Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

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ner. This constitutes simple pruritus or pruritus sine materia.
This is the so-called idiopathic pruritus, a rather frequent condition
in private practice, especially among neurotics; senile pruritus be-
longs in this group.

"2. Under the influence of scratching and rubbing, the skin
may more or less rapidly exhibit a changed appearance ; it may
assume a slightly brownish tint; the creases in it become en-
hanced and more readily visible, deeper, and cross one another
in diamond-shaped fi.gures of varying regularity ; the appearance
at first becomes velvety, then rugose, owing to accentuation of
the dermal papillae and of the epidermis ; histologically, indeed,
there is produced a very marked hyperacanthosis. The process



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1108 SYMPTOMS,

may stop at this point, as is nearly always the case when the
pruritus is of general distribution; when it is circumscribed,
however, the skin lesions undergo further development, suggest-
ing at first species of papules arising through papillary and epi-
dermal hypertrophy, and later infiltrated, thickened, cross-hatched
plaques, more or less scaly and excoriated. These are the changes
characteristic of simple lichenification, 2l process which, like pruri-
tus itself, may be either diffuse or circumscribed; and as I
showed twenty-two years ago while attempting a complete dif-
ferentiation of these morbid types, these are lesions of a purely
traumatic origin, which may be either primary, i.e., show initial de-
velopment on a healthy skin, or secondary, i.e., become superimposed
upon any other pre-existing pruriginous skin disorder. When pri-
mary, the condition constitutes the lichen simplex of the older au-
thors, or, in our own nomenclature, diffuse pruritus or circum-
scribed pruritus with lichenification,

"3. Under the influence of scratching and rubbing the skin may
react by the production of an ordinary urticaria; it may react with
the so-called urticaria papulosa, characterized by small, papular
lesions, and the resulting sequence of changes tends toward the ap-
pearance of prurigo (see below) ; again, it may react with urticaria
bullosa, and the resulting sequence of changes tends toward the
appearance of dermatitis multiformis (see below).

"4. Under the influence of scratching and rubbing, especially
when the pruritus is localized on the inner aspects of the fingers,
the patient may note almost immediately the formation of certain
elevations of the epidermis filled with citrine, clear, serous fluid
and free of surrounding redness, the result being that the skin
appears as though peppered with boiled sago grains, closely
Siggr^gSited and sometimes so confluent as to form rather exten-
sive areas of raised epidermis, almost always discrete, or merely
in apposition. This is the clinical picture for which the term dys-
idrosis should properly be reserved; frequently, however, it is
present in combination with the following type of disturbance,
whence unfortunate mistakes are apt to result.

"5. Under the influence of scratching and rubbing, there de-
velop on the skin, sometimes without redness, but nearly al-
ways with a more or less striking erythema, fine vesicles of un-



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ITCHING, 1109

equal size, of the average size of a pinhead, and which dot the
epidermis in highly irregular fashion. The best plan for observ-
ing them plainly is to first dry the skin either with a piece of
fine cloth or with cotton impregnated with sulphuric ether, then
apply over the affected surface a piece of cigarette paper, over
which is placed a piece of glass to exert pressure. Serous fluid
from the vesicles is then seen through the glass to ooze out and
be absorbed by the paper, thus showing very clearly the shape
and arrangement of the little vesicles. If the latter have not yet
ruptured, one need merely make a few very light strokes with a
curette and then apply the cigarette paper and pressure glass.
To this objective morbid condition, definitely characterized by
the peculiar fundamental skin lesion just referred to, I apply the
term eczema vulgaris, true vesicular eczema, or amorphous eczema,

"6. Under the influence of scratching and rubbing there de-
velop minute lesions of a rather bright red color, slightly ele-
vated above the surrounding skin surface, exhibiting at their
center a slight lifting up of the epidermal layer by citrine serous
fluid, i.e., a small vesicle. These lesions may be scattered here
and there in complete disorder, especially on the extremities, but
exhibit a marked tendency to become agminated and confluent,
thus giving rise to red patches, dotted with minute vesicles simi-
lar to those of the preceding type and oozing more or less freely.
This is the disorder to which the term papulovesi<:ular eczema is
peculiarly applicable. It is made up of a number of transitional
stages which insensibly merge the true, common or amorphous
vesicular eczema with the true prurigoes to be next described.

