Part 3 (2/2)
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 seash.o.r.e, 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 anaemia 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 anaemias 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 anaemia 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 s.e.xual ornaments, placed, like a good advertis.e.m.e.nt, 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 a.s.sumes 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 a.s.sociated 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 a.s.sociated 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 att.i.tude, 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 _debacle_ 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 ma.s.s 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 att.i.tude of impatient incredulity toward the stories of our patients, typified by the story of that great surgeon, but greater bear, Dr. John Abernethy, has pa.s.sed, 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, embarra.s.sed,--”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 cla.s.s 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 att.i.tude 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 grat.i.tude 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!
CHAPTER IV
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