Preventable Diseases. Woods Hutchinson
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 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 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 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 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 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,