It may be a healthy corrective to our overweening conceit to remind ourselves that, remarkable and valuable as it is, it is a mere infant in arms compared to the superb powers of replacement and repair possessed by our more remote ancestors. Most invertebrates and many of the lowest two classes of backboned animals, the fishes and the amphibians, cannot merely stop up a rent, but renew an entire limb, fin,—yes, even eye or head. Cut an earthworm in two and the rear half will grow a new head and the front half a new tail. It may even be cut in four or five segments, each of which will proceed to form a head at one end and a tail at the other. The lobster can regrow a complete gill and any number of claws or an eye. A salamander will reproduce a foot and part of a limb. Take out the crystalline lens in the eye of a salamander and the edge of the iris, or colored part of the eye, will grow another lens. Take out both the lens and the iris and the choroid coat of the eye will reproduce both.
We are in the A, B, C class in powers of repair by comparison with the angleworm, the lobster, or the salamander. Yet we are not without gruesome echoes of this lost power of regeneration in that our whole brood of tumors, including the deadly cancer and sarcoma, are due to a strange resumption, on the part of some little knot of our body-cells, of the power of reproducing themselves or the organ in which they are situated, without any regard to the welfare of the rest of the body. Cancer is, in one sense, a throwing off of the allegiance to the body-state and a resumption of amphibian powers of independent growth on the part of certain groups of our body-cells—literally, a "rebellion of the cells."
These are but a handful of scores of instances thatcould be adduced, showing that the majority of the processes upon which we rely in combating disease and preserving life are the result of the hereditary experiences of our cells. Intelligent physicians are receding completely from that curiously warped and jaundiced view which led us to regard heredity chiefly as a factor in theproductionof disease. It was, perhaps, natural enough, since it was inevitably only its injurious, or, so to speak, malicious, effects which were brought to our attention to be corrected. But, just as in the growth of our ethnic religions it is Evil that is worshiped first as strongest and most aggressive, and the recognition of the greater power of good comes only at a later stage, so it has been in pathology.
Not only do we regard heredity as a comparatively small and steadily receding factor in the production of disease, but we fully and frankly recognize it as the strongest and most important single force in its prevention. All our processes of repair, all the reactions of the body against the attack of accident or of disease, are hereditary endowments, worked out with infinite pains and labor through tens of thousands of generations. The utmost that we can do with our drugs and remedies is to appeal to and rouse into action the great healing power of nature, the classic "Vis medicatrix Naturæ," an incarnation of our past experiences handed down by heredity. Enormously valuable and important as are the services to human welfare, health, and happiness which can be rendered by the destruction of the living external causes of disease and the prevention of contagion, our most permanent and substantial victories are won by appealing to and increasing this long-descended and hard-won power of individual resistance.
"But," says some one at once, "I thought there were a large number of hereditary diseases." Fifty years ago there were a score of such, twenty years ago the score had sunk to five or six. Now there is scarcely one left. There is no known disease which is directly inherited as such. There is scarcely even a disease in which we now regard heredity as playing a dominant or controlling part. Among the few diseases in which there is serious dispute as to this are tuberculosis, insanity, epilepsy, and cancer.
Then there are diseases which for a long time puzzled us as to the possibility of their inheritance, but which have now resolved themselves clearly into instances of the fact that a mother who happens to contract an acute infectious disease of any sort may communicate that disease to the unborn child. If this occurs at an early stage of development the child will naturally be promptly killed. In fact, this is the almost invariable result in smallpox and yellow fever. If, on the other hand, development be further advanced or the infection be of a milder character, like scarlet fever or syphilis, the child may be born suffering with the disease or with the virus in its blood, which will cause the disease to develop within a few days after birth. This, however, is clearly not inheritance at all, but direct infection. We no longer use the termhereditarysyphilis but have substituted for it the wordcongenital, which simply means that a child is born with the disease.
There is no such thing as this disease extending "unto the third and fourth generation," like the wrath of Jehovah. One fact must, of course, be remembered, which has probably proved a source of confusion in the popular mind, and that is its extraordinary "long-windedness." It takes not merely two or three weeks or months to develop its complete drama, but anywhere from three to thirty years, so that it is possible for a child to be born with the taint in its blood and yet not exhibit to the non-expert eye any sign of the disease until its eighth, twelfth, or even fifteenth year.
