Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

. (page 34 of 50)
Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 34 of 50)
Font size
QR-code for this ebook


rapid maneuver, which consists in flexing the
thigh on the pelvis with the leg extended.
During this procedure the sciatic nerve, after
running a practically straight course with the
limb in complete extension, is forced into a
sharp curve in its gluteal course by the flexion
of the limb, and is thereby stretched like a
violin string when the bridge is raised into
position. The resulting tension at once excites
a characteristic pain along the nerve in the
presence of sciatica.

Lasegue's test is merely the simplest and
most commonly used of the various pro-
cedures of stretching the sciatic, which brings
on pain where there is disorder of the nerve.
It is plain that any form of motion, whether
active or passive, which causes stretching will
excite the same sort of pain or a character-
istic posture of the limb having for its pur-
pose to obviate the stretching of the nerve.
When the patient is standing and is asked to
pick up an object from the floor, keeping the
legs extended on the thighs, he will in-
stinctively and necessarily flex the involved
limb or move it backward in order to avoid
tension on the nerve.

When the patient is recumbent and is re-
quested to sit up, keeping his legs straight, he
will similarly, and for the same reason, flex
the affected limb (Sicard's ^'raised knee
V 11 • ' ^^9^")* thus exhibiting what appears as a

points on the poste- unilateral Kemig sign (G. Roussy).

rior aspect of the 2. The origin of the nerve pain may be at

lower extremity, and j^^^ ^^ ^^^ ^^^^^ ^^ ^j^^ ^^^^

their relationship to _ ^

the bony skeleton. The whole course of the nerve should be



Digitized by



Google



LOWER EXTREMITIES, PAIN IN. 1163

examined just as carefully to discover the cause as from the
symptomatic standpoint

Along the spinal portion of the sciatic bony changes should
especially be looked for, vis., Pott's disease, exostoses, spondylitis,
gumma, or cancer of the vertebrae ; and likewise meningeal disturb-
ances, such as acute or chronic meningomyelitis or the common con-
dition termed meningeal hyperemia. An undemonstrable, but
seemingly probable and frequent cause, judging from the percent-
age of cases in which the author found it and the therapeutic efficacy



Fig. 814. — ^Left-sided sciatica. Forward bending of the body is possible
only if the knee of the affected side is flexed (G. Roussy).

of hamamelis in large doses, is intraspinal venous hyperemia or the
"intraspinal varicose state," causing pressure upon and strangula-
tion of the nerve-roots upon their emergence from the bone (see
Lumbar pain).

Along the pelvic portion of the sciatic, disorders of the rectum,
prostate, bladder, Fallopian tubes and ovaries, and uterus may
be and frequently are the source of sciatic neuralgia or neuritis
through one of the four following factors: 1. Pressure, as by
primary new growths or secondary glandular enlargements. 2.
Hyperemia, as in inflammatory pelvic congestion or acute con-
gestion of hemorrhoids. 3. Reflex irritation from a remote struc-
ture, as in urethritis or orchitis. 4. Direct involvement in malig-
nancy or inflammation, as in tumor of the rectum or uterus.



Digitized by



Google



1164 SYMPTOMS.

From the above considerations the importance of a systematic
examination of the pelvic structures in the presence of sciatica
will readily be seen.

Along the femoral portion of the nerve, in the buttock, the con-
ditions oftenest met with as exciting causes of sciatica are trauma-
tism (falls, sudden impacts or blows) and coxofemoral arthritis and
periarthritis. In the femoral region a special search should be made
for factors resulting in compression, chiefly by bone, such as osteo-
periostitis, gumma, and osteosarcoma; in the popliteal space, the



Fig. 815. — Right-sided sciatica. In some instances, when the body
is being bent forward, the patient spontaneously tilts the affected lower
limb backward (G. Roussy),

commonest exciting causes are crypts, aneurysm, and fungous joint
inflammation.

