Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

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The disorder, while incurable, is thus not one attended with
progressive dementia.

"When in the presence of a subject suffering from delirium
of interpretation, one is first of all struck by his correct deport-
ment ; the observer is sometimes deceived by the brilliancy of
his conversation and the accurate logic of his reasoning pro-
cesses, and is rather disposed to consider him at most as a
thinker along fallacious lines, with a tendency to look upon
all events from a peculiar angle, and to systematize all exter-



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DELIRIUM AND DELUSIONS. 789

nal or internal phenomena upon the basis of a questionable
preconcept

'*The imperative need of referring all to his own person
and of interpreting everything in a certain direction, and of
emitting, on the whole, only affective judgments marred by
errors appears as the sole morbid condition in such a subject
"The mistaken interpretation, the delusion of personal sig-
nificance is, indeed, the fundamental manifestation of this psy-
chosis. The autonomy of a morbid entity cannot, however, be
based merely upon a single sign. Delusional interpretation plays
an important role in a number of other psychoses and even in
simple passional states. To warrant a diagnosis of delirium of
interpretation, a whole group of characteristics must be present,
zns., (1) multiplicity and organization of delusional interpretations;
(2) absence (or paucity) of hallucinations, and their casual occur-
rence; (3) retention of lucidity and mental activity; (4) progres-
sion through gradual expansion of the interpretations; (5) incura-
bility, without terminal dementia."

* * *
The reason that the author has — with Grasset — deemed it
proper to recall the main clinical features relating to the various
forms of delirium (or delusion) considered very broadly as "dis-
turbances of the reasoning power and of judgment" is that
definition and delimitation of the various forms of delirium is a
difficult* matter; that the types above recalled and described
condense into a small compass a number of psychiatric facts
indispensable for everyday practice, and that they will bring
to mind various fundamental and necessary acts of psychologic
discrimination.

As a matter of fact, in general practice the term "delirium" is
applied particularly to the common, ordinary form of the disturb-
ance, i.e., to confusion of ideas and the presence of mental images
associated with mistaken interpretations and often hallucinations —
in a word, to oniric delirium, for which careful clinical study
will always detect some cause, either:

1. Toxic (alcohol, opium, belladonna, salicylates).

2. Autotoxic (uremia).

3. Or infectious (typhoid fever, pneumonia, malaria, etc.).



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DIARRHEA. [Suappelv, to /low through.}



Diarrhea is characterized by the passage of liquid stools.

Only the most practical, fundamental, and essential facts re-
quired in the interpretation of this very common symptom can
here be presented.

In diarrhea, liquid stools are passed with variable frequency.
In general, diarrhea seems to depend upon:

Either an exaggeration of the persistaltic contractions (hy-
perperistalsis, intestinal hypersthenia).

Or an exaggeration of the intestinal secretions (hypercrinia).

Or diminished absorption of the intestinal contents.

Clinically, diarrhea may be met with under the following cir-
cumstances :

I. Lesions of the intestinal walls, whether there be irrita-
tion or pathologic changes in the mucous membrane, as is the
case in all instances of toxic, infectious enterocolitis,

A. Infectious or parasitic enterocolitis.

(a) In this group are included ordinary acute enterocolitis,
typhoid fever, and cliolera, of which mere mention is here sufficient.
It should be particularly borne in mind, however, that the greater
number of instances of common acute enterocolitis are as yet not
accounted for ; the characteristic clinical complex may be summar-
ized as comprising diarrhea, fever, leucocytosis, and albuminuria.

(fc) Chronic parasitic dysenteriform diarrhea with paroxysmal
recurrences requires more thorough consideration. As matters now
stand, these dysenteriform types of diarrhea may seemingly be
classified, for practical purposes, as follows:

Ordinary colon bacillus dysenteriform diarrhea, acute or chronic.
These cases yield to interruption of feeding, with restriction of the
patient to water by the mouth ; to castor oil, and to lactose.

Amebic dysenteriform diarrhea, acute or chronic. Ravaut and
Maute have plainly demonstrated the selective action of emetine
and of arsphenamine in these cases.
(790)



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DIARRHEA. 791

BacUlary dysenteriform diarrhea (acute or chronic dysentery),
amenable to irrigations with silver salts and to antidysenteric serum.

Dysenteriform diarrhea due to trichomonas (flagellates).

Tuberculous dysenteriform^ diarrhea, with presence of tubercle
bacilli.