The case of tuberculosis is almost equally clear-cut. In all the thousands of post-mortem examinations which have been held upon newborn children and upon mothers dying in or shortly after childbirth, the number of instances of the actual transference of the bacilli of tuberculosis from mother to child could be counted upon the fingers of two hands. It is one of the rarest of pathologic curiosities and, for practical purposes, may be entirely disregarded. When tuberculosis appears in several members of a family, in eight cases out of ten it is due to direct infection from parents or older children. This is strikingly brought out in the admirable work done by the Associated Dispensaries for Tuberculosis of the Charity Organization Society of New York.
One of the first steps in advance which they took was to establish in connection with every clinic for tuberculosis an attendant nurse, whose duty it was to visit the patients at their homes and advise and instruct them asto improvements in their methods of living, ventilation, food, and the prevention of infection.
It was not long before these intelligent women began to bring back reports of other cases in the same family. Now the procedure is regularly adopted, whenever a case presents itself, of rounding up the remainder of the family group for examination, with the astounding result that where a mother or father is tuberculous, from twenty to sixty per cent of the children will be found to be suffering from some form of the infection. Instances of three infected children out of five living in the same room with a tuberculous mother are actually on record.
No one can practice long in any of our great climatic health resorts for tuberculosis, like Colorado or the Pacific Slope, without coming across scores of painful and distressing instances of children of tuberculous parents dying suddenly in convulsions from tuberculous meningitis, or by a wasting diarrhœa from tuberculosis of the bowels, or from a violent attack of distention of the bowels due to tuberculous peritonitis. The favorite breeding-place of the tubercle bacillus is unfortunately in the home.
On the other hand, while the vast majority of cases of so-called hereditary tuberculosis are due to direct infection, and may be prevented by proper disposal of the sputum and other methods for avoiding contagion, there is probably a hereditary element in the spread of tuberculosis to this degree: that, inasmuch as all of us have been exposed to the attack and invasion of the tubercle bacillus, not merely scores, but hundreds of times, andhave been able to resist or throw off that attack without apparent injury, the development of an invasion of the tubercle bacillus sufficiently extensive to endanger life is, in nine cases out of ten, in itself a proof of lowered resisting power on the part of the patient. This may be, and often is, only temporary, due to overwork, underfeeding, overconfinement, or that form of gradual suffocation which we politely term inadequate ventilation.
In a certain percentage of cases, however, it is due to a chronic lack of vigor and vitality; a lowering of the whole systemic tone, which may have existed from birth. In that case it is hardly to be expected that such an individual, becoming a parent, will be able to transmit to his or her offspring more vigor than he originally possessed. It is therefore probable that the children of a considerable percentage of tuberculous parents would not possess the same degree of resisting power against tuberculosis, or any other infection, as the average individual.
It is doubtful whether this factor of inherited lowered resistance plays any very important part in the propagation of tuberculosis, partly because it is comparatively seldom that consumptive marries consumptive, and such tendencies to lowered vigor and vitality as may be transmitted by one parent will be neutralized by the other; partly also because, by the superb and beneficent logic of nature, the pedigree of any disease is of the most mushroom and insignificant length, while the pedigree of health stretches back to the very dawn of time. In the struggle for dominance which takes place between the germ cells of the father and those of themother, the chances are at least ten to one in favor of the old ancestral traits of vigor, of resisting power, and of survival. How deeply this idea is implanted in the convictions of the scientific world, the bitterly and widely debated biologic question whether acquired characters or peculiarities can under any circumstances be inherited clearly shows. Victory for the present rests with those who deny the possibility of such inheritance, and disease is emphatically an acquired character.
Truth here, as everywhere, probably lies between the extremes, and both biologists and the students of disease have arrived at practically the same working compromise, namely, that while no gross defect, such as a mutilation, nor definite disease factor, such as a germ, nor even a cancer, can possibly be inherited, yet, inasmuch as the two cells, which by their development form the new individual, are nourished by the blood of the maternal body, influences which affect the nutritiousness or healthfulness of that blood may unfavorably influence the development of the offspring.
