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What, of course, originally made the face the face, and, for the matter of that, the head the head, was the intake opening of the food-canal, the mouth.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 device of 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, putting him 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 the genus humanum known 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 glance at 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 of triangulation," 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 only a 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 some disease 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, term La beaute 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 the eyes 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 is pretty safe to show through at the normal blush area on the cheeks; or, failing that, through the translucent epithelium of the lips and gums. If, on the other hand, this yellow tint be due to the escape of broken-down blood-pigments into the tissues, or a damming up of the bile, and a similar escape of its coloring matter, as in jaundice, then we turn to the whites of the eyes, and if a similar, but more delicate, yellowish tint confronts us there, we know we have to deal with a severe form of anaemia or jaundice, according to the tint. In extreme cases of the latter, the mucous membrane of the lips and of the gums will even show a distinctly yellowish hue. The frightful color of yellow fever, and the yellow "death mask," which appears just before the end of several fatal forms of blood poisoning, is due to the tremendous breaking down of the red cells of the blood under the attack of the fever toxins, and their leaking out into the tissues. A similar process of a milder and less serious extent occurs in those temporary anaemias of young girls, known for centuries past in the vernacular as "the green sickness." And a delicate lemon tint of this same origin, accompanied by a waxy pallor, is significant of the deadly, pernicious anaemia and the later stages of cancer.

The most significant single thing about the red flush, supposed to be indicative of health, is its location. If this be the normal "blush area," about the middle of each cheek,—which is one of nature's 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 debacle and the slight droop of shoulders and jaw indicative of beginning trouble there are a thousand shades of expression significant instantly to the experienced eye.

Though more limited in their application, yet most significant when found, are the alterations of the gait itself. Even a maker of proverbs can tell at a glance that "the legs of the lame are not equal." From the limp, coupled with the direction in which the toe or foot is turned, the tilt of the hips, the part of the foot that strikes first, the presence or absence of pain-lines on the face, a snap diagnosis can often be made as to whether the trouble is paralysis, hip-joint disease, knee or ankle mischief, or flatfoot, as your patient limps across the room. Even where both limbs are affected and there is no distinct limp, the form of shuffle is often significant.

Several of the forms of paralysis have each its significant gait. For instance, if a patient comes in with a firm, rather precise, calculated sort of gait, "clumping" each foot upon the floor as if he had struck it an inch sooner than he had expected, and clamping it there firmly for a moment before he lifts it again, as though he were walking on ice, with more knee action than seems necessary, you would have a strong suspicion that you had to deal with a case of locomotor ataxia, in which loss of sensation in the soles of the feet is one of the earliest symptoms. If so, your patient, on inquiry, will tell you that he feels as if there were a blanket or even a board between his soles and the surface on which he steps. If a quick glance at the pupils shows both smaller or larger than normal, and on turning his face to the light they fail to contract, your suspicion is confirmed; while if, on asking him to be seated and cross his legs, a tap on the great extensor tendon of the knee-joint just below the patella fails to elicit any quick upward jerk of the foot, the so-called "knee-kick," then you may be almost sure of your diagnosis, and proceed to work it out at your leisure.

On the other hand, if an elderly gentleman enters with a curiously blank and rather melancholy expression of countenance, holding his cane out stiffly in front of him, and comes toward you at a rapid, toddling gait, throwing his feet forward in quick, short steps, as if, if he failed to do so, he would fall on his face, while at the same time a vibrating tremor carries his head quickly from side to side, you are justified in suspecting that you have to do with a case of paralysis agitans, or shaking palsy.

Last of all, your physiognomy of disease includes not merely its face, but its voice; not only the picture that it draws, but the sound that it makes. For, when all has been allowed and discounted that the most hardened cynic or pessimistic agnostic can say about speech being given to man to conceal his thoughts, and the hopeless unreliability of human testimony, two-thirds of what your patients tell you about their symptoms will be found to be literally the voice of the disease itself speaking through them. They may tell you much that is chiefly imaginary, but even imagination has got to have some physical basis as a starting-point. They may tell you much that is clearly and ludicrously irrelevant, or untrue, on account of inaccuracy of observation, confusion of cause and effect, or a mental color-blindness produced by the disease itself. But these things can all be brushed aside like the chaff from the wheat if checked up by the picture of the disease in plain sight before you.

In the main, the great 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, was considerably puzzled with the gift, and explained to a friend of mine that she really didn't know what to feed it, and it wasn't quite old enough to be able to talk and tell her what it wanted!



CHAPTER IV

COLDS AND HOW TO CATCH THEM

Ancient vibrations are hard to stop, and still harder to control. Whether they date from our driving back by the polar ice-sheet, together with our titanic Big Game, the woolly rhinoceros, the mammoth, and the sabre-toothed tiger, from our hunting-grounds in Siberia and Norway, or from recollections of hunting parties pushing north from our tropical birth-lands, and getting trapped and stormbound by the advance of the strange giant, Winter, certain it is that our subconsciousness is full of ancestral memories which send a shiver through our very marrow at the mere mention of "cold" or "sleet" or "wintry blasts."

From the earliest dawn of legend cold has always been ranked, with hunger and pestilence and storm, as one of the demons to be dreaded and fought. And, at a little later date, the ancient songs and sayings of every people have been full of quaint warnings against the danger of a chill, a draft, wet feet, or damp sheets. There is, of course, a bitterly substantial basis for this feeling, as the dozens of stiffened forms whose only winding-sheet was the curling snowdrift, or whose coffin the frozen sleet, bear ghastly witness. It was, however, long ago discovered that when we were properly fed and clothed, the Cold Demon could be absolutely defied, even in a tiny hut made out of pressed snow and warmed by a smoky seal-blubber lamp; that the Storm King could be baffled just by burrowing into his own snowdrifts and curling up under the crust, like an Eskimo dog. Hence, nearly all the legends depict the hero as finally conquering the Storm King, like Shingebis in the Song of Hiawatha.