"7. Under the influence of scratching and rubbing, the skin
reacts with bright red, acuminate, more or less urticarial papules,
exhibiting at their apices a slight tendency to elevation of the
epidermal layer by a little citrine serous fluid. As the attendant
itching is very marked, these urticarial papulovesicles (Tomma-
soH's seropapules) are nearly always found ruptured by the pa-
tient's finger nails; where, however, the lesion is permitted to run
Its course without traumatic interference, there arises spontane-
ously at its summit a minute brownish-yellow crust formed
through desiccation of the little apical vesicle. Such is the char-
acteristic fundamental lesion of prurigo. As I already stated in



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1110 SYMPTOMS.

discussing the diflferential diagnosis of one of our cases, if these
eruptive units remain separate and discrete, the morbid type
known as prurigo simplex exists ; if they show a tendency to come
together in clusters and form eczematized and lichenified
plaques, the condition is that known as Hehra's prurigo; if they are
very large, the condition present is prurigo ferox Vidali,

"8. Following scratching and rubbing there may be produced
in certain patients only a more or less marked lichenification of
various extent, together with acute out-croppings of eczema ves-
icles. E. Eesnier long ago classified this disorder among the
'diathetic prurigoes.' According to the nomenclature personally
adopted, it cannot be spoken of as a form of prurigo, since it
fails to exhibit the fundamental urticarial papulovesical charac-
teristic of this group. For it I shall therefore retain the term
pruritus with lichenification and ecsematous transformation.

"9. Under the influence of scratching and rubbing, the skin may
finally react in a much more complex manner. In some places there
form patches of erythema, elsewhere urticarial lesions, elsewhere,
either on healthy skin or over pre-existing patches of erythema,
vesicles or blebs of varying size, and sometimes even pustules.
These various eruptive types may be simultaneously present in the
same individual, constituting the multiform eruption par excellence;
they may instead occur in succession, one eruptive outburst being,
e.g., urticarial, another erythematous, another erythematovesicular,
another bullous, another actually multiform, etc. Furthermore, the
various eruptive lesions may be scattered in disorderly fashion;
they may be grouped together, and suggest either herpes, vulgaris or
the circinate lesions of ringworm, in which event the term derma-
titis herpetiformis (Duhring) is particularly applicable. The clin-
ical group as a whole should be termed that of dermatitis muHi
formis.

"Such, briefly summarized, is the vast series of the pruriginous
skin disorders with pre-eruptive pruritus (Jacquet) belonging to
the group of the primary skin reactions.

"It should be added, however, that under the influence of itch-
ing and the attendant scratching, other eruptions, which cannot, for
the present at least, be classed simply among the skin disorders with
pre-eruptive itching, may likewise develop with extreme ease and



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ITCHING. 1111

rapidity. In the front rank among these should be mentioned those
peculiar disturbances, intermediate between eczema and psoriasis,
which have been the subject of such extensive discussion of late
and to which we have applied the term psoriasiform parakeratoses;
now, among these psoriasiform parakeratoses there is one particu-
lar form which is frequently seen to develop under the circum-



Fig. 798.— Scabies. Places of election for burrows. None
are ever noted on the face or scalp.

stances alluded to: This variety is chiefly characterized, objectively,
by the presence of patches of varying extent of a more or less
bright red color, sometimes pale, sometimes rather dark, scaly, and
over which are formed vesicles similar to those of true vesicular
eczema. This condition is therefore actually deserving of the
appellation eczema; it is what most authors term seborrheic psori-
asiform eczema, but what I have referred to as eczematized psori-
asiform parakeratosis, wishing thereby to imply that in many in-
stances this clinical condition is in no wise related to seborrhea/'



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1112 SYMPTOMS.

Along with these various forms of dermatosic pruritus should
be mentioned the itching due to varicose conditions of the lower
extremities. These are always accompanied by trophic disturb-
ances.

The same applies to the localized forms of pruritus, such as
vulvar or perianal pruritus due to some local uterine, vaginal
(leucorrheal), urethral, anal or perianal (fistula or hemorrhoids)
discharge.

Parasitic pruritos is clinically represented chiefly by scabies
and the several varieties of pediculosis. These conditions should
always be kept in mind, though little should be said about them,



Fig. 799. — Burrow containing a female itch-mite and her ova.

even after the diagnosis is certain. The diagnosis of scabies — ^an
important one to render — should be basied chiefly on the transmis^
sion of an itching disorder (the patient "having slept with some one
who was frequently scratching himself"), on the special localisation
of the itching at the points of election shown in the annexed illus-
tration, and if necessary, by microscopic identification of the paror-
sites themselves. For the latter purpose one of the little burrows in
the skin should be opened up with a needle and the minute white
object at the bottom of it removed, likewise with the needle; the
female parasite is thus secured and may be examined with a hand
lens or microscope.

