, especially in
serious disease marked by lethargy or stupor, is that in which the
patient's countenance will appear like a sponged-off slate, so
completely have the lines of worry and of thought been obliterated.
One distinct value of the pain-lines about the eyes and brow is that you
can often test their genuineness. Just engage your hypochondriac or
hysterical patient in lively conversation; or, on the reverse principle,
wound his vanity, so as to produce an outburst of temper, and see how
the lines of undying agony will fade away and be replaced by the curves
of amusement or by the straight-drawn brows of indignation.
As with the painter, next to line comes color. Every one, of course,
knows that a fresh, rosy color is usually associated with health, while
a pale, sallow complexion suggests disease. But our color signals, while
more vivid, are much less reliable and more apt to deceive than our
line-markings.
Surprising as it may sound, careful analyses have shown, first, that the
kind of pigment present in the human skin of every race is absolutely
one and the same. The only difference between the negro and the white
man is that the negro has two or three times as much of it. Secondly,
that every skin except that of the albino has a certain, and usually a
considerable, amount of this pigment present in it.
"The red hue of health" is even more apt to mislead us, because, being
due to the abundance of blood in the meshes of the skin, many fevers, by
increasing the rapidity of the heart-beat and dilating the vessels in
the skin, give a ruddiness of hue equal to or in excess of the normal.
However, a little careful checking up will eliminate most of the
possible mistakes and enable us to obtain information of the greatest
value from color. For instance, if our patient be of Southern blood, or
tanned from the seashore, the good red blood in his arteries is pretty
safe to show through at the normal blush area on the cheeks; or, failing
that, through the translucent epithelium of the lips and gums. If, on
the other hand, this yellow tint be due to the escape of broken-down
blood-pigments into the tissues, or a damming up of the bile, and a
similar escape of its coloring matter, as in jaundice, then we turn to
the whites of the eyes, and if a similar, but more delicate, yellowish
tint confronts us there, we know we have to deal with a severe form of
anæmia or jaundice, according to the tint. In extreme cases of the
latter, the mucous membrane of the lips and of the gums will even show a
distinctly yellowish hue. The frightful color of yellow fever, and the
yellow "death mask," which appears just before the end of several fatal
forms of blood poisoning, is due to the tremendous breaking down of the
red cells of the blood under the attack of the fever toxins, and their
leaking out into the tissues. A similar process of a milder and less
serious extent occurs in those temporary anæmias of young girls, known
for centuries past in the vernacular as "the green sickness." And a
delicate lemon tint of this same origin, accompanied by a waxy pallor,
is significant of the deadly, pernicious anæmia and the later stages of
cancer.
The most significant single thing about the red flush, supposed to be
indicative of health, is its location. If this be the normal "blush
area," about the middle of each cheek,--which is one of nature's sexual
ornaments, placed, like a good advertisement, where it will attract most
attention and add most beauty to the countenance,--and it fades off
gradually at the edges into the clear whiteness or brownness of the
healthy skin, it is probably both healthy and genuine. If the work of
either fever or of art, it will generally reveal itself as a base
imitation. In eight cases out of ten of fever, the flush, instead of
being confined to this definite area, extends all over the face, even up
to the roots of the hair. The eyes, instead of being clear and bright,
are congested and heavy-lidded; and if with these you have an increased
rapidity of respiration, and a general air of discomfort and unrest, you
are fairly safe in making a diagnosis of fever. If the first touch of
the tips of the fingers on the wrist shows a hot skin and a rapid pulse,
the diagnosis is almost as certain as with the thermometer.
Now for two of the instances in which it most commonly puzzles us. The
first of these is consumption; for here the flush, both in position and
in delicacy and gentle fading away at the proper margins, is an almost
perfect imitation of health. It, however, usually appears, not as the
normal flush of health does, upon a plump and rounded cheek, but upon a
hollow and wasted one. It rises somewhat higher upon the cheekbones,
throwing the latter out into ghastly prominence. The lips and the eyes
will give us no clew, for the former are red from fever, and the latter
are bright from the gentle, half-dreamy state produced by the toxins of
the disease, the so-called "_spes phthisica_"--the everlasting and
pathetic hopefulness of the consumptive. But here we call for help upon
another of the features of disease--the hand. If, instead of being cool,
and elastic, this is either dry and hot, or clammy and damp, and feels
as if you were grasping a handful of bones and nerves, and the
finger-tips are clubbed and the nails curved like claws, then you have a
strong _prima facie_ case.
