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Clinical diagnosis, case examination and the analysis of symptoms online

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region) lightly and gradually depressed, beginning with the

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regions manifestly free of pain at the time. If the subject is well
relaxed, the several abdominal regions can be depressed more
or less deeply without meeting with too much resistance, often
with the result that, by slow, "coaxing," gradual pressure the
deep-lying organs may be palpated. In the presence of some
inflammatory visceral disturbance, and particularly in appen-
dicitis, the palpating finger encounters over the site of pain a
firm resistance or insuperable reflex muscular contraction, con-
stituting the so-called **board-like rigidity." This sign, which

Fig. 795. — Combined appendicitis and adnexitis. The appendix (A) is
adherent to the ampulla (P) of the Fallopian tube, which is closed and
distended with pus. The inflammatory cyst (K) is partly covered over by
the omentum (E) (Berard).

is never absent, is the earliest and perhaps the most reliable indi-
cation of appendicitis.

Its exact features must, however, be carefully noted; in some
nervous, pusillanimous subjects there may occur a general abdom-
inal rigidity preventing palpation of any of the regions of the
abdomen, and under these circumstances the rigidity is devoid of all
diagnostic value. The same is true of the muscular contraction in-
duced by unduly rough palpajtion. But whenei'er a correctly con-
ducted palpation, after noting the absence of undue resistance in
other regions of the abdomen, meets with rigid contracture in some

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definite area, the result is to be considered pathognomonic evidence
of a subjacent inflammatory insceral disorder.

By the same proceeding of palpation with one finger one should
endeavor to ascertain the point of maximum pain. The diagnostic
significance of the so-called McBurney's point is well known.

Palpation sometimes leads, moreover, to the detection of a
mass of varying size, sensitiveness, and evenness of outline,
such as an accumulation of feces, an abscess, or a tumor,
thorough examination of which will reveal its actual nature.

**On the second, third, or fourth day of acute appendicitis,
palpation over the right iliac fossa reveals a doughy condition
or broad area of induration which spreads out laterally, is ap-
parently connected with the abdominal wall, and forms a species
of thick, hard shield. This condition, if it possesses and retains
the characteristics just referred to, is an outward expression of
the Vailing off' process which has set in and gradually ex-
tended about the diseased area; such being the case, its pres-
ence is actually of favorable import.

"About the fifth or sixth day the temperature recedes and
drops more or less rapidly to normal, and the pulse rate de-
creases in parallel fashion; the hard *shield,' which has by this
time frequently extended over a broad surface, now ceases to
enlarge and becomes still harder in its central portion, while
softening and yielding at its periphery, and appears less and less
tender on palpation." (Lejars, Chirurgie d'urgence, p. 496).

Finally, it is of advantag^e, though not absolutely indispens-
able, to practise ''decompressive" palpation, which consists,
after more or less deep pressure at some region of the abdomen,
in suddenly removing the compressing finger, so that abrupt
release of pressure results. Sometimes it is noted that, whereas
pressure has been relatively painless, decompression causes
much pain. This seems, to all appearances, to be a reliable in-
dication of inflammation of the peritoneum beneath the palpated

Percussion may prove of great service in the detection of an
abnormal, flat area in certain cases in which satisfactory palpa-
tion is practically impossible. It may, furthermore, be availed
of as a gentle method of palpation.

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The foregoing examination of the right iliac fossa should be
supplemented with the three following procedures :

(a) Manual and bimanual palpation of the right lumbar
region for the detection of any existing pus tracks in retrocecal
disease, to exclude the possibility of renal disorder, etc.

(fc) Vaginal palpation in women for the detection of diseased



Fig. 796. — Radiographic picture of the cecum and appendix twelve
hours after ingestion of bismuth magma. The cecum (/) and the ascend-
ing colon (2) appear dilated and segmented by the constricting bands
due to pericolitis. The appendix (3) is seen occupying a latero-intemal
position (Berard).

adnexa and pelvic infiltration of appendiceal origin, and rectal
palpation in males for prostatitis, ureteral involvement, and ex-
tensions of appendiceal suppurative foci into the pelvis.

