Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

. (page 19 of 50)
Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 19 of 50)
Font size
QR-code for this ebook


puration (puerperal sepsis).

Purulent conjunctivitis of the newborn. Serious accidents to
the eyes (exophthalmus or orbital fracture) due to use of the for-
ceps or various other obstetrical procedures.

Diseases of the Nervousi System. — Hysteropithiatism. — Am-
blyopia and amaurosis, with sudden blindness, total or partial. The
eye-grounds are normal and the pupillary reflexes are preserved. —
Concentric contraction of the visual field with inversion of the color
fields. In some instances, anesthesia of the conjunctiva, blepharo-
spasm, facial hemispasm, strabismus, or spasm of accommodation
(special, transient myopia).



Digitized by



Google



EVES, DISORDERS OF THE. 921

Examination of the eyes is imperative, to obviate confusion (or-
ganic disturbance or simulation). ,

Neurasthenia. — Ocular asthenia (asthenopia) while at work;
muscae volitantes, ophthalmic migraine, or periocular neuralgia;
transitory contraction of the visual field due to fatigue.

Epilepsy. — Frequency of refractive defects and eye disorders,
stigmata of inherited syphilis, alcohol and tobacco amblyopia, etc.

iNsANiTY.-r-Attacks of ocular hyperemia. Auto-mutilation of
the eye, in several instances extending to the rapid tearing out of
both eyes, the preliminary incision about them being made with the
sharp finger nails.

Idiocy. — Stigmata of inherited syphilis; congenital anomalies.

Meningitis. — Mydriasis or myosis. Optic neuritis. Irido-
chorioretinitis. Tubercles of the choroid. Paralyses of ocular
muscles. Total or partial optic atrophy. Nystagmus. Strabismus.

Intracranial thrombophlebitis. — Exophthalmus, generally
bilateral. Paralyses of ocular muscles. Optic neuritis.

Encephalitis of various types. — ^Lethargic encephalitis, among
others, exhibits paralyses of the ocular muscles in successive groups
or "waves;" paralysis of associated movements (convergence);
ptosis; nystagmus.

Hydrocephalus. — Optic neuritis and atrophy; paralyses of
ocular muscles; nystagmus and strabismus. Coexisting signs of
congenital syphilis or tuberculosis.

Brain softening, cerebral hemorrhage, etc. — Amblyopia;
word blindness; hemianopia, usually homonymous, permitting of
localization of the disease in the hemisphere opposite to that of the
field defects (see Fig. 682).

Tumors. — Edema and venous congestion of the optic nerve
owing to increased intracranial pressure. Paralyses of ocular
muscles. Hemianopia. These signs, while frequently present, may
be lacking or present with conditions other than tumor. They con-
firm the diagnosis of endocranial tumor, but seldom suffice in them-
selves to localise it.

Involvement of the cerebellum, peduncles, or pons. — Syn-
dromes of Millard-Gubler or of Weber (p. 909), in conjunction with
other localizing neurologic syndromes ; optic neuritis.



Digitized by



Google



922 SYMPTOMS.

Myelitis. — Optic neuritis (optic neuromyelitis), sometimes pre-
ceding the myelitis.

Tabes dorsalis. — ^Argyll-Robertson pupil; pupillary inequality;
frequently myosis. Irregularity of the pupillary outline (oblique-
ovaloid pupil of A. Terson). Sclerous atrophy of the optic nerve,
as yet incurable and becoming bilateral in spite of the latest forms
of treatment. Highly intensive treatment further accelerates the
reduction of vision, notwithstanding the fact that these patients are
known to be syphilitic. Paralyses of ocular muscles, transient or
persistent.

General paralysis. — Inequality and irregularity of the pupils
with mydriasis and paralysis of the iris. Toward the final stage,
optic neuritis and atrophy, and motor paralyses.

Friedreich's ataxia. — Nystagmus; sometimes optic atrophy.

Little's disease. — Strabismus; nystagmus; stigmata of in-
herited syphilis.

Disseminated sclerosis. — Nystagmus; paralyses of ocular mus-
cles ; rarely, sclerosis of the optic nerve.

Intoxications. — Alcohol and tobacco. — Amblyopia, bilateral
from the start, with central scotoma.

Far vision is impaired, but the subject, while dasded by bright
light and nearly blind in broad daylight, has much better vision in
the evening (crepuscular improvement).

Near vision is greatly interfered with ; the patient is unable to
read, and distinguishes certain colors poorly (green and red), espe-
cially over a small area, on account of the central scotoma. While
he recognizes the color of a sheet of red paper, he is unable to state
the color of disc of red paper o£ the size of a dime. When the
disease is sufficiently advanced, he mistakes a dime for a silver
dollar.