Where, however, all these local causes of neuralgia and neu-
ritis can be excluded, an inquiry should be made for general
causes, some of which are still rather obscure :

Neuralgia a f rigor e (following exposure to cold).

Rheumatic (?) neuralgia.

Diathetic neuralgia ; diabetes should be remembered as a fre-
quent cause of obstinate sciatica.

Post-infectious neuralgia.

Toxic neuralgia; in this connection special attention should be
paid to alcoholism, with the attendant diffuse pains, lack of febrile



Digitized by



Google



LOWER EXTREMITIES, PAIN IN. 1165

temperature, absence of local inflammation and of signs of tabes
dorsalis, and sometimes the steppage gait in an inveterate alcoholic.

If still nothing can be found, the condition may be labelled
a simple, primary, or idiopathic sciatica, the physician thus
escaping the necessity of committing himself concerning the
actual nature of the disturbance.

It is plain that, apart from symptomatic, palliative treatment
of the neuralgia, which, indeed, is frequently all that is required,
an accurate causal diagnosis can alone supply a reliable basis for
curative treatment.



Fig. 816.— Right-sided sciatica. The patient, when in the sitting position,
is unable to extend the aflFected limb completely (G. Roussy).

One should always carefully examine for muscular atrophy
and electric reactions, which afford a distinction between neu-
ralgic sciatica, ordinarily a mild condition, and neuritic sciatica,
which is always serious and sometimes incurable.



The lumbar plexus, formed by anastomoses of the anterior
divisions of the last four lumbar nerves, and its branches — the
ilio-hypogastric, ilio-inguinal, external cutaneous, genito-crural,
obturator, and especially, the anterior crural — is, apparently, much
less frequently affected than the sdatic. Yet lumboabdofninal neur-



Digitized by



Google



1166 SYMPTOMS.

algia with its painful points (lumbar, iliac, abdominal and scrotal),
frequently encountered in pyelonephritic disorders ; external cutane-
ous neuralgia with its superior interiliac painful point, and especially
anterior crural neuralgiCy with its painful points dispersed along
the anterointernal aspect of the thigh, leg, and foot (tender points in



Qi



12th doraal

2d lumbar

3d lumbar

4th lumbar
Bxte:

Genlto-crural

Lumbosacral trunk
^ Sacral plexus



Fig. 817. — The lumbar plexus.

the inguinal region, the crural region, over the internal condyle, the
internal malleolus and the inner margin of the foot) are not very
uncommon, particularly that last mentioned.

Lumboabdominal neuralgia, as we have just seen, 15 an almost
constant clinical appurtenance of many pyelonephritic infections,
especially renal colic.

In anterior crural neuralgia a special examination should be
made for Pott's disease, psoas inflammation, appendicitis, typh-
litis, inguinal and femoral hernia, and in a general way for affec-



Digitized by



Google



LOWER EXTREMITIES, PAIN IN, 1167

tions in the pelvis, especially those involving the Fallopian tubes
or the ovaries.

Lastly, mention should be made of the lightning pains of tabes
dorsalis, exhibiting definite features in their paroxysmal occurrence,
lancinating, fulgurant, and boring character, but the diagnosis of
which should, in short, be based mainly on the major symptom-
group of tabes, vis,, specific history; reflex disturbances, such as



Transve

ntervertehral
oramina



Articulai



Fig. 818. — Relations of the intervertebral foramina of the lower lumbar
region with the lumbar spinal ganglia.

loss of the patellar reflex and the Argyll-Robertson pupil ; disturb-
ances of station and equilibrium (astasia), disturbances of motion
(ataxia), sphincter disturbances, etc.



