the lettsomian lectures on diseases of the muse and throat in relation to general medicine

2
727 The Lettsomian Lectures ON DISEASES OF THE MUSE AND THROAT IN RELATION TO GENERAL MEDICINE. Delivered before the Medical Society of London, BY F. DE HAVILLAND BALL, M.D., F.R.C.P.LOND., PHYSICIAN TO THE WESTMINSTER HOSPITAL, AND JOINT LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE: WESTMINSTER HOSPITAL MEDICAL SCHOOL. LECTURE III.1 Delivered on March 1st, 1897. ANEURYSM. MR. PRESIDENT AND GENTLEMEN, - IN aneurysm of i ’the aorta the laryngoscope is oftentimes of inestimab’l,,- t service in enabling the practitioner to make an early - diagnosis, and consequently to allow of the institution of prompt treatment. It may be laid down as an axiom that when the lef t vocal cord is immobile in the ( cadaveric position pressure of an aneurysm upon the ( recurrent laryngeal nerve is the first thing to be thought of, t .and it is only after an aneurysm has been excluded that other causes for the paralysis of the laryngeal muscles need ,, be considered. This is more especially the case in males between the ages of thirty and sixty years. It must be remembered that, in accordance with Semon’s law, " there is i proclivity of the abductor fibres of the recurrent nerve to i become affected sooner than the adductor fibres, or even i exclusively, in cases of undoubted central or peripheral injury, or disease of the roots or trunks of the pneuino- gastric, spinal accessory, or recurrent nerves," consequently the fisat effect of pressure on the recurrent nerve is to cause abductor paralysis on the affected side. Now, unilateral abductor paralysis presents such slight symptoms ,that in the absence of a laryngoscopic examination it is generally overlooked ; still, numerous cases have been recorded in which this condition has been observed .as a symptom of thoracic aneurysm. When, however, the adductor fibres become implicated and the cord passes into the cadaveric position the effect on the voice is so marked that the patient feels that something is amiss with him, and consequently seeks advice. In looking over the notes of sixteen private cases of aneurysm of which I have full par- ticulars I find that they were all males, the youngest twenty- nine and the eldest sixty-one years of age, the average age baing almost exactly forty-seven years. Of these sixteen cases, in one case there was bilateral paralysis of the abductors, the left vocal cord was in the cadaveric position in eight, in five there was impaired movement (loss of abduction) of the left vocal cord, and in two the laryngoscopic appearances were normal. The right vocal cord was only affected in the case of bilateral paralysis of the abductors. The proportion of - cases in which the left vocal cord was partly or completely paralysed is, of course, much greater in my practice than in ordinary general practice, inasmuch as several of the patients ’consulted me on account of hoarseness and had no suspicion that they were suffering from any serious affection ; still, this only emphasises the importance of a laryngoscopic examination in all cases of hoarseness, and, as I have said before, a loss of mobility of the left vocal cord in a middle-aged male, especially if the cord is in the cadaveric position, should at once arouse the suspicion of an intra-thoracic aneurysm. The reason why the right vocal cord is so seldom affected depends upon anatomical considerations ; the right recurrent nerve winds round the -su7t)clavia-a artery, and is therefore situated at a considerable distance from the arch of the aorta. Should, however, the sac of the aneurysm involve the innominate artery the right recurrent nerve may be implicated, or the trachea may be displaced by an aneurysmal tumour in such a way that its 1 Owing to the present great pressure on our space we have been reluctantly compelled to abbreviate this third Lettsomian Lecture. Lectures I. and II. appeared in THE LANCET of Feb. 6th and Feb. 27th respectively.