The other color condition which is apt to puzzle us is that of the plump
and comfortable middle-aged gentleman with a fine rosy color, but a
watery eye and loose and puffy mouth, a wheezy respiration and apparent
excess of adipose. Here the high color is often due to a paralytic
distention of the blood-vessels of the face and neck, and an examination
of his heart and blood-vessels shows that his prospects are anything but
as rosy as his countenance.
The varying expressions of the face of disease are by no means confined
to the countenance. In fact, they extend to every portion of--in
Trilby's immortal phrase--"the altogether." Disease can speak most
eloquently through the hand, the carriage, the gait, and, in a way that
the patient may be entirely unconscious of, the voice. These forms of
expression are naturally not so frequent as those of the face, on
account of the extraordinary importance of the great systems whose
clock-dials and indices form what we term the human countenance. But
when they do occur they are fully as graphic and more definitely and
distinctively localizing.
Next in importance to the face comes the hand, and volumes have been
written upon this alone. Containing, as it does, that throbbing little
blood-tube, the radial artery, which has furnished us for centuries with
one of our oldest and most reliable guides to health conditions, the
pulse, it has played a most important part in surface diagnoses. To this
day, in fact, Arabic and Turkish physicians in visiting their patients
on the feminine side of the family are allowed to see nothing of them
except the hand, which is thrust through an opening in a curtain. How
accurate their diagnoses are, based upon this slender clew, I should not
like to aver, but a sharp observer might learn much even from this
limited area.
We have--though, of course, in lesser degree--all the color and line
pictures with which we have been dealing upon the face. Though not an
index of any special system, it has the great advantage of being our one
approach to an indication of the general muscular tone of the body, as
indicated both in its grasp and in the poses it assumes at rest. The
patient with a limp and nerveless hand-clasp, whose hand is inclined to
lie palm upward and open instead of palm downward and half-closed, is
apt to be either seriously ill, or not in a position to make much of a
fight against the attack of disease.
The nails furnish one of our best indices of the color of the blood and
condition of the circulation. Our best surface test of the vigor of the
circulation is to press upon a nail, or the back of the finger just
above it, until the blood is driven out of it, and when our thumb is
removed from the whitened area to note the rapidity with which the red
freshet of blood will rush back to reoccupy it.
In the natural growth of the nail, traveling steadily outward from root
to free edge, its tissues, at first opaque and whitish, and thus
forming the little white crescent, or _lunula_, found at the base of
most nails, gradually become more and more transparent, and hence pinker
in color, from allowing the blood to show through. During a serious
illness, the portion of the nail which is then forming suffers in its
nutrition, and instead of going on normally to almost perfect
transparency, it remains opaque. And the patient will, in consequence,
carry a white bar across two or three of his nails for from three to
nine months after the illness, according to the rate of growth of his
nails. Not infrequently this white bar will enable you to ask a patient
the question, "Did you not have a serious illness of some sort two,
three, or six months ago?" according to the position of the bar. And his
fearsome astonishment, if he answers your question in the affirmative,
is amusing to see. You will be lucky if, in future, he doesn't incline
to regard you as something uncanny and little less than a wizard.
Another of the score of interesting changes in the hand, which, though
not very common, is exceedingly significant when found, is a curious
thickening or clubbing of the ends of the fingers, with extreme
curvature of the nails, which is associated with certain forms of
consumption. So long has it been recognized that it is known as the
"Hippocratic finger," on account of the vivid description given of it by
the Greek Father of Medicine, Hippocrates. It has lost, however, some of
its exclusive significance, as it is found to be associated also with
certain diseases of the heart. It seems to mean obstructed circulation
through the lungs.
Next after the face and the hand would come the carriage and gait. When
a man is seriously sick he is sick all over. Every muscle in his body
has lost its tone, and those concerned with the maintenance of the erect
position, being last developed, suffer first and heaviest. The bowed
back, the droop of the shoulders, the hanging jaw, and the shuffling
gait, tell the story of chronic, wasting disease more graphically than
words. We have a ludicrously inverted idea of cause and effect in our
minds about "a good carriage." We imagine that a ramrod-like stiffening
of the backbone, with the head erect, shoulders thrown back and chest
protruded, is a cause of health, instead of simply being an effect, or
one of the incidental symptoms thereof. And we often proceed to drill
our unfortunate patients into this really cramped and irrational
attitude, under the impression that by making them look better we shall
cause them actually to become so. The head-erect, chest-out,
fingers-down-the-seam-of-your trousers position of the drillmaster is
little better than a pose intended chiefly for ornament, and has to be
abandoned the moment that any attempt at movement or action is begun.