The ancient terror, however, still clings, with a hold the more tenacious as it becomes narrowed, to one large group of these calamities believed to be produced by cold,—namely, those diseases supposed to be caused by exposure to the weather. Even here, it still has a considerable basis in fact; but the general trend of opinion among thoughtful physicians is that this basis is much narrower than was at one time supposed, and is becoming still more restricted with the progress of scientific knowledge. For instance, fifty years ago, popular opinion, and even the majority of medical belief, was that consumption and all of its attendant miseries were chiefly due to exposure to cold. Now we know that, on the contrary, abundance of pure, fresh, cold air is the best cure for the disease, and foul air and overcrowding its chief cause. An almost equally complete about-face has been executed in regard to pneumonia. Prolonged and excessive exposure to cold may be the match that fires the mine, but we are absolutely certain that two other things are necessary, namely, the presence of the diplococcus, and a lowered and somewhat vitiated state of bodily resistance, due to age, overwork, underfeeding, or over-indulgence in alcohol.

Not only do these two diseases not occur in the land of perpetual cold, the frozen North, except where they are introduced by civilized visitors,—and scarce a single death from pneumonia has ever yet occurred in the crew of an Arctic expedition,—but it has actually been proposed to fit up a ship for a summer trip through the Arctic regions, as a floating sanatorium for consumptives, on account of the purity of the air and the brilliancy of the sunlight.

There is one realm, however, where the swing of this ancient superstition vibrates with fullest intensity, and that is in those diseases which, as their name implies, are still believed to be due to exposure to a lowered temperature—"common colds." Here again it has a certain amount of rational basis, but this is growing less and less every day. The present attitude of thoughtful physicians may be graphically indicated by the flippant inquiry of the riddle-maker, "When is a cold not a cold?" and the answer, "Two-thirds of the time." This much we are certain of already: that the majority of so-called "colds" have little or nothing to do with exposure to a low temperature, that they are entirely misnamed, and that a better term for them would be fouls. In fact, this proportion can be clearly and definitely proved and traced as infections spreading from one victim to another. The best place to catch them is not out-of-doors, or even in drafty hallways, but in close, stuffy, infected hotel bedrooms, sleeping-cars, churches, and theatres.

Two arguments in rebuttal will at once be brought forward, both apparently conclusive. One is that colds are vastly more frequent in winter, and the other that when you sit in a draft until you feel chilly, you inevitably have a cold afterward. Both these arguments alike, however, are based upon a misunderstanding. The frequency of colds in winter is chiefly due to the fact that, at this time of the year, we crowd into houses and rooms, shutting the doors and windows in order to keep warm, and thus provide a ready-made hothouse for the cultivation and transmission from one to another of the influenza and other bacilli. As the brilliant young English pulmonary expert, Dr. Leonard Williams, puts it, "a constant succession of colds implies a mode of life in which all aerial microbes are afforded abundant opportunities." At the same time, we take less exercise and sit far less in the open air, thus lowering our general vigor and resisting power and making us more susceptible to attack. Those who live out-of-doors winter and summer, and who ventilate their houses properly, even in cold weather, suffer comparatively little more from colds in the winter-time than they do in summer; although, of course, the most vigorous individual, in the best ventilated surroundings, will occasionally succumb to some particularly virulent infection.

The second fact of experience, catching cold after sitting in a draft or a chilly room until you begin to cough or sneeze, is one to which a majority of us would be willing to testify personally, and yet it is based upon something little better than an illusion. It is a well-known peculiarity of many fevers and infections to begin with a chill. The patient complains of shiverings up and down his spine, his fingernails and his lips become blue, in extreme cases his teeth chatter, and his limbs begin to twitch and shake, and he ends up in a typical ague fit. The best known, because most striking, illustration is malaria, or fever and ague, "chills and fever," as it is variously termed. But this form of attack, milder and much slighter in degree, may occur in almost every known infection, such as pneumonia, typhoid, tuberculosis, scarlet fever, measles, and influenza. It has nothing whatever to do with either external or internal temperature; for if you slip a fever-thermometer under your chilling patient's tongue, it will usually register anywhere from 102 to 105 deg..

This method of attack is especially common, not only in influenza, but also in all the other so-called "common colds." In fact, when we begin to shiver and sneeze and hunt around for an imaginary draft or lowering of the temperature which has caused it, we are actually in the first stage of the development of an infection which was contracted hours, or even days, before.

When you begin to shiver and sneeze and run at the eyes you are not "catching" cold; you have already caught it long before, and it is beginning to break out on you. Mere exposure to cold will never cause sneezing. It takes a definite irritation of the nasal mucous membrane, by gas or dust from without, or toxins from within, to produce a sneeze.

As to mere exposure to cold weather and wet and storm being able to produce it, it is the almost unanimous testimony of Arctic explorers that, during their sojourn of from two to three years in the frozen North, they never had so much as a sneeze or a sore throat, even though frequently sheltered in extemporized huts, and running short of adequate food-supply before spring. Within a week of their return to civilization they would begin sneezing and coughing, and catch furious colds.

Lumbermen, trappers, hunters, and prospectors in Alaska give similar testimony. I have talked with scores of these pioneers, visiting them, in fact, in their camps under conditions of wet, cold, and exposure that would have made one afraid of either pneumonia or rheumatism before morning, and found that, so long as they remained up in the mountains or out in the snow, and no case of influenza, sore throat, or cold happened to be brought into the camp, they would be entirely free from coughs and colds; but that, upon returning to civilization and sleeping in the stuffy room of a rude frontier hotel, they would frequently catch cold within three days.

One unusually intelligent foreman of a lumber camp in Oregon told me that an experience of this kind had occurred to him three different times that he could distinctly recollect.

It is difficult to catch a cold or pneumonia unless the bacilli are there to be caught. Boswell has embalmed for us, in the amber of his matchless biography, the fact that it had been noted, even in those days, that the inhabitants of one of the Faroe Islands never had colds in the head except on the rare occasions when a ship would touch there—usually not oftener than once a year. Then, within a week, half the population would be blowing and sneezing. The great Samuel commented upon the fact at length, and advanced the ingenious explanation that, as the harbor was so difficult of entry, the ships could beat in only when the wind was in a certain quarter, and that quarter was the nor'east. Hinc illae lacrimae! (Hence these weeps!) The colds were caused by the northeast wind of unsavory reputation! How often the wind got into the northeast without bringing a ship or colds he apparently did not speculate.

To come nearer yet, did you ever catch cold when camping out? I have waked in the morning with the snow drifting across the back of my neck, been wet to the skin all day, and gone to bed in my wet clothes, and slept myself dry; and have lain out all day in a November gale, in a hollow scooped in the half-frozen ground of the duck-marsh, and felt never a hair the worse. Scores of similar experiences will rise up in the minds of every camper, hunter, or fisherman. You may catch cold during the first day or two out, before you have got the foul city air, with its dust and bacteria, out of your lungs and throat, but even this rarely happens.