(c) Gentle examination of the psoas muscles by flexion, exten-
sion, abduction, and adduction of the lower limbs against a slight
d^ree of resistance. Where the psoas is involved, e.g., if there is

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appendiceal inflammation adjoining this muscle, such an examina-
tion of the latter is a painful procedure.

In conclusion it may be added that it is always well to examine
the right iliac fossa under anesthesia just before the operation.

"Before operating, one should never neglect to conduct a final
examination upon the well anesthetized patient in a state of com-
plete muscular relaxation. Frequently the yielding of the abdom-
inal wall, which is no longer rigid, will lead to the detection of a
more or less distinct prominence in the right iliac fossa, or upon
oblique inspection, a marked lack of symmetry of the two lateral
halves of the abdomen may become apparent.

"Examination by palpation will afford more exact information ;
generally the examiner will find one of the following conditions:
Either a definitely fluctuating pocket, tense, circumscribed, and
sharply defined at its mesial border ; a thick sausage-like mass, com-
pact, indistinctly or partially fluctuating, or with nodular surface
and poorly defined borders below and toward the median line, or a
small, hard mass, rounded or nodular, non-adherent and readily
mistaken for the appendix itself.

"Sometimes the tumor noticed in the waking state will seem
to have almost completely disappeared. It may be added that if,
when the patient has been anesthetized, iliac palpation continues to
give the impression of a diffuse doughy condition, while the ab-
domen fails to recede and remains prominent and tense, the pre-
vious apprehensions, of generalized peritonitis are to a singular de-
gree confirmed." (Lejars.)

The following summary reflections, of general application in the
diagnosis of abdominal disorders, are borrowed from Cabot
C Differential Diagnosis"),

Though it seems judicious and is in accord with current prac-
tice to differentiate the exciting causes of the various localized
and diffuse abdominal pains, as a matter of fact such distinctions
do not always hold good. Disorders such as appendicitis, theo-
retically attended with pain in the right iliac fossa, may very
readily cause pain localized even above the waist line. Again,
lead poisoning, which ordinarily gives rise to distinctly diffuse
pains in the last-named region, may instead readily cause a much
more circumscribed pain.

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Thus, the reader looking up in a certain chapter a variety of
pain commonly described as being localized in a certain region
may wonder at its absence from that point and at finding it else-
where. Again, some causes of pain may be found referred to in

Fig. 797. — Vessels and nerves of the anterior abdominal wall projected
upon the ceco-appendicular region. MB. McBurney's point. M. Morris's
point. L. Lanz's point. The dotted line pointing to MB shows the line
of the McBurney incision. The dotted line ML shows the Jalaguier in-
cision (Berard),

two different chapters (ovarian cyst with twisted pedicle, ectopic
pregnancy, etc.) because they are equally common on the right
and. the left sides of the body.

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In a general way, when the practitioner is seeking to find out the
probable cause of a pain in the abdomen, he should be guided by
the folloTving rules:

1. First of all he should suspect the gastrointestinal tract, and
if the most commonplace disorders, such as constipation and colitis,
can be excluded, he should think especially of appendicitis, peptic
ulcer, neoplasm of the stomach or large bowel, and the ultimate
consequences of these conditions, such as peritonitis and intestinal

2. Next he should suspect (in women) the generative tract —
salpingitis, ovarian cyst, uterine fibroids, and ectopic pregnancy.

3. The gall-bladder and bile-ducts should be particularly in-
vestigated in persons over middle age.

4. The urinary tract, especially in old men and young girls,
comes next in the list of causes of abdominal pain.

Clinical examination, the history, palpation, blood examination,
uranalysis, fluoroscopy, and cystoscopy are the most serviceable aids
in reaching a diagnosis.