So complete is this unconscious muscular relaxation, that it is
noticeable not only in the standing and sitting position, but also when
lying down. When a patient is exceedingly ill, and in the last state of
enfeeblement, he cannot even lie straight in bed, but collapses into a
curled-up heap in the middle of the bed, the head even dropping from the
pillow and falling on the chest. Between this _débâcle_ and the slight
droop of shoulders and jaw indicative of beginning trouble there are a
thousand shades of expression significant instantly to the experienced
eye.
Though more limited in their application, yet most significant when
found, are the alterations of the gait itself. Even a maker of proverbs
can tell at a glance that "the legs of the lame are not equal." From the
limp, coupled with the direction in which the toe or foot is turned, the
tilt of the hips, the part of the foot that strikes first, the presence
or absence of pain-lines on the face, a snap diagnosis can often be made
as to whether the trouble is paralysis, hip-joint disease, knee or ankle
mischief, or flatfoot, as your patient limps across the room. Even where
both limbs are affected and there is no distinct limp, the form of
shuffle is often significant.
Several of the forms of paralysis have each its significant gait. For
instance, if a patient comes in with a firm, rather precise, calculated
sort of gait, "clumping" each foot upon the floor as if he had struck it
an inch sooner than he had expected, and clamping it there firmly for a
moment before he lifts it again, as though he were walking on ice, with
more knee action than seems necessary, you would have a strong suspicion
that you had to deal with a case of _locomotor ataxia_, in which loss of
sensation in the soles of the feet is one of the earliest symptoms. If
so, your patient, on inquiry, will tell you that he feels as if there
were a blanket or even a board between his soles and the surface on
which he steps. If a quick glance at the pupils shows both smaller or
larger than normal, and on turning his face to the light they fail to
contract, your suspicion is confirmed; while if, on asking him to be
seated and cross his legs, a tap on the great extensor tendon of the
knee-joint just below the patella fails to elicit any quick upward jerk
of the foot, the so-called "knee-kick," then you may be almost sure of
your diagnosis, and proceed to work it out at your leisure.
On the other hand, if an elderly gentleman enters with a curiously blank
and rather melancholy expression of countenance, holding his cane out
stiffly in front of him, and comes toward you at a rapid, toddling gait,
throwing his feet forward in quick, short steps, as if, if he failed to
do so, he would fall on his face, while at the same time a vibrating
tremor carries his head quickly from side to side, you are justified in
suspecting that you have to do with a case of _paralysis agitans_, or
shaking palsy.
Last of all, your physiognomy of disease includes not merely its face,
but its voice; not only the picture that it draws, but the sound that it
makes. For, when all has been allowed and discounted that the most
hardened cynic or pessimistic agnostic can say about speech being given
to man to conceal his thoughts, and the hopeless unreliability of human
testimony, two-thirds of what your patients tell you about their
symptoms will be found to be literally the voice of the disease itself
speaking through them. They may tell you much that is chiefly imaginary,
but even imagination has got to have some physical basis as a
starting-point. They may tell you much that is clearly and ludicrously
irrelevant, or untrue, on account of inaccuracy of observation,
confusion of cause and effect, or a mental color-blindness produced by
the disease itself. But these things can all be brushed aside like the
chaff from the wheat if checked up by the picture of the disease in
plain sight before you.
In the main, the great mass of what patients tell you is of great value
and importance, and, with proper deductions, perfectly reliable. In
fact, I think it would be safe to say that a sharp observer would be
able to make a fairly and approximately accurate diagnosis in seven
cases out of ten, simply by what his eye and his touch tell him while
listening to symptoms recounted by the patient. Time and again have I
seen an examination made of a reasonably intelligent patient, and when
the recital had been finished and the hawk-like gaze had traveled from
head to foot and back again, from ear-tip to finger-nail, from eye to
chest, a symptom which the patient had simply forgotten to mention would
be promptly supplied; and the gasp with which the patient would
acknowledge the truth of the suggestion was worth traveling miles to
see.