Disease cannot be inherited any more than a mutilating defect, but the results of both, in so far as they affect the nutrition of the offspring in the process of formation, may be transmitted, though to a very much smaller extent than we formerly believed. In the case of tuberculosis, if the mother, during the months that she is building up the body and framework of a child, is in a state of reduced or lowered nutrition on account of consumption or any other disease, or has her tissues saturated with the toxins of this disease, it is hardly tobe expected that the development of the child will proceed with the same perfection as it would under perfectly normal maternal surroundings.
However, even this influence is comparatively small; for one of the most marvelous things in nature is the perfection of the barrier which she has erected between the child before birth and any injurious conditions which may occur in the body of the mother. Here preference, so to speak, is given to the coming life, and whenever there is a contest for an adequate supply of nutrition, as, for instance, in cases of underfeeding or of famine, it is the mother who will suffer in her nutrition rather than the child. The unborn child, biologically considered, feeds upon the best she has to offer, rejecting all that is inferior, doing nothing and giving nothing in return.
How perfectly the coming generation is protected under the most unfavorable circumstances we have been given a striking object-lesson in one family of the lower animals. In the effective crusade against tuberculosis in dairy cattle waged by the sanitary authorities in Denmark, it was early discovered that the greatest practical obstacle to the extermination of tuberculosis in cattle was the enormous financial sacrifice involved in killing all animals infected. The disease was at that time particularly rife among the high-bred Jersey, Holstein, and other milking breeds. It was determined as a working compromise to test the truth of the modern belief that tuberculosis was transmitted only by direct infection, by permitting the more valuable cows to be saved alive for breeding purposes.They were isolated from the rest of the herd and given the best of care and feeding. The moment that their calves were born they were removed from them altogether and brought up on the milk of perfectly healthy cows. The milk of the infected cows was either destroyed or sterilized and used for feeding pigs.
The results were brilliantly successful. Scarcely one of the calves thus isolated developed tuberculosis in spite of their highly infected ancestry. And not only were they not inferior in vigor and perfection of type to the remainder of their breed, but some of them have since become prize-winners. The additional care and more abundant feeding that they received more than compensated for any problematic defect in their heredity.
As to the heredity of cancer, all that can be said is that the burden of proof rests upon those who assert it. It is really curious how widespread the belief is that cancer "runs in families," and how exceedingly slender is the basis of evidence for such a belief. There are so many things that we do not know about cancer that any positive statement of any kind would be unbecoming. It would be absurd to declare that a disease, of which the cause is still unknown, either is or is not inherited. And this is our position in regard to cancer. An overwhelming majority of the evidence so far indicates that it is not a parasite; if it were, of course, we could say positively that it is not inherited. Although we are getting a discouraging degree of familiarity with the process and clearly recognize that it consists chiefly in the sudden revolt or rebellion of some group of cells, a tendencywhich quite conceivably might be transmitted to future generations, yet it is highly improbable, on both biological and pathological grounds, that such is the case. If this rebellious tendency were transmitted we should at least have the right to expect that it would appear in the cells of the same organ or region of the body. It is a singular fact that in all the hundreds of cases in which cancer has appeared in the child of a cancerous parent it has almost invariably appeared in some different organ from that affected in the parent.
For instance, cancer of the lip in the father may be followed by cancer of the liver in the son or daughter, while cancer of the breast in the mother will be followed by cancer of the lip in a son. Further than this, the percentage of instances in which cancer appears in more than one member of a family is decidedly small, considering the frequency of the disease.
I took occasion to look into the matter carefully from a statistical point of view some ten or twelve years ago, and out of a collection of some fifty thousand cases of cancer less than six per cent were found to give any history of cancer in the family. And this, of course, simply means that some one of the relatives of the patient had at one time developed the disease.
In fact, the consensus of intelligent expert opinion upon the subject of heredity of cancer is, that though it may occur, we have comparatively little proof of the fact; that the percentage of cases in which there is cancer in the family is but little larger than might be expected on the doctrine of probabilities from the average distribution. Though possibly the offspring of acancerous individual may display a slightly greater tendency toward the development of that strange, curious process of "autonomy" than the offspring of the average individual, this tendency is so small and occurs so infrequently as to be a factor of small practical importance in the propagation and spread of the disease.