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I In, negative; somnum, 8leep;'l
I deprivation of sleep. J

Insomnia or agrypnia consists in a more or less complete and
lasting inability to sleep. It occurs in all grades, from simple
hyposomnia, characterized by shorter, lighter, more restless, and
less refreshing sleep than usual, to the obstinate and inveterate
complete insomnia, sometimes attended with a very unfavorable

The causes of sleeplessness are many. For practical purposes
they may be divided into the three following groups :

Insomnia due to pain.

Insomnia due to excessive nervous excitability.

Insomnia due to circulatory or respiratory disturbances.

Insomnia due to pain may be the result of any kind of pain, of
whatever situation and nature, including the most varied forms of
neuralgia, arthralgia, and visceralgia. To attempt to enumerate all
these causes would be tiresome to the reader and plainly superfluous.
At the most it will be well to call attention to the fact that some
"pain insomnias," when carefully traced, lead to the discovery of
certain "algias" which recur at night and are of special clinical
significance, such as the osteocopic pains of syphilis, sometimes the
neuralgias of tabes, and more frequently the myalgias and arthral-
gias of gouty subjects.

Again, it should be noted that itching or pruritus (see Itching)
of whatever cause (parasitic or toxic) may be the source of highly
obstinate insomnia. When correctly traced, this symptom leads to
the detection of numerous "incomplete" cases of diabetes, uremia,
and cholemia.

Lastly, it may be pointed out that the insomnias due to
special sense hyperesthesia and the psychosplanchnic neurosis
merge insensibly with the next succeeding group, affording a
good illustration of the fact that clinical conditions, with their
infinitely numerous variations, always tend to pass beyond the


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group limitations within which the physician, for his conveni-
ence, endeavors to confine them.

Insomnia due to abnormal excitability of the nervous system.
— Such nervous overexcitability may be the result:

1. Of some organic change in the nervous system (type condi-
tion: meningitis).

2. Of an overexcitation of functional origin (type condition:
psychoneuroses ) .

3. Of an intoxication or infection (type conditions: caffeinism
and t3rphoid fever).

In the first group are included the insomnias of meningitis, brain
tumor, general paralysis, and cerebral syphilis. In all these cases
the symptomatic combination of headache and insomnia exists.

The second group, that of the psychoneuroses, is much more fre-
quent. In it are comprised the so-called "nervous** insomnias de-
pendent upon overwork, excessive ideation, worry, mental excite-
ment (irritable weakness, emotivity, emotional impressions), mania,
psychoneuroses, hysteria, neurasthenia, obsession, phobia, and anx-
ious states. "In acute attacks of psychosis," states Regis, "insom-
nia is one of the first symptoms to appear; it is manifested particu-
larly in restlessness, dreaming, and nightmares. On the other hand,
restoration of the ability to sleep towards the close of a period of
mania or melancholia is of excellent prognostic import." In chronic
mental diseases insomnia is uncommon, except among insane subjects
harboring hallucinations or cenesthetic illusions. Insomnia as a
symptom should receive careful treatment in all psychoneurotic
states: A patient able to sleep is already half-cured under these

The third group, the insomnia of toxic and infectious states, is
more complex.

In this group some forms of sleeplessness seem to be instances
of true toxic insomnia due to direct stimulation of the cerebral cells ;
among these are the insomnias due to abuse of tea, coffee, alcohol,
tobacco, morphine, cocaine, etc.

As for the infectious and post-infectious insomnias, their mode
of production is unquestionably much less simple. Some appear to
be algic insomnias dependent upon some predominant painful dis-
turbance (headache, joint pain, or pain in the side), as in meningitis,

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acute rheumatism and pneumonia. Others seem to be true toxic-
infectious insomnias, of dyscrasic origin, due to the action of the
toxins of infection on the nerve centers, as in the early insomnia of
typhoid fever, of grippe, and of erysipelas. Lastly, an additional
g^oup, especially related to convalescence, appears to be dependent
upon neurovascular weakness, e.g., the insomnias of anemic and (w-
thenic cases (starvation, convalescence, sequelae to infections, etc.).
Insomnia due to circulatory or respiratory disturbances. —
Insomnia dependent upon some cardiopulmonary affection, — This is
the insomnia of heart failure, of lost compensation, of cardiopulmon-
ary disorders causing cough and dyspnea, of asthma, of chronic
bronchitis, etc. The causes are many and outstanding, z/is,, cough,
dyspnea, and toxic influences.