In a striking synthetic study concerning cases of neurodocitis
and vertebral funiculitis, Sicard (Presse med., Jan. 7, 1918), gave a
good general account and excellent anatomic classification of the
changes occurring in the spinal nerves from their point of issue in
the spinal cord to their rearrangement in separate fascicular groups.
A good diagram condensing the essential facts in this connection
seems adequate at this point. Neurodocitis is a general term desig-



Digitized by



Google



1168 SYMPTOMS,

nating the changes resulting from compression of certain nerve-
trunks in the natural osseous,, fibro-osseous, or fascial canals. The
word funiculitis is here taken to signify a neurodocitis of the tis-
sues surrounding the intervertebral foramina.

Ordinary sciatic neuralgia is either a neurodocitis resulting
trom compression of the nerve at the great sacrosciatic notch, in



sma/f htanehes

Fig. 819. — ^The several sections of the nerve paths from the spinal
cord to the periphery. Ordinary sciatica is a funiculitis at the inter-
vertebral foramen.

the ischiotrochanteric space, or on the outer aspect of the fibula,
or a funiculitis of the intervertebral foramen of rheumatic, gouty,
or arthritic origin.

True lumbago is a bilateral rheumatic funiculitis involving the
2d, 3d, and 4th lumbar nerves.

Syphilis usually causes radiculitis and myelitis, while tuber-
culosis and cancer oftenest lead to funiculitis.



Digitized by



Google



LOl^BR EXTREMITIES, PAIN IN. 1169

However long and tedious the preceding enumeration may
have been, it constitutes only an incomplete list of the local dis-
orders; yet it includes the majority, at least, of the painful con-
ditions met with in the lower extremities. (In addition there are
to be thought of such discomforts as may arise from tight leggings,
corns, perforating ulcers, ill-fitting footwear, abscesses, lymph-
angitis, suppurative processes and the corresponding glandular
enlargements, etc. — all self-evident local disorders.)

As a parting piece of counsel, it may be stated that whatever
variety of pain in the lower extremity is complained of, one
should never fail to examine :

(a) The spinal column.

(b) The hip joint

(c) The region of the appendix,
(rf) The kidney region.

(e) The urine.



74



Digitized by



Google



LUMBAR PAIN.
BACKACHE.



Few symptoms are so frequently misinterpretea as lumbar
pain, backache, or, as popularly termed, **kidney pains." The



bar muBcles
HUB dorsl
mediuB

maxlmus



Fig. 820. — Lumbar musculature. The spinal muscles on the side
opposite to that of flexion are in contraction. The transverse folds of
skin over the spinal muscles on the relaxed side are readily seen (P.
Desfosses),

author has f)ersonally seen — ^an instance almost unbelievable, yet
absolutely authentic — a case of ordinary lumbago labelled Bright's
disease (needless to state, examination showed neither albumin,
casts, high pressure, nor any increase in blood urea), and con-

(1170)



Digitized by



Google



LUMBAR PAIN. BACKACHE. 1171

versely, an obvious case of Pott's disease of the lower dorsal
region with abscess formation, labelled lumbago.

Such mistakes may be accounted for in many ways.

First and foremost is the unfortunate habit of not examining
the painful region directly and by inspection. Only exception-
ally, indeed, is the lumbar region actually subjected to a sys-
tematic examination in a patient complaining of "kidney pains."



laliB colli
lUocoBtalis cerrl Icalla descendens



Longisslmus dors!

Sacrolumbal is
niocofltalis dorsl

Spdnalis dorai



lumbalis
niocofltalis lumb<

inaliB



Fig. 821. — ^The spinal muscles.

As a matter of fact, there are few regions of the body that de-
mand a more thorough and systematic local examination, since
very few regions exhibit painful manifestations originating in
such diverse and variously situated disturbances. While one
of the anatomic peculiarities of the region is the pres-
ence of the thick sacrolumbar masses of muscular tissue, which
act, to all" intents and purposes, as the muscles governing the
erect posture and are so frequently rendered painful by the most
varied pathologic states, the following regional anatomic divi-
sions should be kept in mind :

1. Muscular region : The sacrolumbar mass of muscle tissue.
* 2. The bony spine and the sacroiliac joints.



Digitized by



Google



1172 SYMPTOMS.

3. The spinal cord and nervous system.

4. Paravertebral organs : The aorta and lymphatic structures.

5. The abdominal viscera, including especially the kidneys,
spleen, liver, colon, and uterus.

When a patient comes complaining of "kidney pains" or back-
ache, the lumbar region should be exposed and a systematic ex-
amination of the structures above enumerated proceeded with.

