Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

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of the blood, an expression of the resistance opposed by the blood
to the circulation. With a low viscosity, as in anemics, there cor-
responds a low pressure; with a moderate viscosity, as in normal
subjects, a moderate pressure, and with a high viscosity, as in ple-
thoric, full-blooded persons, a high pressure. In short, in the per-
son who is normal from the cardiovascular, or better the circula-
tory standpoint, the pressure goes hand in hand with the viscosity.
The converse, however, is not always true, for reasons set forth
at length in an earlier work of the author's^ devoted to a study of
this question.

Furthermore, this relationship, which the author was enabled
to demonstrate only after extensive observations, will seem ob-
vious to any one who will call to mind the fact that the energy
required to cause a fluid to circulate in a given canal system is
proportionate to the resistance offered by the fluid, vis,, to its
viscosity.

Such is the natural relationship of the pulse pressure and
blood viscosity.

Clinical observation leads to the detection of two radically
opposed abnormal sphygmoviscosimetric types of cases in which
there is disharmony between^ the pulse pressure and the blood
viscosity.



1 Alfred Martinet : "Pressions arterielles et viscosite sanguine," Paris,
Masson, 1912.



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LOW BLOOD-PRESSURE. II49

The first type exhibits a pulse pressure which is high in com-
parison to the normal or low blood viscosity; these are hyper-
systolic, hypersphyxic cases, the permanent hypersphyxia being
represented by arteriorenal sclerosis.

The second type, which is the subject of the following brief
study, shows, on the other hand, a viscosity which is high as
compared with a normal or low pulse pressure : These are hy-
posphyxic cases.

The h5rposph)rxic syndrome. — Hyposphyxia consists of the
combination of an absolutely or relatively low pulse pressure with
a high blood viscosity. These two factors, simultaneously present,
constitute the highest expression of the condition of sluggish cir-
culation so frequently noted in young girls, sedentary indiznduals,
pretuberculous subjects, etc., and characterized especially by weak
pulse, a liznd skin surface, habitual coldness and cyanosis of the
extremities, a tendency to venous plethora, varicose veins, enlarge-
ment of the liver, unusual sensitiveness to cold, etc.

Hyposphyxia is almost constantly associated with pluriglandu-
lar insufficiency, of which it is a dominant feature and upon which
it depends. In hyposphyxics there are noted, indeed, gastrointes-
tinal dyspepsia due 'to inadequacy of the several digestive glands,
various disturbances long since attributed to insufficiency of the
endocrin glands (thyroid, ovaries, adrenals, pituitary, etc.), vis.,
headache, migraine, dysmenorrhea, asthenia, asthma, disturbed
nutrition of the hair, etc.

The hyposphyxic syndrome is specifically mentioned in many
descriptions of the syndromes due to insufficiency of glandular
functions.

Stress is to be laid on the fact that hyposphyxia is only a symp-
tom-group and not a definite disease entity, and that one may dis-
tinguish organic and functional forms of hyposphyxia, as well as
constitutional inherited, and accidental {e.g., post-infectious) forms.
Precisely the same is true of the syndrome of pluriglandular in-
sufficiency.

This ascendancy of the circulatory factor over the neuro-mus-
culo-trophic factor had already been clearly expressed by Bris-
saud in relation to feeble children (Bauer) and to mitral dwarf-
ism. "As soon as a certain degree of narrowness of the arteries



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1150 SYMPTOMS,

exists," he wrote, "the poorly nourished tissues and organs may
actually undergo development, but remain small and weak. The
stunted individual that results does attain complete development,
but without proper growth." (Henry Meige.)

From the standpoint of pathogenesis, this syndrome consti-
tutes, in last analysis, the outward manifestation of a circulatory
disturbance characterized by high venous pressure with stasis de-
pendent either upon some obstruction in the left heart (mitral dis-
orders) or in the right heart (tricuspid disorders), or, as is more
usually the case, upon a congenital underdevelopment of the heart
(constitutional cardiac debility), or an obstruction in the lung
(chronic tuberculous lung disorders), liver (cirrhosis or passive
congestion), or veins (varicose veins, phlebitis, and cutaneous
cyanosis).

Absolute or relative weakness of the cardiac contraction, peri-
pheral circulatory weakness through vascular myasthenia, and
respiratory weakness are met with in all these conditions.

