Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

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case of leukoplakia, to be next discussed, the distinction to be
made from syphilitic glossitis is most difficult, and how many derma-
tologists have — as of yore in connection with tabes and general
paralysis — used the phrase **parasyphilitic manifestation" in this
connection? The "What do I know?" attitude of Montaigne is
alone justifiable at the present time.

5. Leukoplakia buccalis appears in the form of amorphous,
pearl-white, patches on the tongue, without any special marginal
band; the patches are irregularly dispersed, thin, bluish, trans-
lucent, discrete at first, and show an almost invincible tendency
to extend, thicken, and undergo hardening, with resulting for-
mation of whitish, thick, adherent patches, which become fissured
and cracked through desquamation. Such patches may also be
observed on the mucous membrane of the lips and on the inner
surface of the cheeks.

Syphilis is noted in a very grtat many of these cases, and it
seems likely that a large number of leukoplakias are of syphilitic
origin. Yet such exciting, provocative, or predisposing causes as
tobacco (nicotinic leukoplakia), traumatism (dental leukoplakia,
with dental caries or poorly made dentures), neuroarthritism
(irritative neuroarthritic leukoplakia of Brocq), etc., play a role
in their production which is not negligible.

The marked clinical interest of leukoplakia resides in its rela-
tionship to syphilitic glossitis and the possibility of the occur-
rence in it of epitheliomatous degeneration.



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TONGUE, DIAGNOSTIC FEATURES. 1301

Brocq, with his usual ability, discussed this question, which
is of prime clinical importance, in 1919.^ The following three
points are worth quoting here:

(a) There occurs a buccal lichen planus which is sometimes
hard to distinguish from other conditions. It is marked by the
presence, on the inner aspect of the cheeks, of white striae exhibiting
occasional small nodular elevations; on the tongue one observes
instead opalescent spots, which coalesce to form more extensive
patches.

(&) Leukoplakia nearly always develops on a syphilitic substrate,
but not always. Non-syphilitic leukoplakic^ do occur.

These two propositions are of marked practical import, for
while they justify antisyphilitic treatment in the majority of
cases, they condemn the blind tendency to institute intensive and
repeated antisyphilitic treatments in all persons with ordinary
white patches. In playing the part of the wise and well-versed
clinician, it is well to make a careful diagnosis in these cases
(discrimination from lichen planus, or syphilis — manifest, prob-
able, or non-existent) and to act accordingly as regards treat-
ment.

(c) It is certain that many leukoplakias undergo epitheliomatous
degeneration. "Yet, many subjects harboring leukoplakial patches
do not show degeneration of the disorder into cancer; such degener-
ation of the disorder is even relatively rare when the patients,
warned in good time, carry out and persistently continue all the
required hygienic measures." (Brocq, loc. cit.)

6. Syphilitic glossitis is of greater importance in the adult
than any of the preceding varieties. It is well established, to be
sure, that the majority of instances of leukoplakia and a few in-
stances of marginal exfoliative glossitis are syphilitic.

Syphilis may yield lingual manifestations in any of its stages :
Primary (chantre of the tongue) ; secondary (various forms of
secondary glossitis, mucous patches) ; tertiary (gummas, tertiary
syphilomas).

Some varieties are merely exudative and exfoliative, like the
majority of the secondary manifestations; others are tumor-



1 Brocq : Presse mid., May 22, 1919.



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1302 SYMPTOMS.

producing and ulcer-forming (gummas). They consequently oc-
cupy a border-line position in the didactic classification herein
followed. Yet they will be placed in the present group. They
serve for purposes of transition to the clinical cases of glossitis
associated with ulcers or tumor-formations.

Chancre of the tongue is relatively uncommon, representing
hardly more than 10 per cent, of the cephalic chancres. It is gen-
erally located at the tip of the tongue, and exhibits either an erosive,
papulo-erosive, or ulcerative character with diffuse induration. The
submaxillary lymph-glands are always and the sternoid mastoid
glands sometimes involved, and exhibit the usual features of pri-



Fig. 874. — Extensive gummatous Fig. 875. — Tertiary syphilitic scle-

ulceratiou of the tongue (Musee de rosis of the tongue (Musce de Saint-
Saint-Louis). Louis).

mary syphilitic glandular enlargements (one large node with sur-
rounding smaller nodes, practically painless; see Neck, glandular
enlargements in). The history of infectious contact, the examina-
tion for the spirochete, and eventually the appearance of the roseola
constitute, as always, the chief diagnostic factors.