How seldom one catches cold from swimming, no matter how cold the water; or from boating, or fishing,—even without the standard prophylactic; or from picnicking, or anything that is done during a day in the open air.

So much for the negative side of the evidence, that colds are not often caught where infectious materials are absent. Now for the positive side.

First of all, that typical cold of colds, influenza, or the grip, is now unanimously admitted by authorities to be a pure infection, due to a definite germ (the bacillus influenzae of Pfeiffer) and one of the most contagious diseases known. Each of the great epidemics of it—1830-33, 1836-37, 1847-48, and, of most vivid and unblessed memory, 1889-90—can be traced in its stately march completely across the civilized world, beginning, as do nearly all our world-epidemics,—cholera, plague, influenza, etc.,—in China, and spreading, via India or Turkestan, to Russia, Berlin, London, New York, Chicago. Moreover, its rate of progress is precisely that of the means of travel: camel-train, post-chaise, railway, as the case may be. The earlier epidemics took two years to spread from Eastern Russia to New York; the later ones, forty to sixty days. Soon it will beat Jules Verne or George Francis Train. So intensely "catching" is it, that letters written by sufferers have been known to infect the correspondents who received them in a distant town, and become the starting-point of a local epidemic.

Of course, it may be urged that when we have proved the grip to be a definite infection, we have taken it out of the class of "colds" altogether, and that its bacterial origin proves nothing in regard to the rest. But a rather interesting state of affairs developed during the search for the true bacillus of influenza: this was that a dozen other bacilli and cocci were discovered, each of which seemed capable of causing all the symptoms of the grip, though in milder form. So that the view of the majority of pathologists now is that these "influenzoid," or "grip-like" attacks, under which come a majority of all common colds, are probably due to a number of different milder micro-organisms.

The next fact in favor of the infectious character of a cold is that it begins with a chill, followed with a fever, runs a definite self-limited course, and, barring complications, gets well of itself in a certain time, just like the measles, scarlet fever, pneumonia, or any other frank infection.

Colds are also followed by inflammations, or toxic attacks in other organs of the body, lungs, stomach, bowels, heart, kidneys, nerves, etc., just like diphtheria, scarlet fever, or typhoid, only, of course, of milder form and less frequently.

Last, but not least practically convincing, colds may be traced from one victim to another, may "run through" households, schools, factories, may occur after attending church or theatre, may be checked by isolating the sufferers; and are now most effectually treated by the inhalation of non-poisonous germicidal or antiseptic vapors and sprays.

One of my first experiences with this last method occurred in a most unexpected field. An old friend, a most interesting and intelligent German, was the proprietor of a wild-animal depot, importing foreign animals and birds and selling them to the zooelogical gardens and circuses. I used often to drop in there to see if he had anything new, and he would come up to see me, to tell me his troubles and keep my dissecting-table supplied with interestingly diseased dead beasts and birds.

One day he came up in a state of great excitement, with a very dead and dilapidated parrot in his hand.

"Choost look, Dogdor; here's one of dose measley new pollies I god in from Zingapore. De rest iss coffin' an' sneezin' to plow dere peaks off, an' all de utter caitches iss kitchen him."

As parrots are worth from fifteen to thirty dollars apiece, "green" (not in color, but training), and he had fifty or sixty in the store, the situation was distinctly serious. Now, I was no specialist in the peculiar diseases of parrots, but something had to be done, and, with a boldness born of long practice, I drew my bow at a venture and let fly this suggestion:—

"Try formalin; it's pretty fierce on the eyes and nose, but it won't kill 'em; and, if you put a teaspoonful in the bottom of each cage, by the time it evaporates no germ that gets into that cage will live long enough to do any harm."

Five days later back he came, red-eyed but triumphant. "Dogdor, dot vormaleen iss de pest shtuff I effer saw. It mos' shteenk me out of de shtore, an' de pollies nearly sneeze dere fedders off, but it shtopt de spret, an' it's cureenall de seek ones, an' I het a cold in de het, an' it's curt me."

Before using it he had fourteen cases and three deaths; after, only three new cases and no more deaths. I would, however, hardly advise any human "coldie" to try such heroic treatment offhand, for the pungency and painfulness of formalin vapor is something ferocious, though the French physicians, with characteristic courage, are making extensive use of it for this purpose, with excellent results under careful supervision.

Another curious straw pointing in the direction of the infectious nature of colds is the "annual cold," or "yearly sore throat," from which many of us suffer. When we have had it we usually feel fairly safe from colds for some months at least, often for a year. The only explanation that seems in the least to explain is that colds, like other infections, confer an immunity against another attack; only, unlike scarlet fever, measles, smallpox, etc., this immunity, instead of for life, is only for six months or a year. This immunity is due to the formation in the blood of protective substances known as anti-bodies, which destroy or render harmless the invading germs. Flabby, under-ventilated individuals, who are always "catching cold," have such weak resisting powers that they form hardly enough anti-bodies to terminate the first attack, without having enough left to protect them from another for more than a few weeks or months. Dr. Leonard Williams describes chronic cold-catchers as "people who wear flannel next their skins, ... who know they are in a draft because it makes them sneeze; who, in short, live thoroughly unwholesome, coddling lives." Strong and vigorous individuals may form enough to last them a year, or even two years.

Now comes the question, "What are we going to do about it?" Obviously, we cannot "go gunning" for these countless billions of germs, of fifteen or twenty different species. Nor can we quarantine every one who has a cold. Fortunately, no such radical methods are necessary. All we have to do is to take nature's hint of the anti-bodies and improve upon it. Healthy cells can grow fat on a diet of such germs, and, if we keep ourselves vigorous, clean, and well ventilated, we can practically defy the "cold" devil and all his works.

Here is the leitmotif of the whole fascinating drama of infection and immunity. We can study only one phrasing here. We shall, of course, catch cold occasionally, but will throw it off quickly, and probably form anti-bodies enough to last us a year or more. How can this be done? First and foremost, by living and sleeping as much as possible in the open air. This helps in several different ways. First, by increasing the vigor and resisting power of our bodies; second, by helping to burn up, clean, and rid our tissues of waste products which are poisons if retained; third, by greatly reducing the risks of infection.

