Preventable Diseases. Woods Hutchinson
delicate, yellowish tint confronts us there, we know we have to deal with a severe form of anæmia or jaundice, according to the tint. In extreme cases of the latter, the mucous membrane of the lips and of the gums will even show a distinctly yellowish hue. The frightful color of yellow fever, and the yellow "death mask," which appears just before the end of several fatal forms of blood poisoning, is due to the tremendous breaking down of the red cells of the blood under the attack of the fever toxins, and their leaking out into the tissues. A similar process of a milder and less serious extent occurs in those temporary anæmias of young girls, known for centuries past in the vernacular as "the green sickness." And a delicate lemon tint of this same origin, accompanied by a waxy pallor, is significant of the deadly, pernicious anæmia and the later stages of cancer.
The most significant single thing about the red flush, supposed to be indicative of health, is its location. If this be the normal "blush area," about the middle of each cheek—which is one of nature's sexual ornaments, placed, like a good advertisement, where it will attract most attention and add most beauty to the countenance—and it fades off gradually at the edges into the clear whiteness or brownness of the healthy skin, it is probably both healthy and genuine. If the work of either fever or of art, it will generally reveal itself as a base imitation. In eight cases out of ten of fever, the flush, instead of being confined to this definite area, extends all over the face, even up to the roots of the hair. The eyes, instead of being clear and bright, are congested and heavy-lidded; and if with these you have an increased rapidity of respiration, and a general air of discomfort and unrest, you are fairly safe in making a diagnosis of fever. If the first touch of the tips of the fingers on the wrist shows a hot skin and a rapid pulse, the diagnosis is almost as certain as with the thermometer.
Now for two of the instances in which it most commonly puzzles us. The first of these is consumption; for here the flush, both in position and in delicacy and gentle fading away at the proper margins, is an almost perfect imitation of health. It, however, usually appears, not as the normal flush of health does, upon a plump and rounded cheek, but upon a hollow and wasted one. It rises somewhat higher upon the cheekbones, throwing the latter out into ghastly prominence. The lips and the eyes will give us no clew, for the former are red from fever, and the latter are bright from the gentle, half-dreamy state produced by the toxins of the disease, the so-called "spes phthisica"—the everlasting and pathetic hopefulness of the consumptive. But here we call for help upon another of the features of disease—the hand. If, instead of being cool, and elastic, this is either dry and hot, or clammy and damp, and feels as if you were grasping a handful of bones and nerves, and the finger-tips are clubbed and the nails curved like claws, then you have a strong prima facie case.
The other color condition which is apt to puzzle us is that of the plump and comfortable middle-aged gentleman with a fine rosy color, but a watery eye and loose and puffy mouth, a wheezy respiration and apparent excess of adipose. Here the high color is often due to a paralytic distention of the blood-vessels of the face and neck, and an examination of his heart and blood-vessels shows that his prospects are anything but as rosy as his countenance.
The varying expressions of the face of disease are by no means confined to the countenance. In fact, they extend to every portion of—in Trilby's immortal phrase—"the altogether." Disease can speak most eloquently through the hand, the carriage, the gait, and, in a way that the patient may be entirely unconscious of, the voice. These forms of expression are naturally not so frequent as those of the face, on account of the extraordinary importance of the great systems whose clock-dials and indices form what we term the human countenance. But when they do occur they are fully as graphic and more definitely and distinctively localizing.
Next in importance to the face comes the hand, and volumes have been written upon this alone. Containing, as it does, that throbbing little blood-tube, the radial artery, which has furnished us for centuries with one of our oldest and most reliable guides to health conditions, the pulse, it has played a most important part in surface diagnoses. To this day, in fact, Arabic and Turkish physicians in visiting their patients on the feminine side of the family are allowed to see nothing of them except the hand, which is thrust through an opening in a curtain. How accurate their diagnoses are, based upon this slender clew, I should not like to aver, but a sharp observer might learn much even from this limited area.
We have—though, of course, in lesser degree—all the color and line pictures with which we have been dealing upon the face. Though not an index of any special system, it has the great advantage of being our one approach to an indication of the general muscular tone of the body, as indicated both in its grasp and in the poses it assumes at rest. The patient with a limp and nerveless hand-clasp, whose hand is inclined to lie palm upward and open instead of palm downward and half-closed, is apt to be either seriously ill, or not in a position to make much of a fight against the attack of disease.
The nails furnish one of our best indices of the color of the blood and condition of the circulation. Our best surface test of the vigor of the circulation is to press upon a nail, or the back of the finger just above it, until the blood is driven out of it, and when our thumb is removed from the whitened area to note the rapidity with which the red freshet of blood will rush back to reoccupy it.
In the natural growth of the nail, traveling steadily outward from root to free edge, its tissues, at first opaque and whitish, and thus forming the little white crescent, or lunula, found at the base of most nails, gradually become more and more transparent, and hence pinker in color, from allowing the blood to show through. During a serious illness, the portion of the nail which is then forming suffers in its nutrition, and instead of going on normally to almost perfect transparency, it remains opaque. And the patient will, in consequence, carry a white bar across two or three of his nails for from three to nine months after the illness, according to the rate of growth of his nails. Not infrequently this white bar will enable you to ask a patient the question, "Did you not have a serious illness of some sort two, three, or six months ago?" according to the position of the bar. And his fearsome astonishment, if he answers your question in the affirmative, is amusing to see. You will be lucky if, in future, he doesn't incline to regard you as something uncanny and little less than a wizard.
Another of the score of interesting changes in the hand, which, though not very common, is exceedingly significant when found, is a curious thickening or clubbing of the ends of the fingers, with extreme curvature of the nails, which is associated with certain forms of consumption. So long has it been recognized that it is known as the "Hippocratic finger," on account of the vivid description given of it by the Greek Father of Medicine, Hippocrates. It has lost, however, some of its exclusive significance, as it is found to be associated also with certain diseases of the heart. It seems to mean obstructed circulation through the lungs.
Next after the face and the hand would come the carriage and gait. When a man is seriously sick he is sick all over. Every muscle in his body has lost its tone, and those concerned with the maintenance of the erect position, being last developed, suffer first and heaviest. The bowed back, the droop of the shoulders, the hanging jaw, and the shuffling gait, tell the story of chronic, wasting disease more graphically than words. We have a ludicrously inverted idea of cause and effect in our minds about "a good carriage." We imagine that a ramrod-like stiffening of the backbone, with the head erect, shoulders thrown back and chest protruded, is a cause of health, instead of simply being an effect, or one of the incidental symptoms thereof. And we often proceed to drill our unfortunate patients into this really cramped and irrational attitude, under the impression that by making them look better we shall cause them actually to become so. The head-erect, chest-out, fingers-down-the-seam-of-your trousers position of the drillmaster is little better than a pose intended chiefly for ornament, and has to be abandoned the moment that any attempt at movement or action is begun.
So complete is this unconscious muscular relaxation, that it is noticeable not only in the standing and sitting position, but also when lying down. When a patient is exceedingly ill, and in the last state of enfeeblement, he cannot even lie straight in bed, but collapses into a curled-up heap in the middle of the bed, the head even dropping from the pillow and falling on the chest. Between this débâcle and the slight droop of shoulders and jaw indicative of beginning trouble there are a thousand shades of expression significant instantly to the experienced eye.