—ED. L. convexity may press on the right recurrent and pneumo gastric nerves, causing paralysis of the right vocal cord, Or centripetal irritation of the trunk of the left vagus may act on the nervous centre, and through it upon the.nerve-supply to the laryngeal muscles on the right side. I have found the combination of complete paralysis of the left vocal cord due to pressure on the left recurrent nerve by malignant disease, together with the existence of valvular disease and edlarge- ment of the heart, extremely difficult to distinguish from an intra-thoracic aneurysm. In some cases it is possible to recognise the direct pressure of an aneuryam upon the trachea by means of the laryngoscope. The bulging forward of the posterior wall can be seen, and with a good light and a tolerant patient pulsation may even be distinguished. DISEASES OF THE DIGESTIVE SYSTEM. The possibility of chronic gastric catarrh being kept up by the irritation produced by swallowing fœtid secretion from the nose and naso- pharynx should be borne in mind by the , physician who finds that his patient does not readily respond to the usual treatment. Whether as the result of the improvement of the general health or from the cessation of the local cause of irritation, I have noted that symptoms of dyspepsia have disappeared after the nose and accessory sinuses have received attention. That the stomach may be involved secondarily to the upper air passages is pretty generally agreed, but it is not so easy to prove that affections of the upper air passages may occur as a result of stomach derangements. Various theories may be propounded to explain the connexion between affections of the upper air passages and diseases of the stomach. We may appeal to the theory of reflexes or we may attribute to the ubiquitous bacillus the rôle of disturbing the functions of remote organs. In i speaking of the treatment of granular pharyngitis in my i book on Diseases of the Nose and Throat" I say that it ; is most important that attention should be paid to the general health of the patient. If there be any symptoms of indigestion these should be seen to." Further experience has only confirmed what I have therein stated, and I am . convinced that the state of the pharynx is much influenced r by the condition of the stomach and liver. DISEASE OF THE LIVER. In connexion with hepatic diseases I have only to remark that very severe epistaxis is not uncommonly an early , symptom of cirrhosis of the liver, the bleeding occurring 1 from dilated veins at the posterior part of the nose. In a middle-aged person the occurrence of epistaxis is almost as suggestive of cirrhosis of the liver as are piles. Haemorrhages 1 from, and ecchymoses in, the mucous membrane of the 1 pharynx and larynx may be recognised in some cases of cirrhosis and cancer of the liver ; also in acute yellow - atrophy. A recent development of throat specialism is the - doctrine that a varicose condition of the veins at the base of the tongue is one of the objective causes for many subjective throat symptoms of the nature of " globus hystericus." A g lengthy discussion which took place in the columns of e THE LANCET in the early part of last year has been the means yt of relegating lingual varix to its proper position. That an g enlargement of the veins at the back of the tongue does e occasionally exist f am quite ready to admit, but that this If f condition is "an etiological factor in many obscure y pharyngeal and laryngeal symptoms" does not agree with n my own observations. I have found that with attention to diet, the administration of saline aperients, and limiting the n amount of alcohol taken the patients have speedily improved 1. and have not required any local treatment. BRIGHT’s DISEASE. ’e Epistaxis is a frequent symptom of chronic interstitial d nephritis and is occasionally met with in the other forms of ill Bright’s disease. It may be quite an early sign of granular kidney ; the urine should therefore be examined in cases of abundant or frequent epistaxis. The bleeding is dependent ai upon the altered blood state, changes in the vessels of the 1e Schneiderian mucous membrane, and upon the cardiac hyper- le trophy and increased arterial tension. The exact connexion between Bright’s disease and cedema of the larynx is still a matter of discussion. The probable explanation is that oe Bright’s disease determines the onset of the cedema in cases ts in which, under ordinary circumstances, the local irritation - would have been too slight to have caused it. en re. LOCOMOTOR ATAXY. th Nasal conditions associated with tabes are rare. That