You can't catch cold by sitting in a field exposed to the draft from an open gate; though I understand that casuists of the old school of the "chill-and-damp" theory of colds are still discussing the case of the patient who "caught his death o' cold" by having his gruel served in a damp basin.

The first thing to do is to get the outdoor habit. This takes time to acquire, but, once formed, you wouldn't exchange it for anything else on earth. The next thing is to learn to sit or sleep in a gentle current of air all the time you are indoors. You ought to feel uncomfortable unless you can feel air blowing across your face night and day. Then you are reasonably sure it is fresh, and it is the only way to be sure of it.

But drafts are so dangerous! As the old rhyme runs,

But when a draft blows through a hole, Make your will and mend your soul.

Pure superstition! It just shows what's in a name. Call it a gentle breeze, or a current of fresh air, and no one is afraid of it. Call it a "draft," and up go hands and eyebrows in horror at once. One of our highest authorities on diseases of the lungs, Dr. Norman Bridge, has well dubbed it "The Draft Fetich." It is a fetich, and as murderous as Moloch. The draft is a friend instead of an enemy. What converted most of us to a belief in the beneficence of drafts was the open-air treatment of consumption! Hardly could there have been a more spectacular proof, a more dramatic defiance of the bogey. To make a poor, wasted, shivering consumptive, in a hectic one hour and a drenching sweat the next, lie out exposed to the November weather all day and sleep in a ten-knot gale at night! It looked little short of murder! So much so to some of us, that we decided to test it on ourselves before risking our patients.

I can still vividly recall the astonishment with which I woke one frosty December morning, after sleeping all night in a breeze across my head that literally made

Each particular hair to stand on end, Like quills upon the fretful porcupine,

not only without the sign of a sniffle, but feeling as if I'd been made new while I slept.

Then we tried it in fear and trembling on our patients, and the delight of seeing the magic it worked! That is an old story now, but it has never lost its charm. To see the cough which has defied "dopes" and syrups and cough mixtures, domestic, patent, and professional, for months, subside and disappear in from three to ten days; the night sweats dry up within a week; the appetite come back; the fever fall; the strength and color return, as from the magic kiss of the free air of the woods, the prairies, the seacoast. There's nothing else quite like it on the green earth. Do you wonder that we become "fresh-air fiends"?

The only thing we dread in these camps is the imported "cold." Dr. Lawrence Flick was the first to show us the way in this respect as in several others. He put up a big sign at the entrance of White Haven Sanatorium, "No persons suffering from colds allowed to enter," and traced the only epidemic of colds in the sanatorium to the visit of a butcher with the grip. I put up a similar sign at the gate of my Oregon camp, and never had a patient catch cold from tenting out in the snow and "Oregon mists" until the small son of the cook came back from the village school, shivering and sneezing, when seven of the thirteen patients "caught it" within a week.

What will cure a consumptive will surely not kill a healthy man. I am delighted to say that it shows signs of becoming a fad now, and sleeping porches are being put on houses all over the country. No house in California is considered complete without them. The ideal bedroom is a small dressing-room, opening on a wide screened porch, or balcony, with a door wide enough to allow the bed to be rolled inside during storms or in severest weather.

Sleep on a porch, or in a room with windows on two sides wide open, and the average living-room or office begins to feel stuffy and "smothery" at once. Apply the same treatment here. Learn to sit in a gentle draft, and you'll avoid two-thirds of your colds and three-fourths of your headaches. It may be necessary in winter to warm the draft, but don't let any patent method of ventilation delude you into keeping your windows shut any hour of the day or night.

On the other hand, don't fall into the widespread delusion that because air is cold it is necessarily pure. Some of the vilest air imaginable is that shut up in those sepulchres known as "best bedrooms," which chill your very marrow. The rheumatism or snuffles you get from sleeping between their icy sheets comes from the crop of bacilli which has lurked there since they were last aired. The "no heat in a bedroom" dogma is little better than superstition, born of those fecund parents which mate so often, stinginess and puritanism. Practically, the room which will never have a window opened in it in winter is the one without any heat.

Similarly, the air in an underheated church, hall, or theatre is almost sure to be foul. The janitor will keep every opening closed in order to get the temperature up. Some churches are never once decently ventilated from December to May. The same old air, with an ever richer crop of germs, is reheated and served up again every Sunday. The "odor of sanctity" is the residue of the breaths and perspiration of successive generations. Cleanliness may be next to godliness, but it is sometimes an astonishingly long step behind it.

The next important step is to keep clean, both externally and internally: externally, by cold bathing, internally, by exercise. The only reason why a draft ever hurts us is because we are full of self-poisons, or germs. The self-poisons can be best got rid of by abundant exercise in the open air and plenty of pure, cold H2O, internally and externally.

Food has very little to do with these autotoxins, and they are as likely to form on one diet as another. In fact, they form normally and in states of perfect health, and are poisonous only if retained too long. It is simply a question of burning them up, and getting rid of them quickly enough, by exercise, with its attendant deep breathing and perspiration. The lungs are great garbage-burners. Exercise every day till you puff and sweat.

A blast of cold air suddenly stops the escape of these poisons through the skin and throws them on the lungs, liver, or kidneys. The resulting disturbance is the second commonest form of a "cold," and covers perhaps a third of all cases occurring. This is the cold that can be prevented by the cold bath. Keep the skin hardened and toned up to such a pitch that no reasonable chill will stop it from excreting, and you are safe. Never depend on clothing. The more you pile on, the more you choke and "flabbify" the skin and make it ready to "strike" on the first breath of cold air. Too heavy flannels are cold-breeders, and chest-protectors inventions of the evil one. Trust the skin; it is one of the most important and toughest organs in the body, if only given half a chance.

But the most frequent way in which drafts precipitate a cold is by temporarily lowering the vital resistance. This gives the swarms of germs present almost constantly in our noses, throats, stomachs, bowels, etc., the chance they have been looking for—to break through the cell barrier and run riot in the body.

So long as the pavement-cells of our mucous membranes are healthy, they can keep them out indefinitely. Lower their tone by cold, fatigue, underfeeding, and their line is pierced in a dozen places at once. One of the many horrifying things which bacteriology has revealed is that our bodies are simply alive with germs, even in perfect health. One enthusiastic dentist has discovered and described no less than thirty-three distinct species, each one numbering its billions, which inhabit our gums and teeth. Our noses, our stomachs, our intestines,—each boasts a similar population. Most of them do no harm at all; indeed, some probably assist in the processes of digestion; others are camp-followers, living on our leavings; others, captive enemies which have been clubbed into peaceful behavior by our leucocyte and anti-body police.