The above state of circulatory dynamism, with a low pulse
pressure and high viscosity, points directly either to a congenital
weakness or underdevelopment of the cardioarterial system (con-
stitutional cardiac debility) or to an obstacle to the circulation
behind the left heart (mitral valve, lungs, right heart, or liver).
Venous plethora is the inevitable result and constitutes a mode
of adaptation or defensive reaction to an unusual condition of
the circulation.

The presence of this syndrome in a chronic form, constituting
an habitual circulatory state, chronic hyposphyxia, has been clin-
ically obsen^ed by the writer:

1. In subjects with certain lesions, chiefly obvious cardio-
pulmonary conditions and corresponding with clearly defined
nosologic entities, to which the term secondary organic hypo-
sphyxia is applicable.

. 2. In subjects apparently free of any organic heart or lung
disorder so far described, the appellation protopathic functional
hyposphyxia (neurocirculatory asthenia) may be used.

3. Occurrence of the syndrome as an acute or subacute, acci-
dental and temporary condition, acute ten:4)orary hyposphyxia,
has also been noted.



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LOW BLOOD-PRESSURE. HSl

Organic hyposphyxia has been observed by the writer :

1. In acute or chronic tuberculous cases, with the exception of
those with added renal complications.

2. In mitral disease, with or without compensation. Congenital
or acquired mitral stenosis affords the most striking examples of
this group. Doubtless the same applies to tricuspid stenosis.

3. In the majority of cases of chronic lung disturbance with
emphysema and bronchitis,

4. In kyphotic patients,

5. In some cases of uremia, or more correctly, azotemia.
Functional hyposphyxia has been very frequently witnessed.
This type is almost the rule in young girls and a large number

of women leading sedentary lives by choice or occupation (dress-
makers, pianists, clerks, etc.), with low breathing capacities and
weak musculatures. The author has also come across it in a
number of youths, scholars or students not interested in sports.

Often it is an inherited condition, dependent upon an actual,
congenital and familial cardiovascular hypoplasia. In one such
family, the grandfather, suffering from varicose veins, had al-
ways exhibited cyanosis and had cold, moist extremities; the
mother, also varicose, was likewise hyposystolic and showed a
high blood viscosity; the uncle had varicose veins and cyanosis
of the face, lips, and extremities; an aunt, cyanotic and with
varicose ulcers, was looked upon as having heart disease; another
aunt was in a similar state; as for the patient himself, he was a
cyanotic, sedentary individual with poor musculature, cold, moist
extremities, and a congested liver; his pulse pressure was 30
millimeters and his viscosity 5.5.

This type of disturbed nutrition, accompanied by many other
states of maldevelopment (dental, palatal, abdominal, etc.), fre-
quently forms part of the symptom-group of congenital syphilis.



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1152



SYMPTOMS.
LOW BLOOD-PRESSURE.



Anemias.
Hemorrhages.

Neurasthenia.

Cachectic states.
Tuberculosis.



Adrenal insuffi-
ciency.



Hjrposphyxia.



Organic



Functional



Low cell count; pallor of mucous membranes;
functional cardioarterial murmurs.



Traumatic or post-operative.

(Progressive reduction of blood-pressure after

trauma or an operation is always an indication

of persistent hemorrhage).



Neuropathic syndrome: Headache, insomnia,
constipation, asthenia, anxiety.



Cancer; senility; phthisic conditions.



Cough, fever, loss of weight, auscultatory signs.
' either lead to exclusion of
the diagnosis of tuber-
culosis,
or lead to the detection of
a renal complication.



High blood-pres-
sure should



Padiognomonic ssrmptom-group: Low blood-
pressure, asthenia, and Sergent's white line. .

' from Addison's disease or acute ad-
renalitis with rapid death,
All grades { to the temporary and mild forms
of post-infectious adrenal insuffi-
ciency.



Slow circulation (low pressure, high viscosity),
very often associated with pluriglandular in-
sufficiency (hypocrinia).

(Pulse small and frequent, lividity, sensitiveness
to cold, coldness and cyanosis of the extremi-
ties, venous plethora, etc.).



1. Tuberculous cases.

2. Mitral cases.

3. Chronic pneumopaths.

4. Kyphotics.

5. Azotemics.

6. Congenital cardiovascular dystrophy (includ-
ing congenital syphilis).



Sedentary life, cardiomuscular debility, etc.
Neurocirculatory asthenia.



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LOWER EXTREMITIES, PAIN IN.



The causal diagnosis of pain in the lower limbs is often ob-
vious, as in rheumatic arthritis, post-infectious phlebitis, acute
gouty attacks, etc. ; yet sometimes it presents insuperable diffi-
culties. Few portions of the body are more accessible and read-
ily examined; yet few are more complex, and none is the seat of
pains that may be due to such a large variety of causes.