These causal distinctions, now absolutely necessary as evidenced
by the specificity of the methods of curative treatment, can be
established only by bacteriologic examination of the stools (see
Examination of the Stools).

(c) By way of a reminder there may also be mentioned here
intestinal cancer which, however, causes obstruction much more
frequently than diarrhea, except where the lesion is situated low
down.

B. Toxic enterocolitis. — In this group are met the actually
toxic and drug forms of enterocolitis (enterocolitis due to mercury,
arsenic, digitalis, colchicum, etc.), and the alimentary forms (botul-
ism, etc.).

There is also the autotoxic or diathetic enterocolitis of uremia,
gout, and diabetes.

Some forms of hyperacute gastroenterocolitis result in a clin-
ical picture well described by Lesieur (choleroid state, reduced
output of urine, and uremia), which may be accounted for by
intense but diflfuse and superficial inflammatory lesions of the
digestive tract, particularly the small intestine (congestion with
hemorrhage, prominence of the follicles).

The bacteriologic basis of enteritis seems to be variable,
different combinations of bacteria being found; a constant fea-
ture, however, is weakness and insufficiency of the liver and
kidneys. This constitutional or acquired weakness sometimes
transforms the clinical picture of gastrointestinal infection into
that of auto-intoxication and azotemia. Hence the appropriate
designation "uremigenous gastroenteritis" proposed by Lesieur.

In all such cases the history or the coexisting diathesic mani-
festations will clear up the diagnosis.

II. Diarrhea of Nervous and Vasomotor Origin.— Enteric
neuroses are very frequent.



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792 SYMPTOMS.

Diarrhea upon emotion and the enter orrhea of exophthalmic
goiter constitute, as it were, an experimental verification of the
neuropathic diarrheal flux that may be met with, frequently in
alternation with constipation, in the course of the majority of
neuroses. Many instances of paroxysmal diarrhea ascribed to
dietary indiscretions are really due to this cause.

In most of these cases the cause of the diarrhea remains
wholly obscure. The physician finds neither infection (no fever
nor leucocytosis), nor ulceration (no blood in the stools), nor
food poisoning (no dietary indiscretion). The diarrheal flux
may supervene even while a most stringent diet is being ad-
hered to, but nearly always appears in conjunction with over-
work, insomnia, nervous shocks, or prolonged stress. It is hard
for the uninitiated to avoid the conclusion that an intestinal
neurosis exists and to suspect as cause a diminution of vaso-
motor tone due to abnormal excitation of the sympathetic, seem-
ingly evidenced by the low blood-pressure, high pulse rate, ex-
cessive emotional susceptibility, general asthenia, tendency to
fainting, and vasomotor disturbances (showing a curious simi-
larity to Graves's disease!) There appears to be some physio-
pathologic relationship between hyperperistalsis and low periph-
eral blood-pressure, occurring in conjunction with vasodilata-
tion in the splanchnic area.

It seems not unlikely that the so-called "mucous enteritis" is
not a true colitis, but rather a spastic enteroneurosis with alter-
nating diarrhea and constipation and excessive mucous secretion.

Diarrhea of circulatory origin is equally well-known, e.g.,
the diarrhea of atrophic cirrhosis, to which Portal referred when
he said: *'Wind precedes the rain," alluding to the sequence of
tympanites and diarrhea met with in cirrhosis. The same con-
dition may occur in cardiac, renal, cardiorenal, and cardiohepatic
disorders, although constipation is rather frequently observed
under these circumstances.

Mention should also be made of the diarrhea, at times pro-
fuse, which may follow reabsorption of edemas, hydrothorax,
and ascites, a feature affording a definite indication for purgation
in the presence of these disorders.



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DIARRHEA. 793

rn. Diarrhea of Digestive Origin. — The causes in this group
are complex and varied.

Any condition of gastrointestinal dyspepsia, especially if
associated with intolerance of fats ("hyposthenic dyspepsia/*
insufficiency of the liver and pancreas), is almost necessarily
accompanied by diarrhea with passage of an excess of fats in
the stools (hypersteatorrhea) .

Diarrhea of gastrointestinal digestive origin is thus, on the
whole, a manifestation of actual indigestion, subdivision of
which may be attempted as follows:

1. Botulism, food intoxication, ptomain poisoning, — The many
undoubted cases of collective intoxication, as by cream puffs,
game, etc., are manifestly produced in this way.

2. Overeating, — In these cases the digestive limit or capacity
is exceeded; this is the well-known indigestion of released
schoolboys and soldiers on leave.