For instance, not a few healthy noses and throats contain the bacillus of diphtheria and the diplococcus of pneumonia. We are beginning to find that these last two groups will bear watching. Like camp-followers elsewhere, they carry knives, and are not above using them on the wounded after dark. In fact, they have a cheerful habit of taking a hand in any disturbance that starts in their bailiwick, and usually on the side against the body-cells.

Finally, while clearly realizing that the best defense is attack, and that our chief reliance should be upon keeping ourselves in such fighting trim that we can "eat 'em alive" at any time, there is no sense in running easily avoidable risks, and we should keep away from infection as far as possible. If a child comes to school heavy-eyed, hoarse, and snuffling, the teacher should send him home at once. He will only waste his time attempting to study in that trim, and may infect a score of others. Moreover, it may be remarked, parenthetically, that these are also symptoms of the beginning of measles, scarlet fever, and diphtheria, and two-thirds of all cases of these would be sent home before they could infect any one else if this procedure were the rule.

If your own child develops a cold, if mild, keep him playing out-of-doors by himself; or if severe, keep him in bed, in a well-ventilated room, for three or four days. He'll get better twice as quick as if at school, and the rest of the household will escape.

When you wake with a stuffed head and aching bones, stay at home for a few days if possible, out of regard for your customers, your fellow-clerks, or your office force, as well as yourself. If one of your employees comes to work shivering, give him three days' vacation on full pay. If it runs through the force, you'll lose five times as much in enforced sick-leaves, slowness, and mistakes. Above all, don't go to any public gatherings,—to church, the theatre, or parties,—when you are snuffling and coughing. You are not exactly a joy to your beholders, even if you don't infect them. It is advisable, and well worth the trifling trouble and expense, to fumigate thoroughly with formalin all churches, theatres, and schoolrooms at least once a month. Reasonable and public-spirited precautions of this sort are advisable, not only to avoid colds themselves, which are disagreeable and dangerous enough, but because mild infections of this sort are far the commonest single means of making a breach in our body-ramparts through which more serious diseases like consumption, pneumonia, and rheumatism may force an entry.

Colds do not "run into" consumption or pneumonia, but they bear much the same relation to them that good intentions are said to do to the infernal regions. They release the lid of a perfect Pandora's box of distempers—tuberculosis, pneumonia, rheumatism, bronchitis, Bright's disease, neuritis, endocarditis. A cold is no longer a joke. A generation ago a prominent physician was asked by an anxious mother, "Doctor, how would you treat a cold?"

"With contempt, madam," replied the great man.

That day is past, and has lasted too long. Intelligently regarded and handled, they are the least harmful of diseases; neglected, one of the most dangerous, because there are such legions of them. To sum up, if you wish to revel in colds, all that is necessary is to observe the following few and simple rules:—

Keep your windows shut.

Avoid drafts as if they were a pestilence.

Take no exercise between meals.

Bathe seldom, and in warm water.

Wear heavy flannels, chest-protectors, abdominal bandages, and electric insoles.

Have no heat in your bedroom.

Never let anything keep you away from church, the theatre, or parties, in winter.

Never go out-of-doors when it's windy, or rainy, or wet underfoot, or cold, or hot, or looks as if it was going to be any of these.

Be just as intimate and affectionate as possible with every one you know who has a cold. Don't neglect them on any account.



CHAPTER V

ADENOIDS, OR MOUTH-BREATHING: THEIR CAUSE AND THEIR CONSEQUENCES

In all ages it has been accounted a virtue to keep your mouth shut—chiefly, of course, upon moral or prudential grounds, for fear of what might issue from it if opened. Then came physiology to back up the maxim, on the ground that the open mouth was also dangerous on account of what might be inhaled into it. Oddly enough, in this instance, both morality and science have been beside the mark to the degree that they have been mistaking a symptom for a cause. This has led us to absurd and injurious extremes in both cases. On the moral and prudential side it has led to such outrageous exaggerations as the well-known and oft-quoted proverb, "Speech is silver, but silence is golden." Articulate speech, the chiefest triumph and highest single accomplishment of the human species, the handmaid of thought and the instrument of progress, is actually rated below silence, the attribute of the clod and of the dumb brute, the easy refuge of cowardice and of stupidity.

Easily eight-tenths of all speech is informing, educative, helpful in some modest degree; while fully that proportion of silence is due to lack of ideas, cowardice, or designs that can flourish only in darkness. It is not the abundance of words, but the scarcity of ideas, that makes us flee from "the plugless word-spout" and avoid the chatterbox.

Similarly, upon the physical side, because children who breathe through the mouth are apt to have a vacant expression, to be stupid and inattentive, undersized, pigeon-breasted, with short upper lip and crowded teeth, we have leaped to the conclusion that it is a fearsome and dangerous thing to breathe through your mouth. All sorts of stories are told about the dangerousness of breathing frosty air directly into the lungs. Invalids shut themselves scrupulously indoors for weeks and even months at a stretch, for fear of the terrible results of a "blast of raw air" striking into their bronchial tubes. All sorts of absurd instruments of torture, in the form of "respirators" to tie over the mouth and nose and "keep out the fog," are invented, and those who have the slightest tendency to bronchial or lung disturbances are warned upon pain of their life to wrap up their mouths whenever they go out-of-doors.

As a matter of fact, there is exceedingly little evidence to show that pure, fresh, open air at any reasonable temperature and humidity ever did harm when inhaled directly into the lungs. In fact, a considerable proportion of us, when swinging along at a lively gait on the country roads, or playing tennis or football, or engaged in any form of active sport, will be found to keep our lips parted and to inhale from a sixth to a third of our breath in this way, and with no injurious results whatever. Nine-tenths of all the maladies believed to be due to breathing even the coldest and rawest of air are now known to be due to invading germs.