Secondary lingual syphilides (mucous patches) are usually
discrete and demand a careful search. They occur in the form of
round or elliptical patches, of smooth "depapillated" appearance,
contrasting with the normal granular background of the lingual
mucous membrane.

Tertiary syphilides occur in two main clinical forms, 7^'c., the
sclerous and the gummatous, which in exceptional instances arc
combined in a mixed sclero-gummatous form.



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TONGUE, DIAGNOSTIC FEATURES. 1303

Gumma of the tongue may be superficial or deep. When
superficial, it causes local elevations of the dorsum in the form of
multiple small nodosities varying in size from a leaden shot to a
pea, and sometimes arranged in a horse-shoe-shaped figure. If
tuitreated, it softens and ulcerates, leaving a relatively deep, cyclic
or polycyclic ulcer with clear-cut margins. When deep, it is situated
in the midst of the muscles of the tongue, forming there a hard
node, nearly spheric or ovoid in shape, of hazelnut to walnut size,
painless, and unaccompanied by any glandular reaction. If allowed
to progress unopposed, it enlarges and involves the dorsal surface of
the tongue, softens, and ulcerates, discharging a characteristic
gummy fluid. This constitutes the deep tertiary syphilitic ulcer, with
punched out margins, discharging base, not bleeding, and unattended
with any glandular reaction unless infection or secondary degenera-
tion sets in.

Fibrous glossitis, like gumma, may be either superficial or
deep-seated.

When superficial, the cords and patches of fibrous tissue form
irregular islets of superficial induration, sometimes smooth, at
other times leucoplastic, the tongue at times assuming a stringy-
appearance owing to the presence of a network of shallow fissures
lined with fibrous tissue.

When deep-seated, they infiltrate the major portion of the
tongue, especially its anterior region, imparting to it a hard,
wood-like consistency. The simultaneous presence of large and
small knob-like elevations, lobulated, smooth, and devoid of papillae,
gives to the tongue an absolutely pathognomonic aspect (lingual
cirrhosis). Like gummatous glossitis, fibrous glossitis is not
accompanied by any secondary glandular enlargement and is
practically painless. These two features should never be over-
looked, as they are of capital diagnostic import.

III. A Tumor-like Enlargement is Present— In most instances
the patient first notices that certain movements of the tongiie are
somewhat hard to execute. Clinical examination thereupon re-
veals some abnormality in the size and consistency of the organ.

Brief reference may be made, as an altogether exceptional pos-
sibility, to cysts (either parasitic, glandular, or congenital), which



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1304 SYMPTOMS.

are very hard to diagnose. Unless an exploratory puncture is made,
there can be nothing more than a mere presumption of the presence
of a cyst, based on its fluid consistency — ^which is, however, not easy
to detect — and on the history. The same is true of the connective
tissue tumors, viz,, lipoma, fibroma, fibrosarcoma, and chondroma.

In the presence of a tumor-like enlargement of the tongue, the
chief possibilities which should come to the physician's mind are
syphiloma, epithelioma, tuberculoma, and actinomycosis.

Nothing more need be said concerning the syphilomas, the
customary features of which have already been briefly referred to
— gumma and fibrous glossitis, characterized by painlessness and
the absence o4 glandular enlargement.

The condition which has most often to be differentiated is
epithelioma. In theory such differentiation is easy. The epi-
thelial induration present shows a special consistency; it is
imperfectly circumscribed, having a tendency to infiltrate the
neighboring tissues ; it is attended with a varying degree of ten-
derness, or may cause actual pain ; the accompanying glandular
enlargement consists at first of small separate nodes, which roll
beneath the finger and coalesce only at a late stage of the dis-
order; finally, the condition occurs only in elderly subjects and
its tendency toward progressive extension to surrounding tissues
is manifest and obstinate. Nevertheless, the actual distinction of
certain hypertrophic forms of epithelioma of the tongue from
fibrous glossitis is sometimes a matter of great difficulty and
baffles even the most astute clinicians, particularly in view of
the fact that there occur mixed forms giving rise to a hybrid
cancerosyphilitic glossitis — a condition which has been carefully-
studied by Verneuil. The physician is thus easily induced to
institute the therapeutic test by brief but active administration
of potassium iodide and mercury or potassium iodide and arsenic-
als — a procedure which rapidly dissipates the disease if it is
syphilitic or, on the other hand, stimulates it temporarily to
greater activity if epithelioma is present

Tuberculomas, which are very uncommon in the tongue as
compared to the syphilomas and epitheliomas, appear usually
on the upper surface of the organ. They are sensitive or pain-
ful on pressure, engorgement of lymph-nodes is exceptional, the



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TONGUE, DIAGNOSTIC FEATURES. 1305

patient is always a tuberculous individual, and, if necessary, ex-
cision of a bit of the tumor tissue for examination and injection
of the diseased tissue into a guinea-pig will lead to recognition
of the presence of the tubercle bacillus.

