Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

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symptom, "pain in the side/' without referring to Head's cones of
cutaneous hyperesthesia. Head showed that in many disorders of
internal organs investigation of skin sensitiveness demonstrates the
existence of corresponding, well-defined hyperesthetic (hyperal-
gesic) zones, and on the basis of natural sequence and reciprocity,
concluded that the observation of such a zone erf hyperalgesia in
any given case definitely means the existence of some disturbance
of the underlying deep organ. His conceptions do account for
many otherwise inexplicable pains and are of considerable service
in the clinical study of many more or less latent affections of
viscera. It seems advisable, therefore, to recall here the various
associations of skin regions to the viscera of the chest and ab-
domen, as established by Head. Through their agency the author
has frequently been enabled to announce the existence of other-
wise completely latent foci of inflammation in the pleura and lung.

The subject appears of sufficient practical importance to war-
rant the reproduction in extenso from Head of a complete table
showing the areas of pain referred to the skin surface from vis-
ceral disease.

Table Showing the Relationships Between the Thoracic and Abdominal

Viscera, the Spinal Segments, and the Peripheral Nerves of the

Trunk. (After Head, in Poirier's "Anatomy.'*)

[The question marks following certain pairs of nerves in the table are
intended to call attention to the fact that the transmission of pain does
not occur constantly in the field of distribution of these nerves].

nbrye8 along which pain is
Orqans. rbfbrrbd to the pabibtes in



Heart and aorta


In angina pectoris the referred pain
extends down the arm to the area of dis-
tribution of Di, D2, and D3, and also in
the thoracic region in the segments D5,
De. D7, Dg, and D9.

The pain in pneumonia is more •espe-
cially localized in the 4th and 5th costal
interspaces; collaterally the area of re-
ferred pain may extend into the segmen-
tal distributions De and D7.


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I Cardiac

Small and large in*

Xiphoid point and spinal point in gas-
tric ulcer.

Dorsolumbar pain in cancer of the in-
testine or mesentery.




Kidney and renal


layer . .


layer .

In gall-stones pain is referred mainly
in the 8th and 9th costal interspaces, less
frequently in the 9th and 10th.

Girdle pains in malignant disease of
the kidney.

Girdle pains and pain referred toward
the nerves of the lumbar plexus in neph-
ritic colic.

Y Dorsolumbar pain in cystitis.

I Pain the result of irritation by foreign
f bodies (stones, etc.).


Body .

Testicle or ovary

Dorsolumbar pain in parturient women.


}Pain due to inflammatory states and
tumors of the cervix.

(Dorsolumbar pain in tumors or tuber-
culosis of the reproductive glands.
Referred girdle-pain in cysts of the

Epididymis | ^^ I Dorsolumbar pain in orchitis, epididy-

Fallopian tube | V^^ f mitis, or suppurative salpingitis.

f ^" f sf ?
Prostate j D12 and j ^

^ ^^ I S3

r>i^„^o- o«^ ^«^; f Referred pains extend along the course of the

fnn^Tim \ Peripheral nerves, and are associated with deep-

loneum ^ seated pain confined to the area actually involved.

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PLETHORA. InXrideLv, to be full]

The terms "plethora" and "plethoric," freely used in the clin-
ical medicine of olden times, are not to be found in the standard
treatises and text-books published in the course of the last forty
years. In this fact lies one of the inevitable weaknesses of the
prevailing nosology, which, soundly based as it was upon the
pathologic conception of a certain clinical picture corresponding
exactly to a certain definite organic lesion, found itself com-
pletely at a loss when required to classify correctly the func-
tional symptom-complexes attendant upon morbid physiology.
It was obliged to yield, unwillingly, in some instances, and at-
tempted to associate a symptom-group with a definite lesion — not
always, nor even frequently, succeeding in its endeavor. One
need merely recall the countless "lestonal" theories of angor pec-
toris, such as the neuritis theory and the theories of coronary
arteritis, of aortitis, of myocarditis, etc. As for certain other
conceptions, such as the morbid temperaments, constitutional
morbid predispositions, the "preorganic" stages of various dis-
eases, and the "boundaries of the disease," according to Heri-
court's very justifiable expression they were deliberately jetti-
soned from the nosological field as it was formerly accepted.