3. Fat intolerance. — An expression of insufficiency of the liver
and pancreas.

4. Achylia gastrica.

5. Pronounced, abrupt discharge of bile occurring in overactivity
of the liver and resulting in sharp diarrhea in the morning after
eating.

According to Cabot, the relative frequency of the various
causes of diarrhea is as follows :

1. AciUe enteritis:

(a) Cryptogenic, five-sixths of all cases.
{b) Specific (typhoid, dysentery, cholera, toxic disturb-
ances), one-sixth of the cases.

2. Chronic enteritis:

(a) Cryptogenic, nine-tenths of all cases.
(&) Of known causation (digestive insufficiency), one-tenth
of the cases.

3. Cancer of the intestine,

4. Pernicious anemia,

5. Mucous colitis.

6. Intestinal neuroses and exophthalmic goiter.

7. Tuberculosis.

8. Fat intolerance.



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794 SYMPTOMS,

Certain signs and symptoms occurring in conjunction with
diarrhea sometimes permit of rather accurate localization of the
causal disturbance.

The presence of blood and pus in the stools (bloody, glairy
stools) is characteristic of ulceration. in the large bowel, of varying
origin (infection or neoplasm).

The presence of mucus and false membrane is often charac-
teristic of an intestinal neurosis.

The customary significance of fat-laden stools is well-known ;
steatorrhea points to insufficiency of the liver and pancreas.

Fluoroscopy after a bismuth meal and proctoscopy, moreover,
permit of a most valuable direct examination of the bowel (see Tech-
nical procedures, in Part II).

Frequently, indeed, direct, gross, macroscopic examination
of the feces affords highly serviceable information. This ele-
mentary clinical procedure is just cts essential as uranalysis, taking
the temperature, or examining the pulse. The '^offending body"
must always be sought, or at least the "evidence" or "witness"
of it.

The patient, then, should always be ordered to collect and keep
the feces for examination.

The following features of the stools should be noted:

Frequency : Four, 6, up to 100 a day — the latter in the pres-
ence of rectal tenesmus, as in dysentery.

Amount: From a few hundred grams to several liters, as in
cholera and choleroid forms of diarrhea, whence the enormous
loss of water from the tissues.

Consistency: Serous, albuminoid (glairy), mushy, pasty.

Color: Brown, as in normal stools.

Dark green: Excessive bile content in certain cases of jaun-
dice; in infantile diarrhea, or after administration of calomel.

Decolorized, gray, clayey: Obstructive jaundice.

Red or rust-colored: Dysentery.

Black, "coffee-ground": Melena, bismuth, or krameria (rhat-
any).

Colorless, serous, "rice water": Cholera and choleroid diar-
rhea.

Odor: This is always more or less unpleasant



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DIARRHEA. 795

Exceedingly malodorous : Putrid diarrhea in botulism, putre-
factive gastrointestinal indigestion, and in street cleaners, anato-
mists, and workers in sewage.

Distinctly acid: In gastrointestinal indigestion with fermen-
tation.

No odor in serous stools.

Kind: Ordinary fecaloid type

Bilious.

Serous.

Watery.

**Stony": Intestinal concretions and coproliths; gall-stones.

The macroscopic examination referred to will frequently re-
veal abnormal constituents of the stools:

Intestinal parasites: Tenia, ascaris, oxyuris.

Undigested food (li enteric diarrhea) : Acute indigestion, ex-
cessive peristalsis.

Fats {fatty stools) : Fats present in oily droplets, spherules,
or larger fatty masses (affections of the liver and pancreas)

Blood: Red: Hemorrhoids.

Black: Melena.

Intestinal shreds: Dysentery.

Blood-stained, glairy material: Neoplasm.

Pus: Infectious or neoplastic enterocolitis.

Mucus and membranous formations: Mucomembranous entero-
colitis, intestinal neuroses.

Intestinal sand: Mucous enterocolitis.

Rice-bodies: Flakes of epithelial cells: Cholera and choleroid
diarrhea.

The above brief review suffices to illustrate the very great
semeiologic value of a mere macroscopic examination of the
stools. Correlated with the medical history, other clinical mani-
festations (temperature, general condition, coexisting digestive
disturbances, urinary evidences, etc.), and examination of indi-
vidual organs (liver, stomach, intestinal canal, etc.), it will generally
lead promptly to a correct diagnosis.

In puzzling cases it should be supplemented by chemical, micro-
scopic, and bacteriologic examination of the stools (see Examina-
tion of the Feces), which is frequently indicated.