Lingual actinomycosis may so resemble fibrogummatous
syphilis or a deep tuberculoma as to be readily mistaken for it.
If the condition is only thought of, however, the diagnosis may
be settled by exploratory puncture and examination on a slide
(with cover-slip) of the characteristic small yellow granules, sug-






Fig4 876. — Actinomycosis.

gesting powdered iodoform, which the fluid withdrawn allows
to settle on the walls of the tube into which it has been ex-
pressed. When stained witof the sensory
disturbances in complete section of the radial nerve. Black area:
Anesthesia to all stimuli except deep pricking, which is often felt as a
mere contact with the tissues. Gray area: Marked hyperesthesia to
pricking, anesthesia to heat, cold, and very superficial tactile stimuli.
Dotted area : Slight hypoesthesia to tactile stimuli and to heat and cold.
(Mtne. Benisty).

features consisting of a striking degree of deformity, extreme re-
laxation of the joint, and painlessness. If only the condition is kept
in mind, the diagnosis can be made by observation of the other
signs of tabes, vis., specific history, reflex disturbances (Argyll-
Robertson pupils and loss of knee-jerks), astasia, ataxia, lightning
pains, sphincter disturbances, etc.

Disorders of bones — osteitis, osteoperiostitis, osteoarthritis,
and osteomyelitis — are, in the order of their frequency :

Tuberculous: Periostitis and osteoarthritis (white swelling).

Syphilitic: Osteoperiostitis and gumma.



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1316 SYMPTOMS.

Post-infectious: Staphylococcic (osteomyelitis) .
Neoplastic : Osteosarcoma.

The following features will insure a proper diagnosis:
1. The history : Lymphatic diathesis, specific taint, infection
(typhoid fever or staphylococcic infection).



Superficial cenrlcal plexus



Circumflex



Intercostal branches*



External cutaneous/
Intercostohumeral .
Internal cutaneous]



Musculocutaneous/



Ulnar
Radial (external branch)

Median (palmar cutaneous branch)

Median (digital branches)
Ulnar (terminal superficial branch) •

Fig. 884. — Peripheral sensory distribution in the upper
extremity (anterior aspect).

2. Fever (generally wanting in syphilis and neoplasms).

3. Localization particularly around the joint in tuberculous
disease.

4. A rather sluggish clinical course in tuberculosis and
syphilis.

5. The nature of the pain, with nocturnal exacerbations in
syphilis.



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UPPER EXTREMITIES, PAIN IN,



1317



6. special tests such as the Wassermann reaction and the
successful therapeutic test (mercury and iodide) in syphilis.

Disorders of the muscles and serous surfaces, viz., myositis,
subacromial bursitis, and deltoid rheumatism, are possible localiza-
tions of rather poorly defined painful manifestations, the origin of
which, however, seems actually to be that mentioned by Le Gendre:
"Deficient functioning of the locomotor apparatus, either through
lack of exercise (sedentary mode of life) or through excessive mus-
cular labor." Such a deficiency through loss of functional balance.




Fig. 885.— Palm of the hand. ^ig. 886.— Dorsum of the hand.



EWstribution of the disturbances of sensation in severe injuries of
the median nerve. Black area: Complete anesthesia of all types. Gray
area: Hypoesthesia to pricking and anesthesia to heat and cold. Dot-
ted area: Less marked hypoesthesia.

''when it has been present in patients, necessarily places the various
component parts of the locomotor apparatus in a weakened state in
which it becomes susceptible to influences ordinarily not noticed by
well persons; these are the influences to which we are constantly
exposed, inc., the cosmic influences. Among these influences, the
best studied has been that of cold, which is even considered an
etiologic factor — especially damp cold and long-continued cold or
exposure.'*

The upper extremity may be, and manifestly is, the seat of
neuralgia and neuritis variously situated (e.g., ulnar, radial, or
median) and of varying cause: Traumatic (contusions, open sur-



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1318 SYMPTOMS.

faces and wounds), toxic (lead poisoning, alcohol, etc.), pressure
(osteoperiostitis, osteosarcoma, or defective callus of the humerus,
radial paralysis of lovers, etc.), and infections. Careful examina-
tion for local sensitiveness (see illustration showing the distribu-
tion of the sensory nerves), as well as of mobility (paralysis; see
illustration showing distribution of the motor nerve fibers) will
soon lead to discovery of the site of the lesion. The history and
even the location of the neuritis will frequently permit of tracing
the cause of the disturbance.