Of course, you pay no attention to any statement of the patient which
flatly contradicts the evidence of your own senses. But even where
patients, through some preconceived notion, or from false ideas of shame
or discredit attaching to some particular disease, are trying to mislead
you, the very vigor of their efforts will often reveal their secret,
just as the piteous broken-winged utterings of the mother partridge
reveal instantly to the eye of the bird-lover the presence of the young
which she is trying to lure him away from. Only let a patient talk
enough about his or her symptoms, and the truth will leak out.
The attitude of impatient incredulity toward the stories of our
patients, typified by the story of that great surgeon, but greater bear,
Dr. John Abernethy, has passed, never to return. When a lady of rank
came into his consulting-room, and, having drawn off her wraps and
comfortably settled herself in her chair, launched out into a luxurious
recital of symptoms, including most of her family history and
adventures, he, after listening about ten minutes pulled out his watch
and looked at it. The lady naturally stopped, open-mouthed. "Madam, how
long do you think it will take you to complete the recital of your
symptoms?" "Oh, well,"--the lady floundered, embarrassed,--"I hardly
know." "Well, do you think you could finish in three-quarters of an
hour?" Well, she supposed she could, probably. "Very well, madam. I have
an operation at the hospital in the next street. Pray continue with the
recital of your symptoms, and I will return in three-quarters of an hour
and proceed with the consideration of your case!"
When you can spare the time,--and no time is wasted which is spent in
getting a thorough and exhaustive knowledge of a serious case,--it is as
good as a play to let even your hypochondriac patients, and those who
are suffering chiefly from "nervous prosperity" in its most acute form,
set forth their agonies and their afflictions in their fullest and most
luxurious length, breadth, and thickness, watching meanwhile the come
and go of the lines about the face-dials, the changes of the color, the
sparkling and dulling of the eye, the droop or pain-cramp, or luxurious
loll of each group of muscles, and quietly draw your own conclusions
from it all. Many and many a time, in the full luxury of
self-explanation, they will reveal to you a clew which will prove to be
the master-key to your control of the situation, and their restoration
to comfort, if not health, which you couldn't have got in a week of
forceps-and-scalpel cross-examination.
In only one class of patients is this valuable aid to knowledge absent,
and that is in very young children; and yet, by what may at first sight
seem like a paradox, they are, of all others, the easiest in whom to
make not merely a provisional, but a final, diagnosis. They cannot yet
talk with their tongues and their lips, but they speak a living language
in every line, every curve, every tint of their tiny, translucent
bodies, from their little pink toes to the soft spot on the top of their
downy heads. Not only have they all the muscle-signs about the
face-dial, of pain or of comfort, but, also, these are absolutely
uncomplicated by any cross-currents of what their elders are pleased to
term "thought."
When a baby knits his brows he is not puzzling over his political
chances or worrying about his immortal soul. He has got a pain somewhere
in his little body. When his vocal organs emit sounds, whether the
gurgle or coo of comfort, or the yell of dissatisfaction, they are just
squeezed out of him by the pressure of his own internal sensations, and
he is never talking just to hear himself talk. Further than this, his
color is so exquisitely responsive to every breath of change in his
interior mechanism, that watching his face is almost like observing a
reaction in a test-tube, with its precipitate, or change of color. In
addition, not only will he turn pale or flush, and his little muscles
contract or relax, but so elastic are the tissues of his surface, and so
abundant the mesh of blood-vessels just underneath, that, under the
stroke of serious illness, he will literally shrivel like a green leaf
picked from its stem, or wilt like a faded flower.
A single glance at the tiny face on the cot pillow is usually enough to
tell you whether or not the little morsel is seriously ill. Nothing
could be further from the truth than the prevailing impression that,
because babies can't talk, it is impossible, especially for a young
doctor, to find out what is the matter with them. If they can't talk,
neither can they tell lies, and when they yell "Pin!" they mean pin and
nothing else.
In fact, the popular impression of the puzzled discomfiture of the
doctor before a very small, ailing baby is about as rational as the
attitude of a good Quaker lady in a little Western country town, who had
induced her husband to subscribe liberally toward the expenses of a
certain missionary on the West Coast of Africa. On his return, the
missionary brought her as a mark of his gratitude a young half-grown
parrot, of one of the good talking breeds. The good lady, though
delighted, was considerably puzzled with the gift, and explained to a
friend of mine that she really didn't know what to feed it, and it
wasn't quite old enough to be able to talk and tell her what it wanted!