This opposition between that which the author has deliber-
ately — and without overlooking the inaccuracy of the terms
when taken in the strict sense— designated as functional nos-
ology and the realm of lesional or organic nosology accounts in
part for the frequently recorded lack of harmony between hos-
pital practice and private practice. Hospital practice deals al-
most exclusively with lesional cases suflFering either from acute
disorders or from chronic, long-standing, lesional, inveterate, in-
curable disorders that have reached the stage of organic decom-
pensation, such as advanced tuberculosis, arteriosclerosis, inter-
stitial nephritis, cirrhosis of the liver, tumors, etc. Private prac-

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tice, on the other hand, deals chiefly with functional cases suf-
fering from morbid affections. or tendencies of relatively recent
advent and generally curable, such as pretuberculosis, hypo-
sphyxia, plethora, transient or mild forms of cardiorenal insuffi-
ciency, active or passive congestion of the liver, etc. Hospital
medicine, which hitherto has afforded the most clearcut material
utilized in standard systems, deals mainly with extreme forms
of disease, very often perfectly established and with highly de-
finite outlines. Private practice generally supplies for the physi-
cian's observation incipient clinical types, an infinitely greater
range of abnormal conditions, and morbid tendencies sometimes
as yet barely outlined; yet any one can see that it is precisely
upon the detection of these premonitory stages of presclerosis,
of pretuberculosis, of cardiac, renal, or hepatic insufficiency, etc.,
latent or incipient, that the efficacy of our therapeutic endeavors

A concise consideration of plethora will illustrate this assertion
as a concrete clinical example.

Plethora {Tdkri^is^^ from TtXyjOeiv, to be full) constitutes a
very distinct and common clinical type. In its simple, uncompli-
cated form, it strikes the eye by virtue of the subject's flourishing,
often ruddy, supernormal, "overfilled,*' "plethoric" appearance^

The plethoric subject is, in truth, by no means a sick person in
the ordinary sense of the term ; on the contrary, apart from certain
minor, intermittent ailments such as skia disturbances, hemor-
rhoids, etc., he enjoys a flourishing, seemingly perfect state of
health ; he even shows an unusual functional activity character-
istic of more intense vitality ; he is polyphagic and his digestive
functions are admirably carried out (as, indeed, they are in dia-
betic, gouty, and obese subjects) ; he is polydipsic and polyuric
(like the diabetic and gouty) ; his skin is ruddy and his general
appearance robust ; without his being actually obese, his weight
is nevertheless above the normal (96 kilograms with a height
of 187 centimeters, 74 kilograms to 166 centimeters, etc.) ; his
powers of endurance are great; he is unusually active and the
amount of work he does may be far above the average (as in
many gouty and diabetic individuals).

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In short, in the absence of any sort of illness on his part,
one would almost be apt to state that the plethoric is a super-
normal person or "superman" from the standpoint of body
physiology. His more powerful, hypertrophied heart contracts
more forcibly, leading to an unusually high systolic and differ-
ential blood-pressure. His blood, more rich and less dilute,
exhibits a higher viscosity and frequently an enhanced number
of blood cells. His kidneys, adapted to more active circulation
and nutrition, excrete unusually large amounts of water, salt,
urea, uric acid, etc., and of urine, which often shows high acidity
and high specific gravity. His digestive glands, copiously sup-
plied with blood, produce unusually laxge amounts of secretion,
causing polyphagia, polydipsia, polyuria, plethora, etc.

The plethoric subject is thus not, strictly speaking, an abnor-
mal, but rather a supernormal individual, clinically characterized
by his flourishing appearance, his supernormal body weight, and
his high blood-pressure and blood viscosity.

He is predisposed, however, to obesity, to diabetes, to gout,
and to urinary lithiasis, of which he already presents certain typ-
ical features as regards body conformation and functionation.
He is predisposed to the development, sooner or later, of cardio-
vascular-renal fibrosis. The chief advantage, indeed, of 'a diag-
nosis of true plethora founded on the symptomatic triad, over-
weight, high blood-pressure, and high viscosity (with their corol-
laries, high urinary acidity and specific gravity), is that it points,
long before any recognized and ordinarily listed morbid mani-
festation has appeared, to the presence of an abnormal tendency
which, at the time, is still susceptible of relatively easy correc-
tion before any irreparable organic change has become estab-
lished (see High blood- pressure).