1. The skin. — This is sometimes the seat of herpes zoster
(zona) covering a varying extent of surface.



dominis
Peritoneum

Small IntesUne '"» extemus

Iquus Internus

Abdominal i ransversalis

Inferior vena

> Psoas

Right kidney
Lumbar vertebra "(covered with

peritoneum
Spinal coi anterioriy)

scending colon

IratuB lumborum



Longisslmus dor

Spinal «'""" «°

-lumbalis



Fig. 822. — Transverse section through the lumbar region.

2. The sacrolumbar muscular system. — Palpation and inspec-
tion with the patient in various positions, especially the erect
posture, together with movements of anteflexion, extension, tor-
sion, and lateral bending will often lead to the discovery that the
seat of pain is actually in the muscle tissue, the condition being
a true lumbar muscular pain for which, seemingly, the term lum-
bago should be set apart, but which may yet be encountered
under very variable clinical circumstances, to wit :

(a) Acute lumbago, following a forceful straightening of the
flexed body, as in lifting a heavy v/eight, such as a trunk.

(&) Subacute lumbago, following a prolonged march, with
fatigue and exhaustion. This represents a "forcing^* of the
muscle, which becomes painful because of overwork, — a tondi-



Digitized by



Google



LUMBAR PAIN. BACKACHE, 1173

tion that might without impropriety be placed in the group of
**rheumatic disturbances the result of defective functioning of
the locomotor apparatus," masterfully described by Le Gendre.^
Undoubtedly there occurs, moreover, an acute or subacute lum-
bago of rheumatic origin which is very favorably influenced by
sodium salicylate.



Fig. 823. — Posterior relations of the kidneys. On the left side is seen
the main mass of spinal muscle (shaded), and projecting beyond it below,
the quadratus lumborum. On the right side the main spinal muscle
mass has been removed, exposing the quadratus lumborum and the lum-
bocostal ligament.

(f ) Subacute or chronic lumbago of psychoneurotic cases, ap-
parently the local clinical expression of an actual constitutional neu-
romuscular asthenia, and which may occur either as: 1. A localized
pain constituting an actual topoalgia. 2. A regional dysesthesia, with
morbid sensations of pressure, of sharp, fleeting pains, of heat, or of
cold, frequently with abnormal sensitiveness of the region to pal-



iLeGendre: Acad, de med., May 9, 1911.



Digitized by



Google



1174



SYMPTOMS,



pation, the whole constituting a vague neuromuscular syndrome. 3.
Deep pain, weakness, and exhaustion with lumbar muscle pains fol-
lowing strong emotional impressions; an actual paroxysmal emo-
tional lumbago superimposed upon a chronic psychoneurotic lum-
bago attending habitual asthenia.

The absence of definite local lesions, the history, the neurotic
stigmata, the habitual psychasthenia, the chronic course of the
morbid manifestations, and their recrudescence after emotional





Figs. 824 and 825. — Osteospondylitis of the vertebrse.

impressions are the most reliable diagnostic features of these
cases.

3. The spinal column, and more particularly the lumbar verte-
brae, with which we are here especially concerned, may be the seat
of many pathologic conditions causing lumbar pain.