This condition, if taken at the start and treated by a strict diet
and suitable remedies, may be completely recovered from if the sub-
ject does not resume his harmful habits.

The practitioner should always have an examination of the eyes
made in order to exclude certain very serious mistakes (diabetic
amblyopia, macular chorioretinitis, retrobulbar neuritis, optic
atrophy, etc.) and diagnose coexisting disorders.



Digitized by



Google



EYES, DISORDERS OF THE. 923

Many other forms of poisoning (lead, male fern, pelletierine,
iodoform, etc.) may give rise to toxic neuritis and a variety of
ocular and oculomotor disorders of a lasting or transient nature.

Ingestion of large amounts of quinine at a single dofse sometimes
induces temporary blindness, which terminates either in recovery
or in partial and lasting sclerosis of the optic nerves.

Atoxyl has been the cause of many cases of optic atrophy and
incurable blindness.

Naphthalene, when ingested, yields an experimental form of
cataract (in animals).

Botulism may bring about optic neuritis and paralyses of the
ocular muscles, including those of accommodation.

Ophthalmic Signs and Reagents Indicating Death. — Exami-
nation of the eye is of assistance in distinguishing actual from ap-
parent death and in obviating premature burial, whether under ordi-
nary or unusual circumstances (wars, epidemics, or catastrophes).

Loss of the winking reflex, loss of corneal sensibility, dilatation
of the pupil following myosis (frequent in the agonal state), a dull
appearance of the eyes, and complete opening or closure of the lids
(a very variable condition in different subjects and according to the
manner of death) constitute merely presumptive evidence. The
pupils of a corpse will often react for several hours, especially to
myotics (eserine and pilocarpine) and electric stimulation. Palpa-
tion of the eyes may be practised; they become particularly flaccid
at the end of several hours.

In S. Icard's procedure (subcutaneous staining injection of fluo-
rescin, which fails to diffuse in a dead body ) , the eye may assume a
greenish tint in a living subject; but this phenomenon is very in-
constant.

Lecha Marzo has made an investigation such as had already
been made in other regions of the body, of the existence of a post-
mortem acid reaction of the tears, which are neutral or alkaline in
the living subject, by placing a piece of litmus paper beneath the
eyelid. Unfortunately the time of appearance of the acidity, as
well as its intensity, are highly variable after actual death. Dis-
tinct acidity, it is claimed, is never present, however, in a living
subject in a condition of apparent death.



Digitized by



Google



924 SYMPTOMS.

Instillations of irritants and mechanical stimuli (scraping or
chemical or actual cauterization of the conjunctiva or of the up-
turned lids, etc.) may be tried, and will induce redness and hyper-
emia in an inert living subject. Instillation of ether (d'Halluin)
may, however, not be without risk to the cornea. The writer pre-
fers the introduction of a wheat-grain-sized amount of powdered
ethyl-morphine hydrochloride (dionin), a substance used in daily
practice without harmful results, and which induces redness and
swelling, often of considerable extent, of the conjunctiva in the eye
of a living subject.

One need not limit himself to the ocular tests of death, but they
should be utilized among the routine measures for the determina-
tion of death.

The foregoing summary considerations on the subject of com-
bined ophthalmology and general medicine may have served at least
to suggest to the practitioner the marked importance of an objective
and functional examination, whether positive or negative, of the
eyes and their adnexa in the diagnosis and prognosis of almost any
disorder affecting the human body — not to mention the cases in
which such an examination, as yet so frequently neglected or inade-
quately performed, actually permits of apprehending, arresting, or
curing a disease of the eye itself.



Digitized by



Google



FAINTING [From aiv, with, and x&JVtBiv, to cvi.^

[ Faintneas, fainting spell. J



(SYNCOPE).



True S3mcopc consists of a sudden, temporary cessation of
the heart's action. It is exceedingly uncommon. On the other
hand, faintness, semifainting, or lipothymia (from ^htislv, to
relinquish, dvfzdg, spirit) is met with rather often, and is char-
acterized by a more or less complete loss of consciousness ap-
parently dependent upon a reduction of varying degree in the
blood flow (ischemia) through the brain. The nervous and
circulatory systems are so intimately interdependent that psy-
chic and circulatory manifestations are in close association, and
the most reliable sign of syncope and of lipothymia, which sign,
moreover, allows of their immediate differentiation from coma,
asphyxia, etc., is the combined observation of a more or less
complete loss of consciousness with weakened and sometimes
slowed heart action, the latter sometimes passing into actual
cessation of the heart beats for a varying period of time. Syn-
copal states, then, are characterized:

1. By a more or less profound state of fainting and uncon-
sciousness, with more or less complete muscular relaxation.

2. By a marked weakening of the pulse (small, feeble pulse)
and of the heart beats.

3. By certain associated vasomotor and secretory disturb-
ances, ins,, pallor of the face and lips, cold sweat, cold ex- '
tremities, etc., which impart in some degree to syncope the ^
appearances of death.

