Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

. (page 3 of 50)
Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 3 of 50)
Font size
QR-code for this ebook


in relation to military fitness. The essential point, therefore,
is to ascertain the condition of renal functioning in each case.
The author is entirely prepared to subscribe, with a few slight
modifications, to the conclusions stated by Gilbert (RSunion midico-
chirurgicale de la Ve armie, Oct. 28, 1916) : An albuminuric sub-
ject, to be kept in the armed service, must answer the following
requisites: 1. A fixed amount of albumin, uninfluenced by exposure
to cold, the standing posture, food conditions, and fatigue. 2.
Absence of casts. 3. Blood urea normal, and urinary urea paral-
lel to the nitrogenous food in the diet 4. Absence of edema,
with a normal chloride balance. 5. No pronounced elevation
of blood-pressure (below 180), and no gallop rhythm. A de-
cision can be reached in such cases, therefore, only after pro-
longed and careful study.



Digitized by



Google



ALOPECIA (COMPLETE
OR PARTIAL LOSS OF
THE HAIRY APPEND-
AGES).



Lat. alopecia;

from the Greek n dXa>7f€;(^ta,

derived from ^ d^nrj^y

the fox.



"Comme il advient au regnart que son poil
chiet une fois ran, aussi est appeli le choir des
cheveux allopice"^

Lanfranc, folio 38, verse XIV
in LiTTRi, article Renard,



Even the general practitioner is frequently consulted by pa-
tients on account of loss of hair. While not a few uncommon
varieties of alopecia are very difficult to diagnosticate, even —
and perhaps, especially — for the specialists, in 9 cases out of 10
the general practitioner may rapidly make such distinctions as
are necessary for the application of suitable treatment.

According as the patient is a nursling, a child, an adult, or
an elderly person, the diagnosis should be oriented, a priori, to the
most frequent forms of alopecia at the patient's age.

In the Nursling. — In this group the condition is practically
limited to:

1. Occipital alopecia, the result simply of wearing away of
the hair on the pillow; the occiput is the area affected, and the
area is ovoid in shape with its long axis directed transversely.

2. Congenital alopecia. — As a matter of fact, it is more par-
ticularly as the patient grows older that this form of alopecia
begins to attract attention.

In the Ohild. — Special thought should be given to the possi-
bility of alopecia areata, ringworm, and cicatricial alopecia in
this group of cases.

1. Alopecia areata. — ^The following lines are reproduced from
Sabouraud's description of this condition: "This is a primary



» "As it happens to the fox that his hair falls out once a year, even so
is loss of the hair termed allopicia."

(661)



Digitized by



Google



662



SYMPTOMS.



form of alopecia, which is not preceded by any functional mani-
festation . . . The hair is lost either diffusely over a limited



Fig. 498. — Hairs in alopecia areata, viewed with a magni-
fying lens (Sabouraud).

region, or as a patch which becomes completely bald from the
start . • . The bald surface is irregular in outline, of varying



Fig. 499. — Alopecia areata in a child (Sabouraud) .

shape, smooth, and devoid of any abnormal feature. It may
become definitely limited or arrested, or even undergo recession.



Digitized by



Google



ALOPECIA. 663

at any time; on the other hand, it may extend until the entire
scalp and the body surface as a whole has lost its hairy cover-
ing. Upon the scalp, extending areas of the disease are marked
by the presence of the typical club-shaped hair stumps, either
singly or in groups or streaks . . . Such a hair, which is
suggestive of the exclamation point in ordinary printing type,



Fig. 500.— Microsporia (Sabouraud), Fig. SOL— Hairs af-

fected with microsporia,
seen with a magnifying
lens (Sabouraud).

is one in process of atrophy ; it is like a portion of a needle with
its point embedded in the skin, etc."

Alopecia areata generally sets in in children between four
and seven years of age and, aside from the severe and recurring
forms, is spontaneously recovered from in from six months to
two years.

2. Ringworm. — (a) Tinea tonsurans due to the small-spored
fungus (microsporia) is the commonest form among the tineas,
i,e., diseases of the epidermis and hair caused by a cryptogamic



Digitized by



Google



664 SYMPTOMS.

microparasite. "It is characterized by dry, scaly, grayish patches
2 to 5 centimeters in diameter, nearly round and with rather
well circumscribed margins. The very first glance at the af-
fected area reveals that the hairs at the surface of these patches
are less numerous than normally. Of these hairs, a very few
have retained their normal features. The others, the ringworm
hairs, are short, broken off at a distance of 3 or 4 millimeters
above the skin surface, decolorized, and apparently covered with



Fig. 502. — Tinea tonsurans due to the small-spored fungus. Micro-
scopic aspect of a hair (Magnified 3(X)X). Some of the spores are seen
by transmitted light (R, Sabouraud).

a grayish shell. The hairs thus affected break off flush with
the skin when depilated. Ten or twelve grayish pieces of hair
may thus be pulled out at once between the fingers. The possi-
bility of thus depilating the surface with the fingers distinguishes
this form of tinea from all others." (Sabouraud).