Nevertheless, mouth-breathing in all ages has been regarded as a bad habit, and with good reason. It was only about thirty years ago that we began to find out why. A Danish throat surgeon, William Meyer, whose death occurred only a few months ago, discovered, in studying a number of children who were affected with mouth-breathing, that in all of them were present in the roof of the throat curious spongy growths, which blocked up the posterior opening of the nostrils. As this mass was made up of a number of smaller lobules, and the tissue appeared to be like that of a lymphatic gland, or "kernel," the name "adenoids" (gland-like) was given to them. Later they were termed post-nasal growths, from the fact that they lay just behind the rear opening of the nostrils; and these two names are used interchangeably. Our knowledge has spread and broadened from this starting-point, until we now know that adenoids are the chief, yes, almost the sole primary cause, not merely of mouth-breathing, but of at least two-thirds of the injurious effects which have been attributed to this habit.

Mouth-breathing is not simply a bad habit, a careless trick on the part of the child. We have come to realize that physical bad habits, as well as many mental and moral ones, have a definite physical cause, and that no child ever becomes a mouth-breather as long as he can breathe comfortably through his nose.

This clears the ground at once of a considerable amount of useless lumber in the shape of advice to train the child to keep his mouth shut. I have even known mothers who were in the habit of going around after their helpless offspring were asleep and gently but firmly pushing up the little jaw and pressing the lips together until some sort of an attempt at respiration was made through the nostrils. Advertisements still appear of sling-like apparatuses for holding the jaws closed during sleep.

To attempt to stop mouth-breathing before providing abundant air-space through the nostrils is not only irrational, but cruel. Of course, after the child has once become a mouth-breather, even after the nostrils have been made perfectly free, it will not at once abandon its habit of months or years, and disciplinary measures of some sort may then be needed for a time. But the hundred-times-repeated admonition, "For heaven's sake, child, shut your mouth! Don't go around with it hanging open like that!" unless preceded by proper treatment of the nostrils, will have just about as much effect upon the habit as the proverbial water on a duck's back. No use trying to close his mouth by any amount of opening of your own.

Fortunately, as does not always happen, with our discovery of the cause has come the knowledge of the cure; and we are able to say with confidence that, widespread and serious as are disturbances of health and growth associated with mouth-breathing, they can be absolutely prevented and abolished.

What, then, is the cause of this nasal obstruction, and when does it begin to operate? The primary cause is catarrhal inflammation, with swelling and thickening of the secretions, and it may begin to operate anywhere from the seventh month to the seventh year. A neglected attack, or series of attacks, of "snuffles," colds in the head, catarrhs, in infants and young children, will set up a slow inflammation of this glandular mass at the back of the nostrils—a tonsil, by the way—and start its enlargement.

Whether we know anything about adenoids themselves or not, we are all familiar with their handiwork. The open mouth, giving a vacant expression to the countenance, the short upper lip, the pinched and contracted nostrils, the prominent and irregular teeth, the listless expression of the eyes, the slow response to request or demand, we have seen a score of times in every schoolroom. Coupled with these facial features are apt to be found on closer investigation a lack of interest in both work and play, an impaired appetite, restless sleep, and a curious general backwardness of development, both bodily and mental, so that the child may be from one to four inches below the normal height for his years, from five to fifteen pounds under weight, and from one to three grades behind his proper school position. Very often, also, his chest is inclined to be narrow, the tip of his breastbone to be sunken, and his abdomen larger in girth than his chest. Is it possible that the mere inhaling of air directly into the lungs, even though it be imperfectly warmed, moistened, and filtered, as compared with what it would be if drawn through the elaborate "steam-coils" in the nostrils for this purpose, can have produced this array of defects? It is incredible on the face of it and unfounded in fact. Fully two-thirds of these can be traced to the direct influence of the adenoids.

These adenoids, it may briefly be stated, are the result of an enlargement of a tonsil, or group of small tonsils, identical in structure with the well-known bodies of the same name which can be seen on either side of the throat. They have the same unfortunate faculty as the other tonsils for getting into hot water, flaring up, inflaming, and swelling on the slightest irritation. And, unfortunately, they are so situated that their capacity for harm is far greater than that of the other tonsils. They seem painfully like the chip on the shoulder of a fighting man, ready to be knocked off at the lightest touch and plunge the whole body into a scrimmage. Their position is a little difficult to describe to one not familiar with the anatomy of the throat, especially as they cannot be seen except with a laryngeal mirror; but it may be roughly stated as in the middle of the roof of the throat, just at the back of the nostrils, and above the soft palate. From this coign of vantage they are in position to produce serious disturbances of two of our most important functions,—respiration and digestion,—and three out of the five senses,—smell, taste, and hearing.

We will begin with their most frequent and most serious injurious effect, though not the earliest,—the impairment of the child's power of attention and intelligence. So well known is their effect in this respect that there is scarcely an intelligent and progressive teacher nowadays who is not thoroughly posted on adenoids. Some of them will make a snap diagnosis as promptly and almost as accurately as a physician; and when once they suspect their presence, they will leave no stone unturned to secure an examination of the child by a competent physician, and the removal of the growths, if present. They consider it a waste of time to endeavor to teach a child weighted with this handicap. How keenly awake they are to their importance is typified by the remark of a prominent educator five or six years ago:—

"When I hear a teacher say that a child is stupid, my first instinctive conclusion is either that the child has adenoids, or that the teacher is incompetent."

The lion's share of their influence upon the child's intelligence is brought about in a somewhat unexpected and even surprising manner, and that is by the effects of the growths upon his hearing. You will recall that this third tonsil was situated at the highest point in the roof of the pharynx, or back of the throat. The first effect of its enlargement is naturally to block the posterior opening of the nostrils. But it has another most serious vantage-ground for harm in its peculiar position. Only about three-fourths of an inch below it upon either side open the mouths of the Eustachian tubes, the little funnels which carry air from the throat out into the drum-cavity of the ear. You have frequently had practical demonstrations of their existence, by the well-known sensation, when blowing your nose vigorously, of feeling something go "pop" in the ear. This sensation was simply due to a bubble of air being driven out through this tube from the back of the throat, under pressure brought to bear in blowing the nose. The luckless position of the third tonsil could hardly have been better planned if it had been devised for the special purpose of setting up trouble in the mouths of these Eustachian tubes.

Just as soon as the enlargements become chronic, they pour out a thick mucous secretion, which quickly becomes purulent, or, in the vernacular, "matter." This trickles down on both sides of the throat, and drains right into the open mouth of the Eustachian tube. Not only so, but these Eustachian tubes are the remains of the first gill-slits of embryonic life, and, like all other gill-slits, have a little mass of this same lymphoid or tonsilar tissue surrounding them. This also becomes infected and inflamed, clogs the opening, and one fatal day the inflammation shoots out along the tube, and the child develops an attack of earache. At least two-thirds of all cases of earache, and, indeed, five-sixths of all cases of deafness in children, are due to adenoids.