In over one-half of all cases of plethora duly substantiated by
the presence of overweight and high blood-pressure and viscosity,
the plethoric state will be found associated with a recognized
metabolic disease, inc., diabetes (see Glycosuria), obesity (q.v.),
gout (see Joint pains), or urinary lithiasis (see Lumbar region,
pain in).

Plethora constitutes, furthermore, a premonitory stage in
arteriorenal fibrosis or arteriosclerosis, which it precedes, heralds.

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and elaborates. When the, plethoric subject has exhausted the
cardio-arterio-renal reserve powers which have up to that time
maintained and insured his abnormally high level of physiologic
performance, he passes gradually into a stage of angiospastic pre-
sclerosis, during which he experiences intermittent attacks of renal
insufficiency with retention, clinically expressed in paroxysmal high
blood-pressure, hydremia, and their consequences — anginose
pains, suffocative sensations, pseudoasthma, transient reduction of
urinary output, etc. If this condition of presclerosis, which is
still in large measure a reducible condition, is not set right, a
definitive and practically irremediable arteriorenal sclerosis becomes
established. The subject is no longer merely a patient, but a per-
manent invalid.

The foregoing concise account will have set before the reader
the prime importance of the syndrome, plethora, which, correctly
interpreted and treated, will obviate in many instances an other-
wise refractory condition of general tissue deterioration. ^

ipor further details, see Martinet: Pressions artirielUs et viscositi
sanguine, Masson, 1912 ; Clinique et thSrapeutique circulatoires, Masson, 1914,
and in the present work, the section on High blood-pressure.

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POLYURIA. [7toXi;$, much; oipov, urine.]

The first thing to do in a patient who states that he passes
much urine or in whose case there is reason to believe that
polyuria exists is to make sure that the condition is actually
present. Many patients confuse the terms frequent urination (pol-
lakuria) and free urination (polyuria). As a matter of fact, no
necessary and intimate relationship exists between these two mani-
festations. The practitioner should therefore have the patient
carefully and systematically collect the twenty-four hour urine in
one or more two-liter (or two-quart) containers. Polyuria can-
not be said to exist unless the twenty- four hour output (e,g., from
8 A.M. to the following 8 a.m.) materially exceeds 1.5 liters, which
is the normal average amount in an adult on a normal diet. The
average degree of polyuria which is by far the most frequently
met with is that ranging between 1.750 and 3 liters. In exceptional
instances, such amounts as 4 to 6, 8, 10 liters, or even more, have
been and are encountered.

Little space will be devoted to the subject of induced polyuria,
whether of physiologic origin and due to spontaneous ingestion of
fluid in large amounts, as in polydipsic subjects, or of therapeutic
origin, in conformity with the physician's orders. Where this form
of polyuria exists care should be taken at least to ascertain s^proxi-
mately the total amounts of fluid ingested and of urine excreted.
Only by a comparison of these two amounts can a reliable conclu-
sion be reached as to the eliminatory power of the kidneys as
regards water (see Functional examination of the kidneys: In-
duced diuresis).

This applies to plethoric subjects ; they eat much food and drink
much fluid and consequently pass a large volume of urine, and if a
careful comparison of their ingesta and excreta is made, a satis-

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factory balance between the two is noted. Their urinary output
per centimeter of differential or pulse pressure is, moreover, nor-
mal, zfis., 250 cubic centimeters (see High blood-pressure).

Polyuria following injections of saline or glucose solutions, the
administration of diuretic agents, or the institution of other
diuretic measures likewise presents an obvious exciting cause, but
should stimulate the physician to record accurate and carefully
made observations such as will ultimately permit of our formulat-
ing a practical and rational system of pharmacodynamics as related
to the diuretic agents.

♦ ♦ ♦

Spontaneous, accidental, temporary polyuria is met with par-
ticularly under two well-defined conditions :

1. After paroxysmal nervous attacks, especially among hys-
teric subjects, epileptics, and exophthalmic goiter (post-hysteric,
post-epileptic, and hyperthyroid polyuria), and even after ordi-
nary spells of nervous excitement among naturally "nervous"
subjects, ue., persons with unusual, excessive nervous reactions
to stimuli.

2. In the critical stage of febrile diseases and more particu-
larly in the stage of resolution in pneumonia, influenza, broncho-
pneumonia, pleurisy, etc. In these it constitutes, as a rule, a
favorable prognostic sign of the greatest importance and which
generally marks the change of trend of the disease from a fatal
to a favorable termination.