(a) First and foremost should be placed the chronic inflamma-
tory states- or spondylitis of the vertebrae, their periosteum, and the
intervertebral joints, leading to the exostoses, adhesions, and anky-
loses frequently encountered in sedentary individuals after the
fourth decade of life. Some rough sketches illustrating these con-
ditions are presented herewith. Such instances of spondylitis are
met with among all the usual cases of arthritis deformans, and post-
infectious rheumatism, e,g,, after pneumonia, tonsillitis, typhoid



Digitized by



Google



LUMBAR PAIN, BACKACHE,



1175



fever, etc. The condition is, in short, a vertebral osteoarthritis, or
a deforming or post-infectious lumbarthritis. Nor is post-traumatic
spondylitis a rare affection.

The limitation of motion, the stiffness in the lumbar region, the
pain induced in the lumbar spine by flexion or torsion of the body,
the cracking sensations experienced by the patients themselves, the
chronic or subacute course of the disorder, the history, and espe-
cially the x-ray examination, will lead to the diagnosis.^ The dis-
order particularly to be excluded in these cases is Pott's disease.

(b) Pott's disease, the recognized evidences of which need
here scarcely be recalled: Localized pain, most marked in one
vertebra ; radiation of pain to the lower extremities ; cessation of
pain upon rest in recumbency and immobilization of the affected
region ; and ultimately, angular deformity at the point of involve-
ment and paretic disturbances of the sphincters and lower extremi-
ties, with exaggerated reflexes, abscess formation, etc.

Pott's disease should always be thought of in the presence of
chrdnic lumbar pain,

(r) Diac and sacroiliac osteoarthritis, the location of which
is determined by careful palpation.



1 Beclere, quoted by Leri (Presse nUd,, Feb. 28, 1918), had already pub-
lished in 1906 the following differential table relating to chronic rheumatism
of the vertebrae and rhizomelic spondylosis :



1. Chronic vertebral rheumatism.

First feature: Distortion of the
bodies of the vertebra consisting of
a broadening of the upper and lower
surfaces and exaggeration of the
circular concavity.

Second feature: The interver-
tebral discs are distinctly more
transparent than the bodies.

Third feature: Little or no sug-
gestion of a vertical opaque band
corresponding to the ligaments is
present



2. Rhizomelic spondylosis.

First feature: No distortion of
the bodies of the vertebra, which
are almost cylindrical in shape.



Second feature: The discs are
not more transparent than the
bodies.

Third feature: Both the bodies
and discs are covered by a broad
band with parallel borders; the
outermost portions of the verte-
bral bodies project beyond this
band; the processes of the verte-
bra exhibit a remarkable and un-
usual degree of transparency.



Digitized by



Google



1176 SYMPTOMS.

4. Inflammatory conditions of the spinal cord and vertebral
column cause well-known forms of backache. They are met with
chiefly in the following disorders.

(a) In acute meningomyelitis (acute meningitis; cerebro-
spinal meningitis), the diagnosis of which is based on the simul-
taneous presence of constitutional signs of infection, such as
fever and leucocytosis, in conjunction with the meningeal symp-
tom-group (headache, backache, Kemig's sign, etc.), and is con-
firmed by examination of the cerebrospinal fluid, showing an ex-
cess of lymphocytes or polynuclears, the presence of meningo-
cocci, etc.

(6) The onset of many infectious diseases, particularly influ-
enza, smallpox, and pneumonia, is, as is well known, frequently
marked by extremely severe backache. Examination of a num-
ber of specimens of cerebrospinal fluid obtained under these con-
ditions led to the surmise that the beginning of these disorders
is often accompanied by a sharp but temporary meningeal con-
gestion, which later passes off along with the backache which
is its clinical manifestation.

(c) Mention may here be made of an expression used in military
medicine, ins,, backache with fever {courbaiure febrile) — on the
whole a rather happy expression since it combines both the symp-
toms, backache and fever, which feature the clinical state to which
it refers. Unquestionably this term comprises a number of diflFerent
conditions and careful investigation would lead frequently to the
discovery of cases of "incomplete" paraityphoid or even typhoid
cases. On the other hand, it is certainly true that if the clinical
entities now recognized are eliminated from it there remains a large
percentage of undetermined, cryptogenic infections, usually tran-
sient and mild, but for which an accurate designation would be
hard to find.