Any of the tissues of the extremity, bones, joints, muscles,
veins, arteries, or nerves, may be the starting-point of painful
affections; the spinal cord, vertebral column, various trophoneu-
rotic disturbances, and various abdominopelvic disorders may
^ likewise cause more or less obstinate pain in the lower extremi-
ties. Proper diagnosis sometimes demands an extremely pains-
taking clinical investigation and penetrating analysis.

Any of the tissues, as we have seen, may be the starting-point
of painful affections. A succinct reference to each kind of tissue
may prove serviceable:

I. The Bones. — Traumatic conditions, such as fractures, con-
tusions, and sprains, generally self-evident, may be dismissed from
the start, leaving for our consideration osteoperiostitis; osteomye-
litis; osteosarcoma; an extremely common skeletal deformity, flat
foot, which should always be kept in mind precisely because of its
common occurrence, and the disorders of the bony spinal column,
foremost among which is Potfs disease.

(a) Osteoperiostitis. — This condition is characterized by the
presence of a more or less localized painful area along the shaft
of one of the bones of the lower limb, usually the femur or tibia,
together with a variable degree of swelling. Osteoperiostitis
may be :

Syphilitic, as suggested by the history, recurrence of the pain at
night (osteocopic pains), a positive Wassermann, and the efficacy
of mixed treatment.

78 (1153)



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1154. SYMPTOMS.

Tuberculous, though this form of osteoperiostitis is actually
much less common than tuberculous osteoarthritis.

Post-infectious, e.g,, post-typhoid; staphylococcic in the pres-
ence of recurring furunculosis or after sore throat.

(6) Osteomyelitis. — This is characterized by more severe and
more diffuse pains and larger oscillations of temperature; it is
generally post-infectious, e.g., typhoid (post-typhoid) or staphy-
lococcic (following sore throat or furunculosis).

(r) Osteosarcoma. — This is fortunately much less common, in
fact exceptional, and is characterized by a rapidly progressive and
generally painful enlargement involving the shaft of the femur. ,
A mere mention of the condition would suffice were it not neces-
sary to point out that it may sometimes be confounded with a
syphilitic gumma of the bone. Indeed, in a case of sciatica resist-
ant to all forms of treatment, in which the progressive develop-
ment of a swelling of the femur had led to a diagnosis of osteosar-
coma and a decision to amputate the limb, and the denials of the
intelligent patient, answering questions in good faith, the absence
of evidence of venereal diseasfe, and the existence of nearly adoles-
cent children free of any appreciable stigmata had seemed to war-
rant exclusion of the diagnosis of syphilis, the swelling was ob-
served to melt away like butter before the sun's direct rays as a
result of mercurial inunctions.

(d) Painful valgus flat foot should be thought of in any ado-
lescent complaining of pains in the legs and muscular contrac-
tures when he is fatigued, and the diagnosis may be made by the
print method, which consists in having the patient place his feet
over sheets of paper covered with lampblack. The footprints
thus obtained show, in such cases, that the inner border of the
foot is completely sagged down and that the foot is resting on
the ground over the entire extent of the sole and not on its three
normal pillars — posterior (os calcis), anterior (toes), and ex-
ternal (outer border of the foot).

(e) In this essential examination of the bony framework the
spinal column, particularly in its dorsolumbar region, should not
be neglected. This step in the examination is made necessary
chiefly by the possibility of Pott's disease:



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LOWER EXTREMITIES, PAIN IN. 1155

Whether the case be that of a child with unsteadiness of gait,
weakness of the legs, more or less definite pains in the lower
extremities, and impairment of general health ;

Whether it be that of a subject whose parents have them-
selves detected a lateral deviation of the spinal column giving
rise to pain ;

Or whether, especially in an adult complaining of pain, an
abscess pointing in the inguinal region brings definitely to light
a Pott's disease which careful examination of the spinal column
by inspection, percussion, motion, and fluoroscopy might have
disclosed many months before.

(/) Lastly, one should bear in mind the rare possibility of an
incipient osteomalacia, which would later be confirmed by charac-
teristic deformities, with exaggeration of the normal curves of the
bones, disordered locomotion, and pain on walking, becoming
fatigued, or local pressure.