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DYSPEPSIA \^^' *''*' ni^ti, coction, digestion; disturb-']
' [ ance of digestion^ particularly gastric. J



The term dyspepsia is here employed in its semeiologic sense,
and is applied in a general way to any disturbance of gastric
digestion complained of by the patient or observed by the phy-
sician. The author would not have attempted to deal with this
extensive and complex subject — at least under the above com-
prehensive term — had he not found certain features of it already
partly considered in a section of Cabot's **DifIerential Diag-
nosis," upon which some of the material which follows is based,
and had not his colleague Leon Meunier consented to draw up
an authoritative plan of diagnosis for ulcer and cancer of the
stomach.

The author's aim will have been fulfilled if, upon reading
this section, the practitioner becomes convinced that dyspeptic
manifestations, indigestion, and vomiting are in most instances
of extragastric origin; that painstaking and complete investiga-
tion of all the organs is necessary, particularly in all cases of
chronic indigestion, and that in a patient complaining of such
disturbances, merely applying the term "dyspepsia'* and ordering
some indefinite antidyspeptic treatment amount to nothing, or
are even worse than nothing.

The very great majority of the causes of indigestion are unre-
lated to the stomach, or at least to any particular disease of the
stomach. On the other hand, there is not a single organ in the
human body which may not be a source of gastric symptoms.
Nausea, dyspeptic disturbances, the vomiting of pregnancy,
uremia, and brain tumor are familiar illustrations of this clinical
aphorism. As a matter of fact, the heart and the stomach may
with equal frequency and in an equal degree be disturbed by
remote and slight organic causes. The stomach is, moreover,
as frequently free of any pathologic changes in subjects com-
(796)



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DYSPEPSIA, 797

plaining of dyspepsia as is the heart in subjects complaining of
palpitations or in whom tachycardia is observed.

The truly "gastric" causes of indigestion or dyspepsia may
practically be reduced to two, vis,, cancer and tdcer. Nervous dys-
pepsia, the gastric neurosis, is of extraordinary frequency ; but only
exceptionally does it originate in the stomach. The same is
true of many other varieties, such as dyspepsia with hyperchlor-
hydria; dyspepsia dependent upon constipation or symptomatic
of appendicitis; gastroptosis, ordinarily the result of general
atony with multiple visceroptosis, alcoholic gastritis, etc. In
short, most varieties of dyspepsia are not, strictly speaking, of
gastric origin, and do not constitute gastric disorders.

What clinical possibilities, then, should come into our minds
when a patient complains of gastric symptoms, and of gastric
symptoms alone?

1. In the presence of a pregnant woman who has not yet reached
the menopause, one should always think first of all of a possible
pregnancy. As is well known, under these circumstances any
symptoms may be observed, from a simple condition of nausea
in the morning to the uncontrollable vomiting of pregnancy—
as is true, moreover, in many toxic states of the blood, such
as alcoholism, uremia, lead poisoning, etc. These digestive
symptoms occur with such frequency that they may properly
be included among the minor evidences of pregnancy. The
classic indications of this state should under these conditions
be sought, vis,, cessation of menstruation, increased size of the
uterus, secretion of colostrum, etc.

2. Uremia, manifest or latent, is also a very frequent condi-
tion, and one present far oftener than it is diagnosticated. Many
obstinate dyspeptic disturbances, either mild (nausea, anorexia,
aversion to food) or severe (vomiting, hematemesis), originate
in this way. Uremia should always be thought of in the pres-
ence of chronic dyspepsia coexisting with albuminuria, edema,
and a definite elevation of blood-pressure, and particularly if
blood examination discloses a high content of urea. Especially
should it be thought of, a priori, in any individual who after pass-
ing the fortieth year, and having had a "good digestion" up to
that time, loses his appetite, experiences nausea or even vomit-



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798 SYMPTOMS.

ing, becomes sallow and loses weight, and in whom examina-
tion of the stomach gives practically negative results. The above
mentioned evidences — albumin, high blood-pressure, edema, and
hyperazotemia — should be carefully searched for, and the appro-
priate antinephritic treatment will remove all doubt as to the
renal origin of the dyspeptic disturbances.

3. Tuberculosis, pulmonary or elsewhere situated, may like-
wise be a cause of many instances of indigestion in the absence
of any internal (cancer or ulcer) or external (food or drug
poisoning) gastric cause. As is well known, incipient tubercu-
losis often takes on the appearances of anemia and dyspepsia;
anorexia and loss of weight are common in this stage of the
disease. In these cases of '^cryptogenic" dyspepsia one should
proceed, therefore, to a careful investigation in this direction,
the temperature being taken morning and evening, careful aus-
cultation carried out in a quiet room, and an x-ray examination
practised.