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Page 1: The Lettsomian Lectures ON DISEASES OF THE MUSE AND THROAT IN RELATION TO GENERAL MEDICINE

727

The Lettsomian LecturesON

DISEASES OF THE MUSE AND THROAT INRELATION TO GENERAL MEDICINE.Delivered before the Medical Society of London,

BY F. DE HAVILLAND BALL, M.D.,F.R.C.P.LOND.,

PHYSICIAN TO THE WESTMINSTER HOSPITAL, AND JOINT LECTURER ONTHE PRINCIPLES AND PRACTICE OF MEDICINE IN THE:

WESTMINSTER HOSPITAL MEDICAL SCHOOL.

LECTURE III.1Delivered on March 1st, 1897.

ANEURYSM.

MR. PRESIDENT AND GENTLEMEN, - IN aneurysm of i

’the aorta the laryngoscope is oftentimes of inestimab’l,,- tservice in enabling the practitioner to make an early- diagnosis, and consequently to allow of the institution of prompt treatment. It may be laid down as an axiom that when the lef t vocal cord is immobile in the (

cadaveric position pressure of an aneurysm upon the (

recurrent laryngeal nerve is the first thing to be thought of, t

.and it is only after an aneurysm has been excluded thatother causes for the paralysis of the laryngeal muscles need ,,be considered. This is more especially the case in males between the ages of thirty and sixty years. It must be remembered that, in accordance with Semon’s law, " there is i

proclivity of the abductor fibres of the recurrent nerve to ibecome affected sooner than the adductor fibres, or even i

exclusively, in cases of undoubted central or peripheralinjury, or disease of the roots or trunks of the pneuino- gastric, spinal accessory, or recurrent nerves," consequentlythe fisat effect of pressure on the recurrent nerve isto cause abductor paralysis on the affected side. Now,unilateral abductor paralysis presents such slight symptoms,that in the absence of a laryngoscopic examinationit is generally overlooked ; still, numerous cases havebeen recorded in which this condition has been observed.as a symptom of thoracic aneurysm. When, however, theadductor fibres become implicated and the cord passes intothe cadaveric position the effect on the voice is so markedthat the patient feels that something is amiss with him, andconsequently seeks advice. In looking over the notes ofsixteen private cases of aneurysm of which I have full par-ticulars I find that they were all males, the youngest twenty-nine and the eldest sixty-one years of age, the average agebaing almost exactly forty-seven years. Of these sixteen cases,in one case there was bilateral paralysis of the abductors, theleft vocal cord was in the cadaveric position in eight, in fivethere was impaired movement (loss of abduction) of the leftvocal cord, and in two the laryngoscopic appearances werenormal. The right vocal cord was only affected in the caseof bilateral paralysis of the abductors. The proportion of- cases in which the left vocal cord was partly or completelyparalysed is, of course, much greater in my practice than inordinary general practice, inasmuch as several of the patients’consulted me on account of hoarseness and had no suspicionthat they were suffering from any serious affection ; still,this only emphasises the importance of a laryngoscopicexamination in all cases of hoarseness, and, as I havesaid before, a loss of mobility of the left vocal cordin a middle-aged male, especially if the cord is inthe cadaveric position, should at once arouse the suspicionof an intra-thoracic aneurysm. The reason why the rightvocal cord is so seldom affected depends upon anatomicalconsiderations ; the right recurrent nerve winds round the-su7t)clavia-a artery, and is therefore situated at a considerabledistance from the arch of the aorta. Should, however, thesac of the aneurysm involve the innominate artery the rightrecurrent nerve may be implicated, or the trachea may bedisplaced by an aneurysmal tumour in such a way that its

1 Owing to the present great pressure on our space we have beenreluctantly compelled to abbreviate this third Lettsomian Lecture.Lectures I. and II. appeared in THE LANCET of Feb. 6th and Feb. 27threspectively.—ED. L.

convexity may press on the right recurrent and pneumogastric nerves, causing paralysis of the right vocal cord, Orcentripetal irritation of the trunk of the left vagus may acton the nervous centre, and through it upon the.nerve-supplyto the laryngeal muscles on the right side. I have found thecombination of complete paralysis of the left vocal cord dueto pressure on the left recurrent nerve by malignant disease,together with the existence of valvular disease and edlarge-ment of the heart, extremely difficult to distinguish from anintra-thoracic aneurysm. In some cases it is possible torecognise the direct pressure of an aneuryam upon thetrachea by means of the laryngoscope. The bulging forwardof the posterior wall can be seen, and with a good light and atolerant patient pulsation may even be distinguished.