Lastly, mention may be made of vasomotor disturbances,
represented in the highest degree by Raynaud's disease (local
asphyxia of the extremities), and seemingly often of specific
origin, whether acquired, inherited, or secondary to a mitral
malformation.

Exceptionally, in particular among the Senegalese, there may be
noted evidences of leprosy of the nervous or anesthetic types, the
nerve symptoms being manifest in a prodromal stage by a monili-
form enlargement, frequently of considerable size, of the nerve
trunks, which are very sensitive to pressure; later, the pain, of
neuralgic t3rpe, is constant and spontaneous,* with repeated violent
paroxysms; it is accompanied by dysesthesias (itching, etc.) and by
vasomotor disturbances ("dead finger" sign), and ends in anes-
thesia, with trophic disorders, atrophy of muscles, and deformity.
These manifestations of leprosy exhibit great clinical analogy with
syringomyelia and with ''Morgan's disease'* or panaritium analgicum.

Pain in the arm occurring in the absence of any local lesion,
whether muscular, articular, 'osseous, nervous, or vascular, may
constitute the outward expression of remote lesions, the most im-
portant of which are :

(a) Aortic and periaortic lesions (radiation of the pains of
angina pectoris and aneurysm to the arm).

(fc) Certain *'high" forms of degeneration of the posterior
columns (lightning pains of cervical tabes).

(c) Lesions of the brachial plexus.

(d) Certain mediastinal tumors.

(a) The pain of angina and of aortic and periaortic disorders in
general is, as a rule, felt in the area of distribution of the fourth



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UPPER EXTREMITIES, PAIN IN. 1319

left dorsal nerve over the chest and arm. It may descend and
radiate as far as the epigastrium in the areas of distribution of the
fiftband sixth dorsal nerves. More often, however, it ascends and
radiates along the first, second, and third dorsal or even the seventh
and eighth cervical nerves, being felt, therefore, along the ulnar



Muscles Nerves Roots

Deltoid Circumflex C,* C.«

Fectoralls major Circumflex C,* C,« C.^

Triceps Musculosplr. C," CJ

Biceps MuBculocut. C,^ C*

Bracbialis ant Musculocut. C,' C."

Pronator teres Median C,« C'

Supinator longus Musculosplr. C,*^ C*

Ext. carpi rad. Musculosplr. C,* C
long, and brev.



Flexor carpi
rad.


Median


C c,» d:


Palmaris longus


Median


C,8 D.i


Flexor sublim.
dig.


Median


C,8 D.i


Flexor carpi
uln.


Ulnar


0,8 D.i


Thenar muscles


Median


c.« c.f


Hypothenar
muscles


Ulnar


C,« D.i



Fig. 887. — Nerve-supply of the muscles of the upper extremity
(anterior aspect).

border of the forearm and hand. This constitutes the typical area
of distribution of anginose pain, vie., precordial (mammillary), left
upper thoracic (axillary), and ulnar.

Exceptionally, the pain extends to the corresponding areas
on the right side (chiefly in cases with aortic dilatation) and to
the neck, including its posterior aspect (nuchal region).



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1320 SYMPTOMS.

Such pain is, as is well known, when present in conjunction with
a feeling of constriction of the chest (squeezing sensation or suffo-
cation) and a fear of impending death, the cardinal indication of
angina pectoris. It should always be borne in mind, however, that
many neuropathic states, whether or not based on some cardioaortic
disease, may lead to a syndrome of "anxiety neurosis" similar in all
respects to the anginose syndrome, yet far more favorable from the
standpoint of prognosis. For a discussion of the differential diag-



Fig. 888. — Distribution of the pain and cutaneous hyperalgesia after
repeated attacks of angina pectoris.

nosis in this connection the reader is referred to the section on
Precordial pain.

(b) Aortic aneurysm may cause pain in the arm of threefold
origin : \

1. Anginose pain of the type above described.

2. Neuralgic or neuritic pressure pain.

3. Pain due to stasis on account of pressure on venous trunks.
These pains may be of unbearable intensity and necessitate

the use of morphine. Oftea the clinical evidences, such as
aneurysmal swelling and signs of pressure on the veins (visible



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UPPER EXTREMITIES, PAIN IN. 1321

venous network in the superior caval area, swelling of the neck,
edema of the face, and inequality of the pulse on the two sides,
etc.), are obvious; fluoroscopic examination will remove all
doubt as to the condition present.