II. The Joints. — It will not be necessary here to review all the
possible causes of joint pains, a special section having already been
included on thisi subject (see Joint pains). Systematic examina-
tion by inspection, palpation, mobilization, and if necessary fluoros-
copy, will in the first place locate the pain in one of the joints of
the extremity. The special features of the joint disturbance, the
history, onset, course, and simultaneous presence of other abnormal
conditions will, as a rule, lead quickly to classification of the dis-
order in one of the following groups : Acute articular rheumatism,
gonorrheal rheumatism, post-infectious rheumatism (scarlatinal,
typhoid, etc.), or rheumatism due to some metabolic disorder
(gout, arthritis deformans, etc.). Too much stress cannot be laid,
here as elsewhere, upon the advisability of examining the seat of
pain carefully and by direct inspection, of palpating and passively
moving it, in short, of locating with care the pain and the seat of
pathologic change, of precisely determining its nature, if possible,
and of not resting content with the vague term "rheumatism,"
which is just as devoid of true diagnostic meaning as "headache"
or "pain in the side."

Some joint involvements exhibit a rather pronounced selective
tendency.



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1156 SYMPTOMS,

Gout very frequently occurs in the joints of the great toe (meta-
tarsophalangeal joints).

Acute rheumatism of the lower extremities is located in the
knees in four cases out of five. The same is true of gonorrheal
arthritis.



Fig. 809.— Bilateral tabetic knee-Joints. (Glorieux and Van
Gehuchten, Revue neurologique, 1895).

Tuberculosis involves almost indifferently any of the joints;
yet its predilection for the knee (white swelling) and the hip
(coxalgia) is well known.

Malum cox(V senilis, the pathogenesis of which is as yet ob-
scure, involves, as the term implies, the hip in elderly subjects.

Nor should one forget the characteristic tabetic or Charcot
joints, with the attendant marked deformity, extreme laxity of the



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LOWER EXTREMITIES, PAIN IN. II57

involved joints and painlessness. If the condition is only kept in
mind, the diagnosis can be made by observation of the other indi-
cations of tabes — specific history, reflex disturbances (Argyll-
Robertson pupil), loss of the patellar reflex, etc.; astasia, abasia,
ataxia, lightning pains, sphincter disturbances, etc.

III. The Muscles. — Disorders of the muscles, tendons, and
serous membranes, occurring, respectively, in the form of myo-
sitis, tenositis, and bursitis, constitute possible localizations of
rather indefinite painful processes the origin of which may be
that described by Le Gendre, vie, "a defective functioning of the
locomotor apparatus either through lack of activity (sedentary
mode of life) or through excessive activity (overstrain)," which
renders it sensitive particularly to cosmic [meteorologic] influ-
ences that are normally not felt.

Mention may here be made of the myalgias, often accom-
panied by arthralgias without objective manifestations, which,
attended with an apparent typhoid state with sudden onset and
albuminuria, frequently features the first or preicteric stage of
primary infectious jaundice (hemorrhagic spirochetosis). Such
pains may dominate the clinical picture sufficiently to mislead an
inexperienced practitioner. Thus, the author saw a fatal case of
primary infectious jaundice which was admitted tp a hospital on
the third day of the illness with a diagnosis of ** rheumatism."
The patient, indeed, complained almost exclusively of pain and
cramps in the thighs and a feeling in the knees as of constriction
in a vice, without any redness or swelling but with a temperature
of 40° C, a pulse rate of 136, albuminuria, a small liver, and
incipient jaundice. This case succumbed in ten days with the
complete clinical picture of grave primary infectious jaundice —
small liver, progressive jaundice, albuminuria, hemorrhages, and
increasing hypothermia. The pains in the muscles subsided as the
jaundice grew more marked. A few spirochetes were found in the
blood and the urine.

To complete the enumeration, mention may be made of the
painful muscular spasms of nervous diseases, of tetanus, etc.

IV. The Veins. — Inflammations of the veins play a far more
important role in pain in the lower extremities than they do in the



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1158 SYMPTOMS.



case of pain of the upper limbs. Here phlebitis is much more
common, being either of chronic nature, as in chronic degenerative
phlebitis (varicose veins) or ck:ute or subacute infectious phlebitis.