The foregoing types of polyuria are, as will have been noticed, of
considerable practical importance, but those to follow are far
more significant still.

Spontaneons, habitnal, chronic, or at least recurring, polyuria.

— The most commonly encountered forms are those of renal fibro-
sis (interstitial nephritis), diabetes, and chronic diseases of the
urinary tract. The several different forms may be intermingled,
but ordinarily they are completely dissociated and their recogni-
tion is easy, rapid, and elementary.

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1. Polyuria in renal fibrosis (interstitial nephritis). — ^The
patient is of ripe or advanced age. Usually he has a moderate
degree of polyuria (1800 to 2000 cubic centimeters), with pol-
lakuria and nycturia. The urine passed is light colored, of low
specific gravity (1014 or less), with small proportions of urea and
chlorides, and traces of albumin, frequently so small as to pre-
clude determination, or even entire absence of albumin.

Sometimes, and even often, the polyuria is accompanied by
the ordinary signs of arteriosclerosis : Cardiac hypertrophy, ac-
centuation of the second sound at the base, or even gallop rhythm,
together with sinuous or sometimes actually hardened peripheral
arteries; at a more advanced stage: Hemorrhages in various
situations, as in the retina, from the nose (epistaxis), etc.

There exists, furthermore, a sign which in the author's view
is pathc^nomonic of renal fibrosis in the stage of eusystoly, i.e,,
of adequate cardiac compensation. In this stage there is always a
high systolic pressure, a high pulse pressure, and also frequently a
high diastolic pressure. Determination of the quotient ^ of the
actual twenty-four hour output of urine, H, over the pulse pressure,
p, as estimated with the Pachon instrument in the sitting patient
in the later morning hours or in the afternoon, yieldst in the
normal subject a^ result equal or superior to 250 cubic centim-
eters. In the patient with interstitial nephritis the same cal-
culation yields constantly and permanently a result more or less
inferior to 250 cubic centimeters, and the lower the figure, the
more pronounced the process of sclerosis. By accident and in a
strictly transient m.anner, such a figure may be recorded in an
angio-spastic case, but- never lastingly and permanently.

2. Polyuria in diabetics. — The patient is generally in middle
adult life and presents a flourishing appearance. The pol3ruria is
usually more marked than in interstitial nephritis, amounting to 2
liters or more. The urine is more highly colored, and at times even
deeply tinted; it is always of high specific gravity, viz,, 1020 or
above, 1030, 1034, etc. Whether glycosuria is present or absent,
this feature alone is almost sufficient to differentiate the polyuria
of low specific gravity of nephritis from the diabetic polyuria
with high specific gravity.

Digitized by VjOOQIC



(a) In 9 cases out of 10 there is glycosuria, signifying diabetes
mellitus, the cause of which is thereupon to be sought.

(b) In 1 case out of 10 glycosuria is absent, but there is excess
of nitrogen, of chlorides, of phosphates, etc. In this event the
condition is termed diabetes insipidus, and in this connection one
is confronted with one of the more complex aspects of polyuria,
since it borders on the condition known as renal hyperpermeability
— a syndrome exactly opposite to the hypopermeability which re-
sults from renal fibrosis^ — as well as on amyloid degeneration of
the kidney, on idiopathic (or cryptogenic) polyuria, sometimes of
hysteric origin (and what now remains of hysteria?), and on poly-
uria symptomatic of nervous disorders, especially bulbar, tumors
of the medulla, disseminated sclerosis, general paralysis, hemor-
rhage, softening, tumors of the pituitary, etc. Discussion of all
these allied and varied conditions would lead us too far afield ; let
the mere mention of their possible clinical occurrence here suffice.

3. Polyuria in "urinary" cases. — In this group are included
the instances of polyuria almost constantly met with in the
course of the chronic diseases of the urinary tract, such as hyper-
trophied prostate, stone in the bladder, chronic cystitis, pyelo-
nephritis (especially of calculous origin), etc.