Microscopic examination of the hair will confirm the diag-
nosis.

"When heated between 2 slides in a drop of caustic potash
solution and examined at a magnification of 100 to 300 diameters,
such a hair reveals a cortex of very small and refractile spores,
arranged in irregular apposition and forming a kind of shell



Digitized by



Google



ALOPECIA. 665

about the hair. . . . The hair appears like a little rod covered
^vith glue and then rolled in sand/'

This condition is less frequently met with in Paris than the
succeeding one, and is rare in children of less than three or
more than thirteen years of age.

(b) Tinea tonsurans due to the large-spored fungus (tricho-
phyton or school type). — This is, in general, less frequent than
the preceding condition. When left untreated, it is characterized
by numerous small areas of involvement, each of which might
easily be covered by the fihger-tip, and which are marked by a




^^



Ck y^



Fig. 503. — Pieces of diseased hair viewed with a magnifying lens, being
seen as they appear beneath the scale (Sabouraud).

small aggregation of adherent scales, presenting the appearance
of a dry scab. The diseased hair is gummed over and sur-
rounded by the scale. In order to see it, the latter must be re-
moved and its deep surface examined ; there are then seen pro-
jecting from it little white rootlets, short and curved over. Mic-
roscopic examination of these rootlets will remove all doubt.
Upon preparation by the technic above described, the parasite
is found to consist of spores much larger than those of the pre-
ceding variety and disposed in regular series or chains and in
groups of parallel, slightly wavy filaments.

This variety of ringworm of the scalp, which is at present the
commonest among the school children in Paris, generally occurs
in girls four to fifteen years of age, though occasionally persist-
ing to the age of sixteen or eighteen years.



Digitized by



Google



666 SYMPTOMS.

(c) Tinea favosa. — In contrast with ringworm of the scalp,
which is more particularly a disease of urban populations, favus
is a rural variety of tinea.



Fig. 504. — Diseased hair in tinea tonsurans of the large-spored
variety in childhood (Sabouraud).

"It invades the scalp only in individuals of school age, but
as it is never spontaneously recovered from, it may be encount-



Fig. 505. — A hair in tinea favosa (Sabouraud).

ered at any period of life. In its ordinary form (favus scutulum)
the disease is characterized by one or more irregular but sharply



Digitized by



Google



ALOPECIA, 667

circumscribed patches, covered with sulphur yellow crusts,
aiul of the color as well as the consistency of clay. The in-
dividual, separate crusts are rounded, annular, and of all differ-
ent sizes, the largest, which measure 1 to 2 centimeters in diam-
eter, showing a series of wave-like circular elevations.

"Of these cup-like formations, the smallest form simply a
ring about the hairs. The cups are pierced by the hairs and



• Fig. 506. — Celsus's kerion (Sabouraud) .

partly embedded in the skin. They may be detached without
great difficulty, in pieces ; in their stead is left a bleeding wound
which appears to extend rather deeply in the tissues.

"A hair affected with favus exhibits a mycelial parasitic
growth composed of a few irregular, wavy, and frequently dead
filaments; in the latter condition their course is shown by a
clearly distinct air bubble of similar shape. The living mycelial
filaments consist of segments of rather variable size and shape,
with some spore-bearing portions."

(d) In connection with the above disorders may be men-
tioned certain trichophyton invasions of animal source, e.g.,



Digitized by



Google



668 SYMPTOMS.

from the horse, dog, cat, or sheep, tending toward suppuration
and leaving behind a permanent cicatricial alopecia. Among
this group is the so-called kerion of Celsus.

(e) Under the general term cicatricial alopecias may be in-
cluded the patches of alopecia, generally circumscribed in more
or less well-defined islets, which follow impetigo, furuncle, or
trauma. The scar-like fibrous condition of the skin in the affected
area, in conjunction with the history, inevitably lead to the
proper diagnosis if the case is carefully investigated.

(/) Congenital temporal alopecia is of importance only by
reason of the mistakes in diagnosis (alopecia areata) to which



Fig. 507. — Congenital temporal alopecia (Sabouraud),

it may lead. The condition occurs on either one or both sides
of the head — in the latter case symmetritally — and is marked
by an oval bald area 2 centimeters long and lyi centimeters
broad situated on the temple and directed obliquely upward
and backward.