The following description of one of these burrows is reproduced
from Sabouraud:^

"The Burrow. — I am for the first time thus alluding to the
familiar burrow of scabies. This is because in any fairly extensive



1 Presse medicale, June 21, 1917.



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ITCHING, 1113

dispensary practice, the dermatologist will have twenty times made
a diagnosis of scabies on the basis of the localizations, of the dis-
order before having searched for a single burrow. The burrow is
• looked for in recent or doubtful, cases in which no light is thrown
on the condition by the history. What, then, is the scabies burrow ?
A homely comparison will give an idea of it at once, for every one
is familiar, from repeated observation, with the burrow of a mole
projecting above the surface of the ground in a field. The burrows
of the itch-mite are constructed similarly. They are most readily



Fig. 800. — Sarcoptes scabiei, female, Fig. 801. — Sarcoptes scabiei, female,
dorsal aspect (R. Blanchard). ventral aspect {R. Blanchard).

observed in uncleanly individuals working in dirty liquids, since
these liquids, entering the burrows by capillarity, stain them black.
To see them well when one is not familiar with them, the palm
of the hand in the children of the very poor should be selected.
The burrows may be accurately compared to the outline of the
spirochete of syphilis stained with silver nitrate, now a familiar
object owing to its frequent reproduction by photography as well
as by delineation. It appears as a wavy black line. Where the
burrow is not blackened with dirt, howerer, it is so hard to see
that the observer, in order to remove all doubt, should stain it
by placing a drop of ink or tincture of iodine over it, wiping it
off a moment later — a simple, but often useful procedure.



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1114 SYMPTOMS,

"The unblackened burrow is even harder to describe than to
descry. X-et the reader imagine that he has pushed a needle
through thick, horny epidermis, e.g., at the finger tip, without



Fig. S02.—Pediculus capitis, male. Fig. 803.— Ovum of Pediculus cap-

Enlarged 25 X (Brumpt), itis attached to a hair. Enlarged.

(Brumpt),

drawing any blood. When the needle is withdrawn, the track
made by it will be visible, the raised epidermis having been ren-



Fig. SOi.—Phthirius pubis. Enlarged 25 X. St. Stigma. Tr. Air-duct.

dered dull and whitish; the channel thus made is, however, a
straight one, while that of the itch-mite is always wavy. Other-
wise, the white, dull condition of the epidermis induced is exactly
the same. Such a channel is quite hard to see, and this is what



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ITCHING. 1115

makes the diagnosis of the disease so difficult, except under hos-
pital conditions. More commonly the lesions of scabies are ele-
vations, papules, or vesicles often opened by scratching, and the
long axis of which exhibits the same direction as the skin fold
at that point."

The diagnosis of pediculosis (phthiriasis) is similarly based on
the situation of the skin lesions (see illustration) and direct exami-
nation of the parasite. It should not be overlooked that these para-



Fig. 805. — Pediculosis or phthiriasis. Areas of election.

sites are not only unpleasant, but also dangerous, being known car-
riers of many instances of relapsing fever and of typhus fever.
The well-known maculce carulece above the pubis, characteristic of
pediculosis pubis, should be kept in mind.

Neurotic pruritus is met with chiefly under the three following
circumstances :

(a) In psychoses, neuroses, exophthalmic goiter, and as a sequel
to overwork, sorrow, and severe emotional impressions.

(&) In lesions of the peripheral nerves (causalgia).

(c) As a reflex manifestation of some deep-seated visceral irri-
tation, as exemplified in the itching of intestinal helminthiasis.



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1116 SYMPTOMS.

To recapitulate: Itching may, for practical purposes, be divided
into the following five gfroups of causes, which account for at
least 95 per cent of all cases:

1. Parasites: Scabies and pediculosis; in these cases the
diagnosis is based on:

(a) Localization of the itching: Head and neck in ordinary
pediculosis; dorsal surfaces of the hands and forearms, anterior
aspect of the axillae, inguinal regions, and penis in scabies; pubic
region in pediculosis pubis.

(fr) The skin lesions due to scratching.

(c) Direct observation of the parasite concerned with a good
hand lens or microscope.

2. Itching skin affections: Observation of the type of skin
disorder present enables the experienced dermatologist to ren-
der an immediate diagnosis.