(c) The same is true in tumors of the medidstinum. The coex-
istence of pain in one or both upper extremities with evidences of
interference with the return circulation in the superior caval area
(cyanosis, visible superficial venous circulation, swelling of the neck
and face, prominence of the eyeballs, and facial edema) is almost
pathognomonic of mediastinal tumor, e.g., dilatation of the aorta,
pericarditis with effusion, enlarged lymphatic glands, etc.

((/) The pains of tabes, although much less common in the upper
than in the lower extremities — the latter constituting the site of
election — ^may occur as the usual "lightning pains," sharp, abrupt,
and fulgurant, like lightning. Sometimes they occur singly, at
others grouped in paroxysmal attacks of varying duration — from
one to several days. They are felt more particularly along the inner
border of the forearm and the fifth and fourth fingers. They may
be of the piercing, burning, lancinating type ; at times, however,
they are of the nature of a constriction, squeezing, or ring-like pain.
This special characteristic of the pains of tabes — ^though not an
exclusive attribute, since it may be met with likewise in peripheral
neuritis (due, e.g., to alcoholism or leprosy) and in pressure on
nerve-roots — is nevertheless, as a rule, highly suggestive. Let the
observer merely recollect the possibility of tabes — and how could he
fail to think of it in such cases? — and the diagnosis will bo quickly
confirmed by examination for the typical tabetic indications (specific
history, reflex disturbances, motor disturbances, visceral disturb-
ances, particularly genitourinary, etc.).



The foregoing review by no means exhausts the possibilities as
regards pain in the upper limbs. Various exceptional clinical con-
ditions, such as supernumerary cervical rib, poliomyelitis, etc., have
been designedly omitted in order not to make the present section too
unwieldy.

The same applies to abscesses, felons, lymphangitis, phlegmonous
inflammations, and the attendant glandular enlargements — all con-



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1322 SYMPTOMS.

ditions met with in everyday practice, but the diagnosis of which is
ordinarily devoid of difficulty and to which reference is here made
merely to call them to the reader's mind.

In conclusion, the hope may be expressed that the reader will
find lessi difficulty in reading and reflecting on this section than
the author experienced in writing it.



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VERTIGO. [Vertigo, frcm vertere, to ium.'\



Vertigo is characterized by a mistaken subjective sensation in
virtue of which the patient believes himself to be rotating al-
though he is motionless, or sees surrounding objects turning
about him although they are at rest. When vertigo is persistent
or very marked, it may induce loss of equilibrium and a fall to
the ground if the subject is in the standing position at the time.
It may be, and frequently is, attended with nausea, or even
vomiting, and by nystagmus or even deviation of the eyes.

The highly complex pathogenesis of this symptom seems, at the
present time, to be rather well condensed in the following definition
formulated by Grasset: Vertigo is the symptom of functional in-
sufficiency (intermittent claudication) of the automatic centers
(mesencephalic and cerebellar) of equilibration. Bonnier, as is well
known, has made a profound study of vertigo from the physio-
pathologic, clinical, and therapeutic standpoints.

These automatic mesencephalic and cerebellar centers of
equilibration:

1. Receive:

(a) Vestibular fibers coming from the semicircular canals
through the auditory nerve.

(b) Visual fibers coming from the retina through the optic
nerve.

(c) Muscle-sense fibers from Clarke's columns and the posterior
columns.

2. Send:

(a) Fibers terminating in the Rolandic area on the opposite side
and acting on the motor centers.

(b) Fibers terminating in the nucleus of Deiters, which is con-
nected with the oculomotor nerves, these in turn governing the
ocular muscles.

(c) Fibers terminating in the anterior horns of the spinal cord,
whence radiate motor fibers to the voluntary muscles.

(1323)



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1324 SYMPTOMS.

(rf) Fibers to other bulbar centers (glossopharyngeal and pneu-
mogastric).

These anatomic and physiologic connections of the mesen-
cephalic and cerebellar centers account for the following:

(a) The clinical combination of vertigo, disturbances of equilib-
rium, nausea, and ocular disturbances (nystagmus and deviation of
the eyeballs). (Normal equilibrium is the result of harmony of the
retinal, labyrinthine, and muscular impressions).



AflFerent paths.
EflFerent paths.



1. Vestibular fibers.

2. Semicircular canals.

3. Acoustic nuclei of Bech-

terew and Deiters.

4. Visual fibers.

5. Corpora quadrigemina.

6. Sensory fibers.

7. Columns of Clarke.



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 44 of 50)