It should be noted that frequently, just before the termina-
tion of syncope, a short general convulsive seizure is observed,
independently of any epileptic tendency.

Thorough realization of the three above mentioned characteris-
tic features will suffice to eliminate, usually at the first glance,
artificial fainting spells, "theatrical faints," and "suggestive syn-

(925)



Digitized by



Google



926 SYMPTOMS.

copal states" so prevalent in certain quarters, and seemingly
in all historical periods, judging from the high percentage of
**swoons" referred to in the romantic literature of all ages and
all climes. '*Clarisse Manson," wrote Lenotre (the celebrated
witness of the Fualdes episode), "succeeded in holding in
anxious suspense the attention of the entire world for two whole
years merely by swooning, a proceeding which she carried out
to perfection and repeated indefinitely without becoming fa-
tigued."

Syncope and syncopal states are met with chiefly under the
following conditions:

1. Ordinary fainting, probably due to acute anemia of the brain
(by vaso-constriction or nervous cardiovascular inhibition) acting
upon predisposed individuals when in a confined or poorly venti-
lated room, in the presence of a crowd, or unexpectedly witnessing
some accident or a hemorrhage. The sight of blood-shed regularly
causes faintness in some persons who may properly be said to be
hemophobic, and in these individuals personally experienced pain
or hemorrhage has, of course, an even more certain eflFect in this
direction. The wearing of a. corset or other tight garment, and
either the period of digestion or that of fast, plainly predispose to
fainting in some persons. In short, at the bottom of the condition
there are always found: 1. Some emotional impression (anxiety,
apprehension, pain, fear, terror, etc.). 2. An emotional neuro-
cardiovascular predisposition, finding its ultimate expression in an
exaggeration of the nervous vasomotor and inhibitory reflexes.

Allied to ordinary fainting are the faintness and lipothymic
attacks of patients with low blood-pressure, of convalescents, of
septic cases, and of cases of visceroptosis, accounted for in each
case by a manifest state of neurovascular weakening.

2. Certain minor forms of epilepsy are commonly considered
related to ordinary fainting, but in these cases the vasomotor
manifestations characteristic of syncopal states, zns,, small pulse,
coolness of the extremities, etc., are, as a rule, absent. Yet
it must be admitted that some of these conditions are very simi-
lar to syncope. They should always be thought of in the pres-
ence of recurring pseudolipothymic attacks or repeated faints
ot obscure causation.



Digitized by



Google



FAINTING. 927

3. Certain cerebrocardiac forms of arteriosclerosis, especially
if accompanied, as is the rule, by aortitis, may lead to particu-
larly dangerous syncopal states. The fatal syncope of the major
forms of angina pectoris belongs in this group. It is mainly
the possibility of such an occurrence that furthers an unfavor-
able prognosis in the latter disorder. Yet it should be mentioned
and repeated that even in the major forms of angina pectoris,
even in the presence of definite and extensive aortk lesions,
such as dilatation or actual aneurysm, and even wijth a rather
marked elevation of blood-pressure, fatal syncope is exceptional
and, in any case, perhaps, is generally long delayed. The author
has had, and still has, under observation such subjects for peri-
ods of ten or twtlve y^ars or over.

For practical pmrposes the following general rule may be
adopted :

Syncope is ordinarily a mild condition in young individuals;
on the other hand, it is always a serious, at times a dangerous, and
sometimes even a fatal, occurrence in old persons,

4. The fainting of paroxysmal bradycardia (Stokes- Adams'
disease) is easily diagnosticated if one merely takes care to count
the pulse (see Arhythmia: Auriculoventricular Dissociation). A
subsequent thorough general examination and, if need be, a good
polygraphic tracing will eliminate all doubt.

5. Chloroformic syncope is, as is well known, a dangerous
manifestation. Following are the warning signs of this condition,
as recalled by Desfosses:

(a) Respiration: Arrest of respiration occurring together with
pallor of the face.

(&) Facial appearance: "If the face is seen suddenly to become
blanched or dusky, and the pupil to dilate, this means that the
respiration, or perhaps the pulse, has just stopped; the result is
'white syncope.' The patient is in extreme danger."