3. Hepatic and renal insufficiency: Cholemia and azotemia,
(a) Blood-pressure estimation, uranalysis, the presence of other

evidences of azotemia (vertigo, cramps, epistaxis, and nycturia),
and in particular, determination of the blood urea will lead unmis-
takably to the diagnosis of azotemia,

(fc) The itching attending jaundice is a familiar symptom. One
should be able, however, to detect even an early cholemia, of
which itching is itself a valuable indication.

4. Metabolic disorders, in the front rank of which should be
placed diabetes. Pruritus in certain regions, e.g., the inveterate
pruritus vulvce of women, is particularly significant. One should
never omit examining the urine in a case of pruritus, for four dis-
tinct reasons — sugar, albumin, bile, and acidity. Glycosuria, nephr-
itis, cholemia, and acidosis are extremely common causes of itching.

5. Neuropathic states in which pruritus is an actual cutaneous
dysesthesia, accompanied by the usual characteristic evidences
of neurosis. The diagnosis of neuropathic pruritus should, how-
ever, be made only by exclusion, after having systematically
eliminated the causes already mentioned, %nz., parasites, skin
disorders, cholemia, azotemia, glycosuria, and dietetic or phar-
maceutic intoxication.



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ITCHING.
ITCHING.



1117



Cad SIS.


Special Pbatcbbs
AND Location

or ITCHING.


Urini
Examination.


Obnbral Condition.

Associated Clinical

Signs.


Parasitic.

Pediculosis.

Scabies
(burrows).


Scratch marks.
Special parasite.
Head and back of
neck.

Dorsal aspect of
hands and forearms.

Anterior aspect of
axillx.

Prepuce ; inguinal
regions.

Pubes.

Nocturnal paroxysms.








Denna-
toaic


Typical skin affec-
tions, such as pru-
rigo, urticaria, lichen,
eczema, seborrhea,
ringworm, chicken-
pox, mycosis, etc.


Sometimes al-
bumin if the
skin disorder
is generalized.





Cholemic


Generalized itching
sine materia, some-
times predominantly
on the lower ex-
tremities.

Scratch lesions late
in appearing.


Sometimes bile
pigments.

Nearly always
urobilin, and
frequently ali-
mentary gly-
cosuria.


Established or in-
cipient jaundice.
Bradycardia.
Familial cholemia.


Azotemic


Generalized itching

sine materia.
Sometimes nocturnal

paroxysms.
Scratch lesions late

in appearing.


Frequently
albumin.


Evidences of Bright's
disease and arterio-
sclerosis.

High blood-pressure.

Headache, vertigo,
epistaxis, nycturia,
etc.


Diabetic


Itching often localized
at the vulva, or skin
folds on flexor sur-
faces; extremely
marked and obsti-
nate.


Glycosuria.


The usual signs of

diabetes :
Polyuria, polydipsia,

poyphagia, etc.


Toxic


Generalized itching
sine materia, or urti-
carial, or dermatitis
medicamentosa (Ex. :
Exfoliative derma-
titis of mercurial
origin).



Or transitory

albuminuria.
Or transitory

urobilinuria.


Dietetic or pharma-
ceutic intoxication,
more or less obvious.

Yields more or less
quickly to removal
of the cause.



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1118



SYMPTOMS.
ITCHING (conHnued).





Special Features


Ubinb


GENERAL CONDITION.


Causes.


AND LOCATION


BXAM I NATION.


Associated Clinical




OF Itch I NO.




SIGNS.


Neuro-


General or local





(a) Psychopathic


pathic


itching sine materia.




disorder, neurosis,
exophthalmic
goiter, emotions,
overwork, etc.

(b) Peripheral neu-
ritis (causalgia).

(c) Remote visceral
irritation (helmin-
thiasis).



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JAUNDICE (ICTERUS).



The term icterus is applied in all cases in which — whether the
urine and stools are or are not aflfected — the conjunctivae and
skin exhibit a yellow or yellowish hue. In this work the word
icterus, in conformity with its etymologic derivation (from
lyTfpog, jaundice), will be taken as synonymous with jaundice
and as being free of any implication that the discoloration is of
biliar>% hepatic, or other origin.

Icterus or jaundice may be caused :

1. By retention and reabsorption of the bile and of the normal
biliary pigments : Hepatic jaundice.

2. Through a special change in the blood (hemolysis) : Hematic
(hemolytic) jaundice.

3. Through a special kind of intoxication (picric acid) : Picric
jaundice.

I.— HEPATIC JAUNDICE.