(g) The diffuse alopecias of childhood comprise particularly
the infectious and post-infectious alopecias (typhoid fever, oste-
omyelitis, eruptive fevers, etc.), but are generally much less pro-
nounced in children than in the adult.

(h) Lastly, mention may be made of the alopecia following
application of the x-rays. The hair falls out twenty to thirty
days after depilation with the rays, and begins to grow out
again two and a half months after the exposure — unless there
results an actual radiodermatitis causing, even when slight, a



Digitized by



Google



ALOPECIA. 669

permanent alopecia, A mistake in diagnosis in this connection
cannot possibly be made. The regular, romided shape of the
bald area, suggesting a tonsure, is in itself sufficient evidence
for a positive diagnosis. The ritual alopecia of the clergy alone
exhibits such a circular shape of the bald area and the same
relatively large size.

4t 4t 4t

In the Adult. — In this group there are more particularly en-
countered: Seborrhea decalvans, the ordinary baldness of male



Fig. 508. — Alopecia due to- x-ray exposure (Sabouraud) .

neuro-arthritic subjects; the scaly alopecia pityrodes of women,
and the various infectious and post-infectious alopecias, a sepa-
rate place being reserved for syphilitic alopecia and various con-
ditions suggesting alopecia areata but as yet of uncertain origin.

(a) Seborrhea decalvans (the ordinary baldness of men). —
"This presents as its objective sign and fundamental lesion a
cylindrical plug of fat contained in the sebaceous duct and which
is caused by pressing on the skin to emerge from the duct in
the form of a small vermicular mass or rudimentary comedo.
This plug of fat is the seat of a bacterial colony consisting ex-
clusively of the microbacillus of seborrhea.

"The alopecia attending seborrhea is much less diffuse than
that of pityriasis ; it is located at the vertex, over the very area
at which baldness is later to result ... As a rule, the earlier



Digitized by



Google



670 SYMPTOMS.

in life seborrhea of the scalp sets in the more rapid its course.
When it begins at the age of 18 it results in complete baldness
at 25 years, some 200 to 400 hairs falling out each day. When
it sets in at the age of 25, it results in partial baldness only at
55 to 60 years ; from 50 to 60 hairs are lost a day, the number
varying according to the season of the year."

Sometimes this local condition appears to be associated with



Fig. 509. — Seborrhea decalvans of the vertex. Common baldness in
process of development (Sabouraud),

or secondary to that rather indefinite, though frequently en-
countered diathesis: neuro-arthritism.

(b) Alopecia pityrodes. — In women this plays a role as im-
portant as seborrhea does in man. One half of all women show
some evidence of this disturbance, which should be thought
of a priori by the physician whenever a young woman consults
him on account of loss of hair. From the age of 10 years to 20
years the affected scalp is found to be scaly and covered with
dandruff. Later there results an elimination, not of scales and
dandruff, but of the hairs themselves, which fall out whole with
their bulb-like follicles and are replaced by other shorter and



Digitized by



Google



ALOPECIA, 671

weaker hairs until finally alopecia is established — never amount-
ing, however, to complete baldness. The hair becomes more
sparse, shorter, less abundant and luxuriant, with open spaces
interspersed, but never with anything actually suggestive of
the seborrheic baldness of males, with its large, regular, elliptical,
smooth and polished areas of involvement.

(r) Infectious and post-infectious alopecia is of great practi-
cal interest. Influenza, the eruptive fevers, mumps, erysipelas,



Fig. 510. — Alopecia following erysipelas (Sabouraud),

and in particular typhoid fever, cause a more or less pronounced
loss of hair. "Slight alopecia may follow these conditions as
soon as they have terminated, particularly those which, like ery-
sipelas, are attended with intense local inflammation, but all of
them have a definite period for the production of alopecia. The
latter follozvs its cause after an interval of eighty- five days. In
different cases there may be five days' discrepancy, one way or
the other, from this time interval." (Sabouraud). The hair con-
tinues to fall out for about six weeks ; this occurs in a diffuse,
irregular manner, without ever terminating in true alopecia.
Restoration of the hair is constant in these <:ases.

A separate place in the classification may be set apart for
the alopecia? of chronic tuberculous subjects, suggesting alopecia



Digitized by



Google



672 SYMPTOMS.

areata; this form is occipital in situation and circumferential in
arrangement.