(c) Condition of the pulse: "If the pulse stops, there is present
cardiac, syncope, a very serious or 'white syncope' ; but as a rule
the arrest of respiration will already have served to warn the care-
ful anesthetist."

(d) Examination of the eye: "If the pupil, after having been
contracted, suddenly dilates, the corneal reflex should be tested at



Digitized by



Google



928 SYMPTOMS.

once; if present, vomiting and return to consciousness are to be
apprehended; if not present, a severe syncopal attack is to be
feared."

6. All weakening, exhausting, debilitating illnesses lead to a mani-
fest predisposition to faintness, which may pass into actual syncope.
The mere change from the horizontal to the vertical position is
sufficient, in many convalescents, to bring on a lipothymic attack.
Sphygmomanometric study of these cases reveals in this connec-
tion a considerable d^free of tachycardia with markedly low blood
pressure. As is well known, in such cases a post-infectious
adrenal insufficiency, with low pressure, asthenia, and Sergent's
white line, is nearly always found. This seems to be the case, in
particular, in attacks of pernicious malarial fever (of the syncopal
type).

7. Cases of syncope in the presence of extensive pleural effu-
sion, with large areas of flatness, have been reported. "Do not
wait till the patient faints to tap," wrote Trousseau. Doubtless
it is through having followed this rule that the author has never
witnessed syncope in these cases, neither spontaneously nor
during the process of tapping.

8. Any extensive hemorrhage, e.g., the intestinal hemorrhage
of typhoid fever, the intraperitoneal hemorrhage of extra-uterine
pregnancy, postpartum hemorrhage, internal hemorrhage follow-
ing wounds of the chest or abdomen, or an uncontrolled ex-
ternal hemorrhage, bring on a syncopal condition which may
pass into fatal syncope.

Syncopal states are, as a rule, easily distinguished, as was
previously pointed out, from "s3mcopomorphic" hysterical seiz-
ures by their shorter duration (hysterical coma persists for min-
utes or hours; syncope only for seconds), the existence of an
actual provocative cause, and especially, the observation of
actual cardiac and vasomotor disturbances, such as slowing, or
suppression of the pulse, pallor, cold sweat, cooling of the tis-
sues, etc.



Digitized by



Google



FEVER. [Febris, from ^eSofiai, to tremble.]



In practice, the words "fever," "pyrexia," and "hyperthermia"
are often used indiscriminately, without marked disadvantage.

A patient is spoken of as having "fever" when his temperature
is continuously above the normal.

The rectum and the floor of the mouth are the points of election
for taking the so-called ''central" or "internal" temperature. In
adults the normal internal temperature ranges between 37° and
37.6° C. (98.6° and 99.68° F.), the physiologic oscillations of tem-
perature during the 24 hours, and the difference between the mini-
mal or morning and the maximal or evening temperature being
sometimes as great as 0.5 to 0.6° C.

The axilla and the inguinal fold are the points of election for
taking the so-called ''peripheral" or "superficial" temperature. In
adults the normal superficial temperature ranges between 36.4® and
37° C (97.52° and 98.6° F.), with diurnal oscillations of 0.5 to
0.6° C. There is thus a mean interval of 0:5° C. between the in-
ternal and superficial temperatures. The sources of error, how-
ever, vis., sweating, cooling of the surface, and faulty mode of
application of the thermometer, are much more pronounced over
the surface.

Preference should, therefore, be given wherever possible to the
internal temperature. Ordinarily the internal, rectal, and oral tem-
peratures are the same ; but sometimes they are markedly different ;
it should be borne in mind that a local inflammation or hyperemia,
as in proctitis, hemorrhoids, high portal pressure, etc,, may result
in a localized h)rperthermia unaccompanied by true fever {i.e,,
there is no actual pyrexia). The author has seen patients considered
febrile and kept in bed for weeks or even months because of a
rectal temperature persisting in the neighborhood of 38° C.
(100.4° F.), but having no true fever, as was later proved by regu-
lar and careful notation of an absolutely normal buccal temperature

59 (929)



Digitized by



Google



930 SYMPTOMS.

(37° to 37.4° C— 98.6° to 99.32° R), a pulse rate of 60 to 72,
and the absence of all symptoms, in spite of persistence of the
rectal temperature in the vicinity of 38° C. All these were cases
of proctitis, hemorrhoids, portal hypertension, or congestion of the
liver. Sometimes . repeated introduction of the thermometer, two
or more times a day, or the local use of irritant antiseptics seem
to be the exciting cause of the local irritation.