As a matter of fact, the opposite mistake is also made, and
an attack of nervous dyspepsia with anemia and loss of weight
too often labelled pulmonary tuberculosis without any adequate
reason. The fact cannot too often be repeated : One should be
a "realist" in clinical work, and like St. Thomas, one must be
desirous to come into actual touch, i,e., to establish by contact
with our senses, the sufferings of our patients and the theories
evolved in our minds.

Furthermore, tuberculous patients — apart from the ordinary
causes of dyspepsia to be mentioned later (rapid eating, poor
teeth, excessive intake of fluid, etc.), and to which they are sub-
ject like other patients — are very often and very particularly the
victims of two serious sources of error regarding the stomach,
vie, drug intoxication (opium, morphine and its substitutes caus-
ing hypopepsia and apepsia; creosote and its derivatives, anti-
pyrin, pyramidon, etc., inducing ar "gastritis medicamentosa"),
and alimentary overwork the result of ill-considered overfeeding.

4. Numerous cases of indigestioit in women are the result
of inanition. In this connection the- author cannot do better than
to quote literally from Cabot, having nowhere found a better
or more judicious critical exposition of the abuse of dietetic



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DYSPEPSIA. 799

measures among dyspeptics. "This [inanition] comes about as
follows: Something, we need not now inquire what, produces
an upset of digestion. The patient attributes it to certain food,
probably what she took last, just before the attack occurred.
Accordingly, in future she omits this article of diet from her
bill of fare. The indigestion recurs, an article of diet is ag^n
blamed, and something else is cut out of the diet because she
thinks it hurts her. So in this way food after food is given up,
until the patient gets down to a regimen of slops or their equiva-
lent. We have now a typical vicious circle. The patient is ill-
nourished because she is dyspeptic, and she is dyspeptic because
she is ill-nourished. We can break this circle by forcing her to
eat despite grievous suffering. An ill-nourished stomach will
complain, yet it must be nourished nevertheless. If we can per-
suade the patient to undergo such suffering, we can honestly
hold out the hope that at the end of it she will break her chain,
will get back her nutrition, and lose her symptoms. The trouble
is that ordinarily the physician does not believe this himself.
He has not seen enough cases in which forcing the patient to eat
achieves this happy result; but anyone with extensive hospital
experience knows that what is called "dieting" — that is, cutting
out of one's diet most of the foods that ordinary people live on
— is usually a most pernicious process, and leads to a great
deal of long and unnecessary suffering. Most cases of this
type can be cured by nothing in the world but forced feeding.

"The greatest improvement that I have seen in the manage-
ment of stomach cases in the last twenty years has been the recog-
nition of causes outside the stomach and the successful attack
upon these*causes. Next to this, the greatest improvement has
been through giving up our habits of making strict, narrow diet
lists which result in more or less chronic starvation. Whatever
we do for a gastric patient, we must not starve him. We must
get in food enough to maintain the caloric needs of the body,
and the greatest error in the treatment of the past has been the
failure to recognize this necessity."

5. Cholelithiasis is a very common cause of paroxysmal pains,
very often ascribed to the stomach. After cancer and ulcer have
been correctly excluded, one may state that it is almost always



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800 SYMPTOMS.

a mistake to attribute really severe pain to the stomach. In
other words, the only disorders of the stomach causing severe
pain are cancer and ulcer. All the other varieties of dyspepsia
run their course with their usual assortment of symptoms and vary-
ing combinations of flatulence, heart-bum, discomfort, nausea, sen-
sations of constriction or oppression, and vomiting, but without
violent pain.

Gall-stones often induce attacks of pain situated in the epi-
gastrium and not in the gall-bladder region. Overlooking of
this fundamental fact leads to many mistakes. If the patient
has repeated attacks, some will sooner or later become localized
in or be referred to the right hypochondrium, but in the
earlier stages of the disease such localization is very frequently
lacking.

Allied to the gastralgia of cholelithiasis are the obstinate dyspep-
tic phenomena, with delayed pain and eructations, dependent upon
adhesions between the gdl-bladder and the neighboring viscera
(stomach, liver, transverse colon, etc.) the result of a former chole-
cystitis with pericholecystitis. These may assume the extremely



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 11 of 50)