^* Superior

mesent.
plexus



gf Inferior

mesent.
plexus

Hy



moid
(xure



sclati



idder



Fig. 810. — Lumbosacral and hypogastric plexuses in the male
(sources of the sciatic nerve) {Hirschfeld).

the latter especially post-infectious, post-operative or puerperal in
origin. The diagnosis of the condition is, as a rule, easy. The
mere finding of dilated veins, which in the chronic forms are par-
ticularly prominent with the patient in the standing posture, the
observation upon palpation of phlebosclerosis and frequently of



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LOWER EXTREMITIES, PAIN IN. 1159

induration around the vein, and the presence of trophic changes of
the skin lead to the proper diagnosis in chronic forms. In acute
and subacute phlebitis, the history (as of infection, a surgical pro-
cedure, or parturition), the fever, edema, special sensitiveness



1st saci
gangli



Hypogaatric
plexus



Great
sciatic
nenre

Visceral
nenres



Uterine
plexus



Fig. 811.— Lumbosacral and hypogastric plexuses in the female
(sources of the sciatic nerve) (Hirschfeld).

along the course of the vein, and sometimes the finding of a hard,
cord-like vein insure recognition of the existing disorder.

V. The Arteries. — Pain attending disease of the arteries in
the lower extremities is not of very frequent occurrence, but
when present is very obstinate. It is the result of arteritis of the
femoral or of the tibial or peroneal vessels. Arteriosclerosis,



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1160 SYMPTOMS.

gout, specific disease, and infections, especially typhoid fever, are
by far the most frequent causes — in fact, the only oties met with
in the author's experience.

As serviceable diagnostic indications of such a condition the
following features may be mentioned :

A distinct difference of blood-pressure in the two limbs ; grad-
ual diminution of the beats below the involved portion of the
artery; intermittent claudication (in the chronic forms) ; lowered
local temperature of the affected limb ; coldness and pallor ; some-
times, where the vascular distribution from a certain trunk is
actually obliterated and no collateral circulation forms, hypo-
thermia, vasomotor disturbances, and cyanosis occur and are fol-
lowed by the appearance of areas of necrosis of varying extent,
which may later result in mutilation of the part.

VI. The Nerves. — The sciatic nerve is the one by far the most
frequently involved in the lower extremities. One should remember
that the course of the sciatic nerve comprises a spinal portion, origi-
nating in the anterior branches of the last two lumbar and first four
sacral nerves; a pelvic portion, in which the sacral plexus, formed
by the convergence and subsequent fusion of the foregoing nerve-
roots, enters into direct or indirect anatomical relationship with
nearly all the pelvic organs; a gluteal portion, beginning at the
great sacro-sciatic notch, from which the single, combined trunk
of the sciatic issues at the gluteal fold, being ensconced in this
region in a musculo-osseous recess bounded within by the
ischium and externally by the greater trochanter; a deep, intra-
muscular femoral portion, in which the nerve is lodged in a ver-
tical muscular trough bounded externally by the long head of the
triceps and internally by the semitendinosus and semimembran-
osus, and finally, a terminal portion, in which it divides, four
fingerbreadths above the plane of the tibiofemoral joint, into its
two terminal branches, the external popliteal nerve, which, after
having passed around the external condyle of the femur and the
inner surface of the head of the fibula, continues through the
thickness of the peroneus longus and along the external and dor-
sal aspects of the foot, and the internal popliteal nerve, which
crosses the popliteal space obliquely, passes above the soleus



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LOWER EXTREMITIES, PAIN IN.



1161



(posterior tibial nerve) and extends to the plantar surface of the
foot, nearly the whole of which is innervated by it.

Brief reference to these anatomic facts was necessary because:



Sup. gluteal nerye
Nerve to pyriformla
Inf. gluteal nerye |

Post, cutaneous ner

Post, cutaneous neri^
of the thigh



Inf. gluteal nerye
Sciatic nerye



Nerve to semitendinosui



Nerve to semimem- J
branosus ]



Nenre to semitendinosui



Nerve to short head of
biceps



^erve to long head of
biceps



, popliteal nerve



Int. popliteal ner



Nerve to int. gastrc
nenoiius



;>opliteal nerve
to plantarls

to ext. gastroc-
us



Ext saphenous e



Fig. 812.— The greater sciatic nerve (Sappey). The small sciatic nerve
consists of the two small trunks designated above as the inferior gluteal
nerve and the posterior cutaneous nerve of the thigh.

1. The sciatic nerve must be investigated in every portion of
its course, from the lumbosacral vertebrae to the os calcis and the
sole of the foot. There are certain points which, on account of
their regional anatomic relationships, lend themselves especially
well to examination and the eliciting of tenderness. Valleix made
a special study of these elective points, whence the designation



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1162



SYMPTOMS.



"Valleix^s points" which has remained attached to them. These

points are shown in the annexed diagram.

Mention should be made of Lasegue's well-known, simple and



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 33 of 50)