(rf) The same sort of a sharp, temporary meningeal reaction
with backache and fever has been noted by the author in certain
cases of secondary syphilis running an acute, febrile course.

{e) The author has been led to consider as symptomatic of
venous congestion of the spinal and perispinal plexuses certain in-
stances of chronic lumbago in subjects suflFering from hemorrhoids,
with high venous pressure and low arterial pressure, the lumbar pain



Digitized by



Google



LUMBAR PAIN, BACKACHE. 1177

showing daily, almost periodic exacerbations; these cases were, as
a matter of fact, greatly relieved by counterirritation with fly blisters
and wet cupping over the lumbar region and medication directed
toward overcoming the venous congestion, vis., adrenalin, strych-
nine, and hamamelis. This condition must play an important role
in the lumbago of psychoneurotic subjects.



Lateral ant.
plexus

ant



irse

lexus iBverae

. plexus



us of the

jrvert

unen



iteral ant.
lexuB



Figs. 826 and 827. — Intraspinal venous plexuses.

(/) Lastly, it should not be forgotten that the spontaneous or
artificially induced pain in some cases of sciaticalgia may ascend
above the great sacrosciatic notch to the vicinity of the sacroiliac
joint or of the transverse processes of the lumbar vertebrae and the
lumbosacral masses of muscle tissue.

Examination for Lasegue's sign is of the greatest service in
these cases.

In the frequent instances of sciatica combined with kypho-
scoliosis or scoliosis, hyperesthesia and hyperkinesia of the lum-



Digitized by



Google



1178 SYMPTOMS,

bosacral muscular mass are constantly present. It is noteworthy,
however, that this hyperesthesia and hyperkinesia are in some
instances homologous {i.e., present on the same side as the sciatic
pain), while in others they are on the opposite side; no reliable
explanation of this fact can at present be vouchsafed.

This peculiarity is of importance in the exposure of maling-
erers. Where, in conjunction with the symptoms of sciatica,
there is noted spontaneous or induced hyperesthesia of the lum-
bar region on the opposite side, one may aimost certainly, unless



Fig. 828. — Diploic veins in the body of a vertebra.

the subject is thoroughly familiar with the clinical features of
sciatica, exclude the possibility of malingering.

5. The popular exp-ression "pain in the kidneys" correctly
suggests the anatomic relationships of the kidneys to the lumbar
regions. It is an actual fact that many renal disorders are accom-
panied by lumbar pain, the following succinct description of
which is borrowed from Cathelin :

"The first indication of reno-ureteral affections which plays
a predominant role in the patient's own estimation is pain, which
may be either spontaneous or artificially brought on by motion
or by pressure in the costovertebral angle, particularly at the
apex of this angle. It is seldom present anteriorly, yet radiates
either in the direction of the ureter obliquely downward and in-



Digitized by



Google



LUMBAR PAIN, BACKACHE, 1179

ward or along the iliohypogastric and ilioinguinal nerves, extend-
ing around the body.

**In other instances, it radiates even to the neck of the bladder
or the spermatic cord, as in stone, a fact accounted for by the
existence of the genital fibers of the ilioinguinal nerve.

"The pain may be located sympathetically (Guyon's reno-renal
reflex) in the opposite kidney, thus bringing in a disturbing factor
in the interpretation of the case. A patient with a stone in the right
kidney often experiences pain in the left kidney. The same sort of
thing is observed in renal congestion.

**The pain may be either slight, dull, and deep-seated or occur
in paroxysms introducing the symptom-group of renal colic (hydro-
nephrosis) or of nephritic colic (descent of a stone) ; while gen-
erally wanting in nephritis, in cancer, and in some common forms



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 34 of 50)