Thus, insomnia is a very common symptom and consequently one
of very restricted diagnostic value, except possibly in the psycho-
neuroses. This does not apply, however to its causal diagnosis,
for it is from such a study of its cause that the basis for rational
and effectual treatment can be found. A patient with heart weak-
ness is made to sleep by restoring circulatory balance; a coffee
fiend by withdrawing the drug, and a syphilitic subject by specific

Even with reference to much less definite groups of cases,
however, rational use of special hypnotic remedies depends upon
a partial knowledge of the pathologic physiology of insomnia,
and as an illustration of this fact it seems of interest to consider
summarily the respective indications of chloral hydrate and of
morphine in this class of cases.


Chloral hydrate and morphine are probably — ^and with reason —
the two most commonly employed hypnotics. They should not,
however, be thought of as being interchangeable. While they
may sometimes be administered with advantag'e in combination,
they actually meet wholly different indications and should be pre-
scribed only for definite reasons.

Chloral hydrate and morphine appear to be directly acting hyp-
notics, i.e., drugs inducing sleep by a selective, direct action upon

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the nerve cell. This constitutes, however, about the only property
they have in common. Indeed,

L Opium and its derivative, morphine, exert, in moderate dosage,
— as Sydenham had plainly noted — ^a tonic action on the heart; under
their influence the heart beats develop increased amplitude and
power, the blood-pressure rises, and circulation through the viscera
becomes more active.

Chloral, on the other hand, is a cardiovascular depressant; un-
der its influence the heart beats become weaker and less frequent,
the blood-pressure is reduced, and visceral circulation is less

2. In the first stage, at least, opium and morphine produce evi-
dences of cerebral stimulation (a property availed of by morphin-
ists), in all likelihood through hyperemia of the brain and meninges
and direct nervous action. The sleep induced is frequently associ-
ated with dreaming; sometimes it presents features suggesting the
so-called "coma vigil.*'

Chloral sleep, on the other hand, is not preceded by any stage
of stimulation; it is in all respects comparable to normal sleep as
to general features and duration.

. 3. Finally, morphine is an analgesic agent of the first order,
being the type of the pain-relieving drugs.

Chloral, on the other hand, is neither analgesic nor anesthetic;
pain prevents chloral sleep from coming on, while loud noises
awaken the sleeping patient.

Such are the more salient diflFerences between chloral hydrate
and morphine. Their respective indications and contraindica-
tions are logically based on these differences in action.

Morphine, a cardiac and vascular stimulant, at least temporarily
a sPimulant of the brain functions, and an analgesic agent of the
first order, is especially indicated in insomnia dependent upon or as-
sociated with neurovascular zveakness or some painful disorder.

Such being the case, it is serviceable in pain insomnia, generally
due to neuralgia or visceral pain, as well as tabes dorsalis, cancer,
etc. In these cases, however, in order to obviate or postpone as
much as possible the risk of morphine habit, it is well not to
resort to it until after the entire list of pure analgesics, such as
acetphenetidin, antipyrin, exalgin, salipyrin, etc., has been exhausted.

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In the insomnia of anemic or asthenic subjects (inanition, con-
valescence, typhoid fever, pneumonia, etc.) or of persons with weak
heart action or low blood-pressure, morphine, with or without the
addition of heart tonics, remains the hypnotic remedy of choice.

In these cases, on the other hand, chloral hydrate proves ineffec-
tual or even usually does harm.