Hepatic jaundice, dependent upon retention and reabsorption of
bile and biliary pigments, is that which displays in its greatest inten-
sity the well-known symptom-group of jaundice with its cardinal
symptoms, viz,, jaundice of the skin and conjunctivae and urinary
jaundice (from canary yellow to mahogany color, with more or less
pronoimced decolorization of the stools), and its associated symp-
toms due to bile intoxication, viz., slow pulse, itching, loss of weight,
depression, oozing of wounds, etc.

It should be at once pointed out that this classical symptom-
group, which, as we shall see, is of markedly variable origin, ex-
hibits a diminishing degree of intensity of the jaundiced color
of the skin, conjunctivae, and urine in the following three classes
of cases :

Maximum intensity: Cholelithiasis, cancer of the pancreas,
and chronic obstruction of the bile duct.

(1119) '



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1120 SYMPTOMS.

Intermediate intensity: Catarrhal jaundice, benign infectious
jaundice, and picric jaundice^

Minimum intensity: Infectious, cirrhotic, syphilitic, and
hemolytic forms of jaundice.

Hepatic jaundice may be the result either of an obstruction or
impediment to the flow of bile or of disease of the hepatic lobules or
dyshepatia.

Intrinsic (Intracanaliculobiliary) Causes of Obstruction. —
Cholelithiasis, affecting the gall-bladder, but more particularly
the biliary canal or bile-duct, is by far the most important among
the possible causes of jaundice; tenderness of the gall-bladder,
acute attacks suggestive of hepatic colic, and the history will
generally point directly to the diagnosis.

Catarrhal jaundice comes next, with its usual accompaniment
of febrile gastric disturbance and running its course in one or
two weeks; as a rule the diagnosis of these cases occasions no
difficulty.

Exceptionally there have been reported instances of foreign
bodies that had passed out through the walls of the intestine (fruit
stones, grape seeds, and parasitic ascarides or hydatid disease) ; in
such cases the diagnosis can be made only as an unexpected finding
during an operation or at the autopsy. In the case of a cicatricial
stenosis following duodenal ulcer, the diagnosis would be made on
the basis of the history and the symptoms of duodenal disease.

Extrinsic (Extracanalicular) Causes of Obstruction. — 1. Out-
side of the liver: Usually, cancer of the head of the pancreas,
which is by far the commonest cause of jaundice of extrahepatic
origin. Exceptionally : Secondary tuberculous or malignant gland-
ular involvement at the hilum of the liver, peritoneal bands, ad-
hesions of the biliary channels, lower hepatic surface and colon on
the right side, tumors of the kidney, and aneurysm of the abdominal
aorta.

2. Within the liver: Cancer of the biliary ducts and liver,
hepatic abscess, and cysts of the liver.

Disease of the lobules of the liver, or dyshepatia, may result
from some intoxication or infection acting injuriously upon the liver
cells. It is generally manifest in the lengthy chain of infectious
jaundiced states, a mere enumeration of which will here suffice :



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JAUNDICE, 1121

Catarrhal jaundice, simple or prolonged, always benign, and
occurring sporadically and indigenously.

Benign infectious jaundice, or pseudocatarrhal infectious icterus.

Pleiochromic jaundice.

Recurring infectious jaundice.

Grave icterus, usually secondary to some pre-existing liver dis.-
turbance, such as cirrhosis, etc., or to an infectious disease, such as
typhoid fever, staphylococcic infection, malaria, etc.; exceptionally
as a primary disorder, as in phosphorus poisoning, yellow fever,
icterohemorrhagic spirochetosis, etc.

This type of jaundice is essentially characterized clinically by
a certain symptomatic triad, viz., (1) jaundice; (2) typhoid state,
and (3) various sorts of hemorrhage. According to the kind of
case the condition may be attended with hypothermia, as in
colon bacillus infection and phosphorus poisoning, or with fever,
as in yellow fever and staphylococcic or streptococcic infection.

Larrey, in his Memoires, already wrote of an "icteroid typhus"
which assailed the troops of the Army of Egypt in 1800. Dur-
ing the War of the Rebellion, over 70,000 American soldiers be-
came afflicted with jaundice. More recently, in Macedonia, the
belligerent armies developed many cases of grave malarial
bilious fever (intermittent bilious fever, hemorrhagic bilious
fever, hemoglobinuric bilious fever, etc.).

Special mention may here be appropriately made of an appar-
ently primary variety of infectious jaundice which has only of late
come to notice. It is manifested in a recurring febrile infectious
jaundice, ordinarily accompanied by myalgia and hemorrhage, and
brought on by a spirochete discovered and studied in 1913-1915 by
two Japanese authors, Inada and Ido, whence the term ictero-



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 30 of 50)