Part 3 (1/2)
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 pa.s.sing 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 s.h.i.+fting 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 ca.n.a.l, 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 ca.n.a.l. 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, a.s.sisted 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 ca.n.a.l, 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 antic.i.p.ation 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-ca.n.a.ls get beyond control; or if for any other reason the tissues be kept from getting their proper supply of nourishment from the food-ca.n.a.l, 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 antic.i.p.ation 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 ca.n.a.l 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, s.h.i.+ning eye, and a cl.u.s.tering 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 beaute 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 pa.s.sed 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 amus.e.m.e.nt 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 a.s.sociated 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 a.n.a.lyses 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.