In the so-called nervous insomnia, however, dependent upon
overwork, excessive ideation, worry, mental excitement, mania,
alcoholism, meningeal congestion, and high blood-pressure, mor-
phine not only proves ineffectual, but is frequently even dangerous.
Chloral hydrate is the hypnotic of choice, in these cases.

Lastly, there occur a large number of hybrid clinical species,
and various "mixed" insomnias, which warrant combined use of
the two drugs to some extent.

Such, for example, is the insomnia of overworked anemic sub-
jects, the painful insomnia present in high blood-pressure (neu-
ralgia in a case of arteriosclerosis), etc. Under these circum-
stances the combination of chloral with morphine, while it doubt-
less fails to afford an ideal pharmacodynamic procedure, consti-
tutes a logical solution of the problem of sleep induction.

Were it necessary to summarize in one concise sentence the
above considerations, it might be stated that:

Opium and morphine are indicated in insomnia associated with
neurovascular weakness or pain; chloral hydrate, in insomnia re-
lated to neurovascular overactivity, without pain.


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The least inaccurate definition of itching or pruritus would
appear to be that of Jaccoud, vk., pruritus is the sum of the sub-
jective sensations which awaken the desire and need of scratching.

The frequent association of pruritus with vasomotor disturb-
ances, as in dermographia, has led to the view that its cause may
be an organic or functional disturbance of the sympathetic nerves.

Many diflferent classifications of pruritus, based on its patho-
genesis and clinical features, have been formulated. The best,
for practical purposes, appears to be the following :

Toxic (and metabolic) pruritus.

Derma tosic pruritus (due to skin lesions).

Parasitic pruritus.

Keurotic pruritus.

Toxic pruritus or itching includes all those forms of pruritus
in which the cause seems to be actually some change in the tissue
fluids or blood, whether this change be metabolic (autotoxic) in
nature, or a true intoxication of food or drug origin (exotoxic).

Autotoxic metabolic pruritus is extremely common. It is
met with in diabetes {diabetic pruritus), in gout, in uremia, in ster-
coremia (constipation), in cholemia (itching in jaundice), in arter-
iosclerosis {senile pruritus), in dyspepsia, and in dysmenorrhea. Its
outstanding feature is plainly the conception of an altered humoral
state consequent upon the insufficiency of the liver and kidneys
which is characteristic of most of the above mentioned disorders.

Pruritus of alimentary origin is no less common, and the
large number of the persons predisposed to it is well known. The
more particularly prurigenous articles of food are crustaceans and
Other shell fish, preserved and salted meats, gam-e, stale fish,
spices, an excessive meat diet, fermented cheeses, and strawberries. *
A partial insufficiency of the liver and kidneys seems to be at
the bottom of these various types of food intolerance. Possibly

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the factor of anaphylaxis is also concerned, as in the succeeding
group of cases.

Pruritus of pharmaceutic origin, due to coffee, tea, alcohol,
belladonna, cocaine, antipyrine, mercury, bromides, chloral hydrate,
opium and its derivatives, and the balsamic remedies. Abuse of
these drugs in some persons, and their use in ordinary dosage in
many, may be the source of itching with or without actual skin

Pruritus of hydatid origin should also receive recognition in
this group.

Dermatosic pruritos comprises all the skin aflfections which
give rise to itching. The commonest are: Prurigo, urticaria,
lichen, eczema, mycosis fungoides, chicken-pox, seborrhea, hy-
peridrosis, Duhring's dermatitis herpetiformis, the ringworms,
etc. One cannot resist the temptation to reproduce in extenso
Rrocq's lecture on the topic of pruriginous skin disorders :

"I am reviewing for you briefly how one may understand and
classify the pruriginous dermatoses which fall into the group
I term that of the simple skin reactions with pre-emptive pruritus

"1. When a patient is seized with pruritus and scratches him-
self, the integument, even though exposed to the trauma of
scratching and rubbing, may retain its normal appearance, show-
ing no structural change appreciable to the naked eye, i.e., no
eruption. One may thus say that it is not reacting in a visible man-

Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 29 of 50)