Earache is simply the pain due to acute inflammation in the small drum-cavity of the ear. This in the large majority of cases will subside and drain back again into the throat through the Eustachian tube. In a fair percentage of instances, however, it will break in the opposite direction, and we have the familiar ruptured drum and discharge from the ear. In either case the drum becomes thickened, so that it can no longer vibrate properly; the delicate little chain of bones behind it, like the levers of a piano, becomes clogged, and the child becomes deaf, whether a chronic discharge be present or not.

This is the secret of his "inattention," his "indifference,"—even of his apparent disobedience and rebelliousness. What other children hear without an effort he has to strain every nerve to catch. He misunderstands the question that is asked of him, makes an absurd answer, and is either scolded or laughed at. It isn't long before he falls into the attitude: "Well, I can't get it right, anyhow, no matter how I try, so I don't care." Up to five or ten years ago the puzzled and distracted teacher would simply report the child for stupidity, indifference, and even insubordination. In nine cases out of ten, when children are naughty or stupid, they are really sick.

Not content with dulling one of the child's senses, these thugs of the body-politic proceed to throttle two others—smell and taste. Obviously the only way of smelling anything is to sniff its odor into your nose. And if this be more or less, or completely, blocked up, and its delicate mucous membranes coated with a thick, ropy discharge, you will not be able to distinguish anything but the crudest and rankest of odors. But what has this to do with taste? Merely that two-thirds of what we term "taste" is really smell. Seal the nostrils and you can't "tell chalk from cheese," not even a cube of apple from a cube of onion, as scores of experiments have shown. We all know how flat tea, coffee, and even our own favorite dishes taste when we have a bad cold, and this, remember, is the permanent condition of the palate of the poor little mouth-breather. No wonder his appetite is apt to be poor, and that even what food he eats will not produce a flow of "appetite juice" in the stomach, which Pavloff has shown to be so necessary to digestion. No wonder his digestion is apt to go wrong, ably assisted by the continual drip of the chronic discharge down the back of his throat; his bowels to become clogged and his abdomen distended.

But the resources for mischief of this pharyngeal "Old Man of the Sea" are not even yet exhausted. Next comes a very curious and unexpected one. We have all heard much of "the struggle for existence" among plants and animals, and have had painful demonstrations of its reality in our own personal experience. But we hardly suspected that it was going on in our own interior. Such, however, is the case; and when once one organ or structure falls behind the others in the race of growth, its neighbors promptly begin to encroach upon and take advantage of it. Emerson was right when he said, "I am the Cosmos," the universe.

Now, the mouth and the nose were originally one cavity. As Huxley long ago remarked, "When Nature undertook to build the skull of a land animal she was too lazy to start on new lines, and simply took the old fish-skull and made it over, for air-breathing purposes." And a clumsy job she made of it!

It may be remarked, in passing, that mouth-breathing, as a matter of history, is an exceedingly old and respectable habit, a reversion, in fact, to the method of breathing of the fish and the frog. "To drink like a fish" is a shameful and utterly unfounded aspersion upon a blameless creature of most correct habits and model deportment. What the poor goldfish in the bowl is really doing with his continual "gulp, gulp!" is breathing—not drinking.

This remodeling starts at a very early period of our individual existence. A horizontal ridge begins to grow out on either side of our mouth-nose cavity, just above the roots of the teeth. This thickens and widens into a pair of shelves, which finally, about the third month of embryonic life, meet in the middle line to form the hard palate or roof of the mouth, which forms also the floor of the nose. Failure of the two shelves to meet properly causes the well-known "cleft-palate," and, if this failure extends forward to the jaw, "hare-lip." In the growth of a healthy child a balance is preserved between these lower and upper compartments of the original mouth-nose cavity, and the nose above growing as rapidly in depth and in breadth as the mouth below, the horizontal partition between—the floor of the nose and the roof of the mouth—is kept comparatively flat and level. In adenoids, however, the nostrils no longer being adequately used, and consequently failing to grow, and the mouth cavity below growing at the full normal rate, it is not long before the mouth begins to encroach upon the nostrils by pushing up the partition of the palate. As soon as this upward bulge of the roof of the mouth occurs, then there is a diminution of the resistance offered by the horizontal healthy palate to the continual pressure of the muscles of the cheeks and of mastication upon the sides of the upper jaw, the more readily as the tongue has dropped down from its proper resting position up in the roof of the mouth. These are pushed inward, the arch of the jaw and of the teeth is narrowed, the front teeth are made to project, and, instead of erupting, with plenty of room, in even, regular lines, are crowded against and overlap one another.

When from any cause the lower jaw habitually hangs down, as in the open mouth, it tends to be thrown slightly forward in its socket. Then, when the jaws close again, the arches of the upper and lower teeth no longer meet evenly. Instead of "locking" at almost every point, as they should, they overlap, or fall behind, or inside, or outside, of each other. So that instead of every tooth meeting its fellow of the jaw above evenly and firmly, they strike at an angle, slip past or even miss one another, and thus increase the already existing irregularity and overlapping. Each individual tooth, missing its best stimulus to healthy growth and vigor, firm and regular pressure and exercise against its fellow in the jaw above or below, gets a twist in its socket, wears away irregularly, and becomes an easy prey to decay, while from failure of the entire upper and lower arches of the teeth to meet squarely and press evenly and firmly against one another, the jaws fail to expand properly and the tendency to narrowing of the tooth-arches and upward vaulting of the palate is increased.

In short, we are coming to the conclusion that from half to two-thirds of all cases of "crowded mouth," irregular teeth, and high-arched palate in children are due to adenoids. Progressive dentists now are insisting upon their little patients, who come to them with these conditions, being examined for adenoids, and upon the removal of these, if found, as a preliminary measure to mechanical corrective treatment. Cases are now on record of children with two, three, or even four generations of crowded teeth and narrow mouths behind them, but who, simply by being sharply watched for nasal obstruction and the symptoms of adenoids, by the removal of these latter as soon as they have put in an appearance, have grown up with even, regular, well-developed teeth and wide, healthy mouths and jaws. Unfortunately, attention to the adenoids will not remove these defects of the jaws and teeth after they have been produced. But, if the child be under ten, or even twelve, years of age, their removal may yet do much permanently to improve the condition, and is certainly well worth while on general principles.