{d) Syphilitic alopecia is separated from the preceding group,
of which it constitutes merely a single type, because of its great
clinical importance. It appears about six months after the onset
of the disease — in the course of the second six months' period,
never later. "This lesion is temporoparietal and irregularly



Fig. 511. — Syphilitic alopecia, rather more pronounced
than usual (Sabouraud) .

diffuse, so that when the patient's hair is cut short the hairy-
covering over these surfaces appears as though chopped up
with poorly directed scissor cuts. At each of these points a tuft
of some 12 to 15 hairs will have disappeared, leaving behind
an open space; even in women with long hair these open spaces can
still be recognized. Upon examination of the eyebrows these
are found to show parallel streaks; the cervical glands are en-
larged; upon looking into the mouth mucous patches are to be
found. Or, general examination of the patient may reveal the
indurated remnant of the chancre, the inguinal lymphatic en-
largements, sometimes a still visible roseola, etc." (Sabouraud.)



Digitized by



Google



ALOPECIA. 673

Mention should here be made of the alopecia of old syphilitic^
and of congenital syphilitics, which resembles alopecia areata.
In the congenital cases, it is accompanied by the classical stig-
mata — dental dystrophies, facial dystrophies, interstitial kera-
titis, etc. (see Syphilis), of the condition and will assume the
form of an indefinitely protracted, recurring alopecia areata.

(e) Brocq's pseudopelade variety of folliculitis decalvans, on
the whole rather rare, is met with almost! exclusively in males
20 to 45 years of age and leads ultimately to the formation of



Fig. 512. — ^Tinea decalvans causing almost complete baldness in a dwarf
presenting all the stigmata of inherited specific infection (Sabouraud).

patches of alopecia measuring 1 or 2 centimeters on either side,
polycyclic, serpiginous, and separated by spaces surrounded by
normal hair. It exposes irretrievably more or less extensive sur-
faces, later coming to an end spontaneously. Its onset, course,
and termination remain wholly obscure.

In the Elderly. — ^At this period of life the conditions most
frequently met with are:

The advanced forms ofl seborrheic baldness of the adult;

A form of alopecia due to sclerosis of the follicles and repre-
senting, properly speaking, senile alopecia.

The alopecia areata of the fifties.

Cicatricial alopecia of varying origin.

43



Digitized by



Google



674 SYMPTOMS.

Of the first of these forms, nothing in particular need be said.
Regarding the second, only slight qualifications are required.
The process of sclerosis or fibrosis leads to connective tissue re-
placement and disappearance of the hair follicle. The scalp, de-
prived of its follicles, assumes a smooth, scar-like appearance.

In the period of the menopause, or the process of involution
taking place in women in the forties, there occurs a rather uncom-



Fig. 513. — Brocq's pseudopelade variety of folliculitis
decalvans {Sabouraud),

mon parietal and frontal form of alopecia areata consisting of
more or less extensive irregular patches, which are spontaneously
recovered from after one or two years.

In this period of life, finally, the scalp may exhibit, in the form
of cicatricial patches of alopecia of varying shape and extent, the
end-results of all of the foregoing possible causes of destruction
of the scalp : Traumatism, furunculous eruptions, necrotic acne,
cold abscesses, bone suppurations, burns, gummas, syphilitic se-
•questra, etc.



Digitized by



Google



AMPmrT A r^> ^"» from di^d, privative; alfia^ blood J



As a general rule, abnormal pallor, if associated with a pale-
appearance of the mucous membranes of the lips, gums, and
conjunctivae, is due to anemia. It is a fact, however, that simple,
essential, or primary anemia is very uncommon, whereas morbid
pallor is of very frequent occurrence. The reason for this is
that in by far the greater proportion of cases, if not invariably,
the anemia is secondary to or symptomatic of some other dis-
turbance, and that actually the diagnostic problem set before
the practitioner confronted with a pale individual is that of in-
'^estigating the condition which underlies the anemia.

Despite the recommendations made in current text-books,
confusion of the customary pallor of anemia with the yellowish
discoloration of incipient jaundice or the evanescent pallor of
nenous angiospasm could occur only as a result of gross care^
lessness on the part of the clinician. What is more to the point,
in the author's view, is that both in hyposphyxic cases and in
many tuberculous patients, actual anemia may be masked by a
certain amount of lividity, cyanosis, or even jaundice, particu-
larly in hemolytic icterus. Hence, exatmination of the blood is,
as a rule, indicated in cases exhibiting pallor. This examination
should relate more especially to the cell count and the estimation
of hemoglobin (see Blood examination), Hayem's classification
is generally followed: A^ (tmntber of red cells); R (hemoglobin
value) ; C=-^ (cell value).