In insanity and epilepsy we have probably the last refuge and almost only valid instance of the old belief in the remorseless heredity of disease. But even here the part played by heredity is probably only a fraction of that which it is popularly, and even professionally, believed to play. It is, of course, obvious that diseases which tend quickly to destroy the life of the patient, especially those which kill or seriously cripple him before he has reached the age of reproduction, or prevent his long surviving that epoch, will not, for mechanical reasons, become hereditary. The Black Death, or the cholera, for instance, could not "run in a family." Supposing that children were born with a special susceptibility to this disease, there would obviously soon be no family left.
The same is true in a lesser degree of milder or more chronic diseases. The family which was hereditarily predisposed to scarlet fever, measles, smallpox, or tuberculosis would not last long, and in fact the whole progress of civilization has been a continuous process of the weeding out of those who were most susceptible and the survival of those who were least so.
But when we come to deal with certain conditions, fortunately rare, such as functional disturbances of the nervous system, which neither seriously unfit their possessor for the struggle of life nor prevent him from reproducing his kind, then it becomes possible that a tendency to such disease may be transmitted through several successive generations.
Such is the case with insanity, with epilepsy, withhemophilia, or "bleeders," and with certain rare and curious disturbances of the nervous system, such as the hereditaryataxiasand "tics" of various sorts. However, even here the only conditions on which these diseases can continue to run in a family for more than one or two generations is either that they shall be mild in form or that only a comparatively small percentage of the total family shall be affected by them. If, for instance, two-thirds, one-half, or even a third of the descendants of a mentally unsound individual were to become insane, it would only need a few generations for that family to be crushed to the wall.
While the descendants of insane persons are distinctly more liable to become insane than the rest of the community, yet, on account of their fewness, this tendency probably does not account for more than a small fraction of the total insanity. We should, by all means, prevent the marriage of the insane and discourage that of their children, and the development of any well-defined form of insanity should act at once,ipso facto, as a ground and cause of divorce.
But the consoling fact remains that even of such children, providing, of course, as usually happens, that the other parent—husband or wife—is sound and sane, not more than ten or fifteen per cent would probably become insane. In other words, insanity isacquired and the result of individual stress and strain at least five times as frequently as it is inherited. We have absolutely no rational or statistical basis for gloomy predictions that, at present rates, within a couple of centuries more, we shall all be shut up in asylums with nobody left to support us and pay the taxes. The apparent increase of insanity of recent decades is probably only "on paper," due to better registration.
To put it very roughly, probably ninety-eight per cent of us are so born, thanks to heredity, that the possibility of our becoming insane, even under the severest stress, is almost infinitesimal. Of the two per cent born with this taint, this possible tendency to mental unbalance, only about one-tenth now become completely insane,[1]and this percentage might be greatly diminished by general sanitary improvements. Our alienists now claim that, by checking the reproduction of the obviously unstable, and careful hygienic treatment and training of the predisposed two per cent, insanity is almost as preventable as tuberculosis.
In fine, from all the broad field of pathology, the mists of tradition which have dimmed the fair name and reputation of heredity are slowly but surely lifting, until we now behold it, not as our worst enemy, but as our best friend in the prevention of disease and the upbuilding of the race.
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,—thetactus eruditusof 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 factunless 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 firstcoup d'œil, "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 outof 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 arenotdeceptive—except to fools. Every line of the human figure, every proportion of a limb, every detail of size, shape, or relation in an organ,meanssomething. 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 deviceof 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, puttinghim 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 thegenus humanumknown 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 glanceat 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 oftriangulation," 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 onlya 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 somedisease 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, termLa 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 theeyes 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 ispretty 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 edgesinto 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 anddamp, 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 strongprima faciecase.
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 healthconditions, 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 opaqueand whitish, and thus forming the little white crescent, orlunula, 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 thisdébâcleand the slight droopof 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 oflocomotor 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, andon 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 ofparalysis 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 andludicrously 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 theyoung 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 meanwhilethe 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!