Preventable Diseases. Woods Hutchinson
or wife—is sound and sane, not more than ten or fifteen per cent would probably become insane. In other words, insanity is acquired 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.
CHAPTER III
THE PHYSIOGNOMY OF DISEASE: WHAT A DOCTOR CAN TELL FROM APPEARANCES
It is our pride that medicine, from an art, and a pretty black one at that, originally, is becoming a science. And the most powerful factor in this development, its indispensable basis, in fact, has been the invention of instruments of precision—the microscope, the fever thermometer, the stethoscope, the ophthalmoscope, the test-tube, the culture medium, the triumphs of the bacteriologist and of the chemist. Any man who makes a final diagnosis in a serious case without resorting to some or all of these means is regarded—and justly—as careless and derelict in his duty to his patient.
At the same time, priceless and indispensable as are these laboratory methods of investigation, they should not be allowed to make us too scornful and neglectful of the evidence gained by the direct use of our five senses. We should still avail ourselves of every particle of information that can be gained by the trained eye, the educated ear, the expert touch—the tactus eruditus of the medical classics—and even the sense of smell. There is, in fact, a general complaint among the older members of the profession that the rising generation is being trained to neglect and even despise the direct evidence of the senses, and to accept no fact as a fact unless it has been seen through the microscope or demonstrated by a reaction in the test-tube. As one of our keenest observers and most philosophic thinkers expressed it a few months ago:—
"I fear that certain physicians on their rounds are most careful to take with them their stethoscope, their thermometer, their hemoglobin papers, their sphygmomanometer, but leave their eyes and their brains at home."
And it is certain that the art of sight diagnosis, which seems like half magic, possessed in such a wonderful degree by the older physicians of the passing and past generations, has been almost lost by the new.
A healthful reaction has, however, set in; and while we certainly do not love the Cæsar of laboratory methods and accuracy the less, we are beginning to have a juster affection for the Rome of the rich harvest that may be gained from the careful, painstaking, detective-like exercise of our eye, ear, and hand.
As a matter of fact, the conflict between the two methods is only apparent. Not only is each in its proper sphere indispensable, but they are enormously helpful one to the other. Instead of our being able to tell less by the careful, direct eye-and-hand examination of our patients than the doctor of a century ago, we can tell three to five times as much. Signs that he could interpret only by the slow and painful method of two-thirds of a lifetime of plodding experience, or by occasional flashes of half-inspired insight, we are now able to interpret absolutely upon a physiological—yes, a chemical—basis from the revelations of the microscope, the test-tube, and the culture medium. His only way of determining the meaning of a particular tint of the complexion, or line about the mouth, or eruption on the skin, was by slowly and laboriously accumulating a long series of similar cases in which that particular symptom was found always to occur, and deducing its meaning. Now, we simply take a drop of our patient's blood, a scraping from his throat, a portion of some one of his secretions, a little slice of a tumor or growth, submit them to direct examination in the laboratory, and get a prompt and decisive answer.
The observant physician begins to gather information about a patient from the moment he enters the sick-room or the patient steps into his consulting-room; and the value of the information obtained in the first thirty seconds, before a word has been spoken, is sometimes astonishingly great. While no intelligent man would dream of depending upon this first coup d'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 out of five, your most elaborate and painstaking study of the case with all the modern methods will bring you to the same conclusion as that sensed within forty-five seconds by this keen-eyed old sleuth-hound of the fever trails. Time and again, in my interne days, have I gone the rounds of the wards or the out-patient departments with some kindly-faced, keen-eyed old Sherlock Holmes of the profession, and seen him point to a new case across the ward with the question: "When did that pneumonia come in?" or pick out a pain-drawn, ashy mask in the waiting line, with an abrupt, "Bring me that case of cancer of the stomach. He's in pain. I'll take him first."
And, in later years, I have had colleagues with whom it was positively painful to walk down a crowded street, from the gruesome habit that they had of picking out, and condemning to lingering deaths, the cases of cancer, of Bright's disease, or of locomotor ataxia, that we happened to meet. Of course, they would be the first to admit that this was only what they would term a "long shot," a guess; but it was a guess based upon significant changes in the patient's countenance or gait, which their trained eye picked out at once, and it was surprising how often this snapshot diagnosis turned out to be correct.
The first thing that a medical student has to learn is that appearances are not deceptive—except to fools. Every line of the human figure, every proportion of a limb, every detail of size, shape, or relation in an organ, means something. Not a line upon any bone in the skeleton which was not made by the hand-grip or thumbprint of some muscle, tendon, or ligament; no bump or knuckle which is not a lever or hand-hold for the grip of some muscle; not a line or a curve or an opening in that Chinese puzzle, the skull, which was not made to protect the brain, to accommodate an eye, to transmit a blood-vessel, or to allow the escape of a nerve. Every minutest detail of structure means something to the man who will take the pains to puzzle it out. And if this is true of the foundation structure of the body, is it to be expected that the law ceases to run upon the surface?
Not a line, not a tint, not a hollow of that living picture, the face, but means something, if we will take the time and labor to interpret it. Even coming events cast their shadows before upon that most exquisitely responsive surface—half mirror, half sensitive plate—the human countenance. The place where the moving finger of disease writes its clearest and most unmistakable message is the one to which we must naturally turn, the face; not merely for the infantile tenth part of a reason which we often hear alleged, that it is the only part of the body, except