In a general way, as is well known, fever is an indication of the



Fig. 685. — Respiratory type of influenza.

presence of infection. Clinically, the equation, fever = infection,
is justified in 19 cases out of 20. There remains, however, a small
percentage of non-infectious fevers, to be briefly discussed later.
To review all the causes of fever would thus entail a tiresome enum-
eration of all the infections, with the further addition of a few non-
infectious forms of pyrexia.

As a matter of fact, the solution of the clinical problem of fever
is sometimes immediately manifest; erysipelas, herpes, the eruptive
fevers, etc., become plainly apparent sooner or later.

In other instances the cause remains for a long time, if not
permanently, obscure, and for a solution of the problem application
of the most recent technical procedures is required.



Digitized by



Google



FEVER. 931

From the exclusive standpoint of practical diagnosis, a useful
clinical division of fever is that into:

Fevers of short duration, lasting altogether not over two
weeks.

Fevers of long duration, persisting over two weeks without
descending to normal.

Intermittent fevers, or recurring fevers, made up of variable
periods of pyrexia separated by intervals of apyrexia.

Little need be said concerning the fevers of short duration,
since in these cases either the diagnosis becomes more or less



Fig. 686.^Frank pneumonia in an adult

plain sooner or lat^, or, if the cause remains obscure (as is
often the case) , more or less prompt recovery occurs in any case,
thus settling the main practical question of import to the patient
as well as to the physician.

In this group of fevers are encountered:

The eruptive fevers or exanthemata: Measles, scarlet fever,
rubella, etc., and diphtheria. .

Common or specific infections of the respiratory tract: Catarrhal
conditions, acute bronchitis, sore throat, pharyngitis, pneumonia,
bronchopneumonia, etc. ; also influenza, etc.

The ordinary gastro-intestinal infections: Febrile gastric up-
sets, acute gastro-enteritis, appendicitis, etc.

Acute infections of the various other systems and structures:
Acute arthritis, lymphangitis, pelvic infections, sinusitis, erysipelas,
poliomyelitis, etc.



Digitized by



Google



932 SYMPTOMS.

In truth, most of these fevers of short duration are actually
of unknown etiology and origin, or at least are "non-specific," and
many of the terms applied to them, such as cold, grippe, influenza,
febrile pains in the limbs, ephemeral fever, rheumatoid fever, etc.,
are none other than makeshift "clinical labels" applied to "cryp-
togenic fevers," generally mild and of brief duration.

Further, some of these conditions, persisting for unduly long
periods, may pass into the group of the fevers of long duration,
to be next considered, and conversely, a few of the clinical states
ordinarily attended with fever of long duration may be cut short
in some unusual way and fall into the present group. The possible
occurrence of such exceptional cases should be kept in mind. For
practical purposes the general division given above nonetheless re-
mains of marked clinical service.

The fevers of long duration are attended with a more urgent
need of proper diagnosis because in them prompt recovery,
which would quickly solve the clinical problem in spite of the
physician's doubt, fails to occur.

In 90 per cent, of cases the underlying condition is either
tuberculosis, typhoid fever, septicemia, or deep-seated suppura-
tion.

The remaining 10 per cent, of cases refer to a wide variety
of conditions, including rheumatic feVer, influenza, meningitis,
chronic appendicitis, leukemia, syphilis, cancer, etc.

Cabot's statistics, referring to 784 febrile cases recorded at
the Massachusetts General Hospital, are as follows:

Typhoid fever 586

Sepsis 70

Tuberculosis 54

710 (90 per cent).

Meningitis 27

Influenza 10

Acute rheumatism 9

Leukemia 5

Cancer 2

Syphilis 2

Trichiniasis 2

Cirrhosis 2

Gonorrhea 2

Scattering 11

74 (10 per cent).



Digitized by



Google



FEVER, 933

These statistical results manifestly do not in the least represent
those of private practice; the disproportionately great number of
typhoid cases is accounted for by the special concentration of these



Fig. 687. — Temperature chart in a case of acute miliary tuberculosis with
onset suggesting typhoid fever (Letulle and Debri),

cases in the Massachusetts General Hospital. In private practice
tuberculosis, deep-seated sepsis, and the indefinite infections labelled



Fig. 688. — Infectious pericarditis.

influenza and rheumatism greatly exceed typhoid fever. Yet, on
the whole, in private practice as in the statistics above presented,
it may be said that 98 per cent, of the cases of prolonged fever
fall, in the order of frequency, under the five following headings:



Digitized by



Google



934 SYMPTOMS.

Tuberculosis, sepsis of visceral origin, influenza, rheumatism, and



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 19 of 50)