Take care of the nose, and the jaws will take care of themselves. An ounce of adenoids-removal in the young child is worth a pound of orthodontia—teeth-straightening—in the boy or girl; though both are often necessary.

The dull, dead tone of the voice in these children is, of course, an obvious effect of the blocked nostrils. Similarly, the broken sleep, with dreams of suffocation and of "Things Sitting on the Chest," are readily explained by the desperate efforts that the little one makes to breathe through clogging nostrils, in which the discharges, blown and sneezed out in the daytime, dry and accumulate during sleep, until, half-suffocated, it "lets go" and draws in huge gulps of air through the open mouth. No child ever became a mouth-breather from choice, or until after a prolonged struggle to continue breathing through its nose.

This brings us to the question, What are these adenoids, and how do they come to produce such serious disturbances? This can be partially answered by saying that they are tonsils and with all a tonsil's susceptibility to irritation and inflammation. But that only raises the further question, What is a tonsil? And to that no answer can be given but Echo's. They are one of the conundrums of physiology. All we know of them is that they are not true glands, as they have neither duct nor secretion, but masses of simple embryonic tissue called lymphoid, which has a habit of grouping itself about the openings of disused canals. This is what accounts for their position in the throat, as they have no known useful function. The two largest, or throat-tonsils, surround the inner openings of the second gill-slits of the embryo; the lingual tonsil, at the base of the tongue below, encircles the mouth of the duct of the thyroid gland (the goitre gland); and our own particular Pandora's Box above, in the roof of the pharynx, is grouped about the opening of another disused canal, which performs the singular and apparently most uncalled-for office of connecting the cavity of the brain with the throat. They can all of them be removed completely without any injury to the general health, and they all tend to shrink and become smaller—in the case of the topmost, or pharyngeal, almost disappear—after the twelfth or fourteenth year.

Not only have they an abundant crop of troubles of their own, as most of us can testify from painful experience, but they serve as a port of entry for the germs of many serious diseases, such as tuberculosis, rheumatism, diphtheria, and possibly scarlet fever. They appear to be a strange sort of survival or remnant,—not even suitable for the bargain-counter,—a hereditary leisure class in the modern democracy of the body, a fertile soil for all sorts of trouble.

Here, then, we have this little bunch of idle tissue, about the size of a small hazelnut, ready for any mischief which our Satan-bacilli may find for its hands to do. A child kept in a badly ventilated room inhales into his nostrils irritating dust or gases, or, more commonly yet, the floating germs of some one or more of those dozen mild infections which we term "a common cold." Instantly irritation and swelling are set up in the exquisitely elastic tissues of the nostrils, thick, sticky mucous, instead of the normal watery secretion, is poured out, the child begins to sneeze and snuffle and "run at the nose," and either the bacteria are carried directly to this danger sponge, right at the back of the nostrils, or the inflammation gradually spreads to it. The mucous membrane and tissues of the nose have an abundance of vitality,—like most hard workers,—and usually react, overwhelm, and destroy the invading germs, and recover from the attack; but the useless and half-dead tissue of the pharyngeal tonsil has much less power of recuperation, and it smoulders and inflames, though ultimately, perhaps, it may swing round to recovery. Often, however, a new cold will be caught before this has fully occurred, and then another one a month or so later, until finally we get a chronically thickened, inflamed, and enlarged condition of this interesting, but troublesome, body. What its capabilities are in this respect may be gathered from the fact that, while normally of the size of a small hazelnut, it is no uncommon thing to find a mass which absolutely blocks up the whole of the upper part of the pharynx, and may vary from the size of a robin's egg to that of a large English walnut, or even a small hen's egg, according to the age of the child and the size of the throat.

Dirt has been defined as "matter out of place," and the pharyngeal tonsil is an excellent illustration. Nature is said never to make mistakes, but she is apt to be absent-minded at times, and we are tracing now not a few of the troubles that our flesh is heir to, to little oversights of hers—scraps of inflammable material left lying about among the cogs of the body-machine, such as the appendix, the gall-bladder, the wisdom teeth, and the tonsils. One day a spark drops on them, or they get too near a bearing or a "hot-box," and, in a flash, the whole machine is in a blaze.

Never neglect snuffles or "cold in the head" in a young child, and particularly in a baby. Have it treated at once antiseptically, by competent hands, and learn exactly what to do for it on the appearance of the earliest symptoms in the future, and you will not only save the little ones a great deal of temporary discomfort and distress,—for it is perfect torment to a child to breathe through its mouth at first,—but you will ward off many of the most serious troubles of infancy and childhood. We can hardly expect to prevent all development of adenoids by these prompt and painless stitches in time, for some children seem to be born peculiarly subject to them, either from the inheritance of a particular shape of nose and throat,—"the family nose," as it has been called,—or from some peculiar sponginess and liability to inflammation and enlargement of all these tonsilar or lymphoid "glands" and "kernels" of the body generally—the old "lymphatic temperament."

We are, however, now coming to the opinion that this so-called "hereditary" narrow nose, short upper lip, and high-arched palate are, in a large percentage of cases, the result of adenoids in infancy in each successive generation of parents and grandparents. At all events, there are now on record cases of children whose parents, grandparents, and great-grandparents are known to have been mouth-breathers, and who have on that account been sharply watched for the possible development of adenoids in early life, and these removed as soon as they appeared, and they have grown up with well-developed, wide nostrils, broad, flat palates, and regular teeth, overcoming "hereditary defect" in a single generation.

Curiously enough, their origin and ancestral relations may have an important practical bearing, even in the twentieth century. At the upper end of this curious throat-brain canal lies another mass, the so-called pituitary body. This has been found to exert a profound influence over development and growth. Its enlargement is attended by giantism and another curious giant disease in which the hands, feet, and jaws enlarge enormously, known as acromegaly. It also pours into the blood a secretion which has a powerful effect upon both the circulation and the respiration. It is found shrunken and wasted in dwarfs. Some years ago it was suggested by my distinguished friend, the late Dr. Harrison Allen, and myself, that some of the extraordinary dwarfing and growth-retarding effects of adenoids might be due to a reflex influence exerted on their old colleague, the pituitary body. This view has found its way into several of the textbooks. Blood is thicker than water, and old ancestral vibrations will sometimes be set up in most unexpected places.