Its mode of production is undoubtedly complex, the symptom
being the result of a reflex stimulation (possibly vasodilator), of
secondary interstitial changes in the kidney with secondary high
blood-pressure, and probably of other as yet poorly understood

At all events, such a polyuria seldom exceeds 2 or 2^^ liters.
Only very exceptionally is the urine passed clear as in the pre-
ceding categories. The associated infection of the urinary tract
makes of it a cloudy polyuria, in which the turbidity is due to pus
in the urine and sometimes, likewise, to alkalinity (or hypoacidity)
and phosphaturia. In relatively recent cases the urine clears up on
standing, the pus and other solid substances forming a voluminous
deposit at the bottom of the receptacle ; in inveterate cases, on the
other hand, with more advanced renal lesions, the urine remains
cloudy, with a much less abundant sediment.

1 See Martinet : *'Clinique et therapeutique circulatoires" section on
Renal hyperpermeability.

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This cloudy form of polyuria may be met with in renal tuber-
culosis, especially when in an advanced stage. At the beginning a
copious, clear polyuria is more frequently observed, with traces of
albumin, phosphaturia, and quite frequently with slight, mani-
fest or occult hematuria, the latter being examined for by centrifu-
gation and examination of the sediment for red blood cells.

Such are, for practical purposes, the three main varieties of
chronic, persistent, lasting polyuria. Yet, as in all other clinical
groupings, there remains, in last analysis, a residue of cases still
obscure and which lend themselves poorly to any satisfactory
didactic description. This is the g^oup alluded to above in con-
nection with the polyuria of diabetes insipidus, vis., the essential
or idiopathic polyurias, or better, the cryptogenic polyurias, the
latter term being more in accord with our present state of knowl-
edge, since we are ignorant of their cause and even of their prob-
able mode of production. Most of the case reports refer to young
subjects, twenty to forty years of age, frequently alcoholic, and
nearly always hysteric. The onset is almost abrupt, with frequent
urination. The amounts reported by many of the authors are so
amazing, e.g,, 10 liters, 15 liters, or even 30 liters, that they in-
evitably suggest the "Tales of Hoffmann" and that it is difficult
to believe that there are not among them some instances of "colos-
sal" faking. Personally, the author has never observed any
amount approaching the above figures. The highest amount recorded
has been 7 liters, already a remarkable figure, and even in this case
the circumstances as regards supervision of the patient, although a
rather close watch was kept, were not such as to exclude all pos-
sibility of faking on the part of the patient — an irresistible tendency
in such subjects, who are always going after that which is excessive
and extraordinary and seeking mainly, like the members of certain
schools of art, to "astound the physician." "The spider," said Mar-
cus Aurelius, "takes pride in catching a fly ; another creature takes
pride in catching a hare ; another, in catching a sardine ; another, in
destroying a wild boar; another, in killing Sarmatians." Another,
we may add, in . . .

Where will pride not seek its outlet !

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There are many patients who complain of pains in the region
of the heart and believe, therefore, that their heart must be af-
fected.' As a matter of fact, precordial pain, while sometimes
of cardiac origin, is far more frequently of extracardiac origin.
The commonest among these extra-cardiac causes are dyspepsia,
aerophagia, neuroses, and more particularly the so-called "psy-
chosplanchnic neurosis;'* in addition, a host of other factors may
on occasion be operative.

The fact is that the precordial region is anatomically highly

The precordial parietes comprisie, from before backward :

1. The skin, subcutaneous cellular tissue, mammary gland, and
subjacent muscles, in particular the pectoralis major,

2. The chest wall proper, consisting of muscle, bone, and car-
tilage, and including the sternum, ribs, costal cartilages, together with
the costal interspaces and their vessels and nerves,

3. The pericardium and heart.

4. Anteriorly, the tongue-like projections of the pleurcc and lungs
between the pericardium and the thoracic wall.

5. Posteriorly, the heart is ensconced in its medic^tinal recess
in more or less direct relationship zvith the esophc^us, the descend-
ing aorta, and the mediastinal lymph-glands.

6. Above, it is prolonged by the great vessels at the base, viz,,
the aorta and the pulmonary vessels,

7. Below, it rests on the thin diaphragm, which alone separates
it from the fundus of the stomach.

8. Laterally, it is in relationship with the mediastinal pleura, the
lungs, the phrenic nerves, and the vessels to the diaphragm.

There is not one of these structures which may not be the
source of pain in the precordial region, some commonly, like the
stomach, others exceptionally, like the mammary glands.


Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 39 of 50)