Normally, ^ N=5,000,000; /?=5,0(X),000; G=l.

ANEMIC STATES.

1st degree: N and R, and hence also G, are very slightly reduced.

2d degree: N = 5,000,000 to 3,000,000: R = 3,000,000 to 2,000,000; G =
0.80 to 0.30 (extreme figures).

3d degree: N = 3,000,000 to 1,000,000; R = 2,000,000 to 800,000; G =
0.84 to 1.00.

4th degree: N = 1,000,000 to 300,000; R = 800,000 to 300,000; G =



0.88 to 1.70.



(675)



Digitized by



Google



676 SYMPTOMS.

In the 4th degree is comprised the group of the so-called "per-
nicious anemias," the confines of which have not as yet been thor-
oughly d^emiined, and which certainly occur in more than one
form or variety. Determination of the differential leucocyte count
is always necessary in these cases. The total white cell coiuit is
seldom increased ; much more frequently the number of white cells
remains normal or is diminished, in which eveiTt leucopenia is
present. In a general way, a plastic anemia may be said to exist
where blood repair is manifested in the appearance of young or
immature cells; there may be present a leucocytosis, with granular
myelocytes; nucleated red cells may be found in variable numbers,
vis,, erythroblasts with mitotic nuclei or with nuclei in a state of
pyknosis, many reds exhibiting multiple and manifest deformations,
microcytes or megalocytes, etc.

In the much less common condition known as aplastic anemia,
there is an absence of defensive reaction in the bone marrow and
hence also in the blood. There is a leucopenia with preponderance
of the mononuclear cells. Nucleated reds and myelocytes are
absent.

Anemia having been observed to be present, the next step
is to ascertain its cause, since — it cannot be too often repeated —
primary, idiopathic anemia is exceedingly rare.

The classification of A. Jousset appears to the author par-
ticularly serviceable because it possesses all of the three cardinal
virtues of clinical classifications, being both practical, etiologic,
and pathogenetic. It combines at once the causal diagnosis and
the (capitally important) diagnosis that affords rational thera-
peutic indications.

I. Anemias by spoliation may follow any traumatic, surgical,
or spontaneous hemorrhage. Included in this group, in particular,
are all the secondary anemias attending the hemorrhagic affections;
Hemophilia, purpura, scurTTy, epistaxis, metrorrhagia, hemoptysis,
hematemesis, cmkylostomiasis, etc.

The causal diagnosis is often self-evident in these cases. Special
mention should, however, be made of the occult gastrointestinal
hemorrhages attending ulcer and cancer cases, which require for
their detection a systematic examination of the feces (see Exami-



Digitized by



Google



ANEMIA,
THE ANEMIAS.



677



I. — Spoliatory Type.



1. Traumatic or operative hemorrhage.

2. Spontaneous hemorrhage in disorders attended with bleeding

(hemophilia, purpura, metrorrhagia, etc.).

3. Gastro-intestinal hemorrhage, manifest or occult (ulcers or neo-

plasms of the digestive organs).



II. — Toxic-infectious Tjrpe.



A. Infectious.
Chronic:

1. Malaria.

2. Syphilis

3. Tuberculosis.

Acute :

1. Acute rheumatism.

2. Typhoid fever.

3. Suppurative disorders.



B. Toxic.

1. Carbon monoxide.

2. Lead.

3. Mercury (?)



III.— Autotoxic Type.



1. Bright's disease.

2. Hepatic disorders.

IV.— Insufficiency of the Hematopoietic Functions.

Disorders of the blood-forming organs.

V. — Crjrptogenic Type.



1. So-called "primary,"

2. Chlorosis.



essential, or idiopathic anemias.



nation of feces; Tests for blood). Hookworm ova are likewise
detected only by examination of the stools; the patient's environ-
ment will generally aflFord a serviceable indication, as in miners
[and in the endemic foci of the disease in the Southern U. S. —
Translator] .

II. Anemias due to Toxic Action on the Erythrocytes. — In-
fectious and Post-infectious Anemias.

In the first sub-group are placed the three major chronic
infections : Malaria, tuberculosis, and syphilis. These are three of
the most frequent causes of chronic anemia; if the practitioner will
constantly bear them in mind he will never err when seeking the
source of many chronic anemias apparently cryptogenic to a su|>er-
ficial observer. Should cancerous anemia logically be classed with
the preceding forms? At any rate it should and can be classed



Digitized by



Google



678 SYMPTOMS.

with them clinically, whether the anemia be due to manifest or
occult hemorrhage, to toxic action on the red cells, or to both of



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 3 of 50)