DISEASES OF THE DIGESTIVE SYSTEM.The possibility of chronic gastric catarrh being kept up by

the irritation produced by swallowing fœtid secretion fromthe nose and naso- pharynx should be borne in mind by the, physician who finds that his patient does not readily respondto the usual treatment. Whether as the result of the

improvement of the general health or from the cessation ofthe local cause of irritation, I have noted that symptoms ofdyspepsia have disappeared after the nose and accessorysinuses have received attention. That the stomach may beinvolved secondarily to the upper air passages is prettygenerally agreed, but it is not so easy to prove that affectionsof the upper air passages may occur as a result of stomachderangements. Various theories may be propounded to explainthe connexion between affections of the upper air passages anddiseases of the stomach. We may appeal to the theory of

’ reflexes or we may attribute to the ubiquitous bacillus the. rôle of disturbing the functions of remote organs. Ini speaking of the treatment of granular pharyngitis in myi book on Diseases of the Nose and Throat" I say that it; is most important that attention should be paid to the

general health of the patient. If there be any symptoms ofindigestion these should be seen to." Further experience

has only confirmed what I have therein stated, and I am. convinced that the state of the pharynx is much influencedr by the condition of the stomach and liver.

DISEASE OF THE LIVER.

In connexion with hepatic diseases I have only to remarkthat very severe epistaxis is not uncommonly an early

, symptom of cirrhosis of the liver, the bleeding occurring1 from dilated veins at the posterior part of the nose. In a

middle-aged person the occurrence of epistaxis is almost assuggestive of cirrhosis of the liver as are piles. Haemorrhages

1 from, and ecchymoses in, the mucous membrane of the

1 pharynx and larynx may be recognised in some cases ofcirrhosis and cancer of the liver ; also in acute yellow

- atrophy. A recent development of throat specialism is the- doctrine that a varicose condition of the veins at the base ofthe tongue is one of the objective causes for many subjective throat symptoms of the nature of " globus hystericus." Ag lengthy discussion which took place in the columns of

e THE LANCET in the early part of last year has been the meansyt of relegating lingual varix to its proper position. That an

g enlargement of the veins at the back of the tongue doese occasionally exist f am quite ready to admit, but that thisIf f condition is "an etiological factor in many obscure

y pharyngeal and laryngeal symptoms" does not agree withn my own observations. I have found that with attention to

diet, the administration of saline aperients, and limiting then amount of alcohol taken the patients have speedily improved1. and have not required any local treatment.

BRIGHT’s DISEASE.

’e Epistaxis is a frequent symptom of chronic interstitiald nephritis and is occasionally met with in the other forms ofill Bright’s disease. It may be quite an early sign of granular

kidney ; the urine should therefore be examined in cases ofabundant or frequent epistaxis. The bleeding is dependentai upon the altered blood state, changes in the vessels of the

1e Schneiderian mucous membrane, and upon the cardiac hyper-le trophy and increased arterial tension. The exact connexionbetween Bright’s disease and cedema of the larynx is still amatter of discussion. The probable explanation is that

oe Bright’s disease determines the onset of the cedema in casests in which, under ordinary circumstances, the local irritation-

would have been too slight to have caused it.en

re. LOCOMOTOR ATAXY.th

Nasal conditions associated with tabes are rare. That

Page 2: The Lettsomian Lectures ON DISEASES OF THE MUSE AND THROAT IN RELATION TO GENERAL MEDICINE

728

there is hyperæsthesia of the nasal mucous membrane is shown by the fact that laryngeal crises can at times beelicited by irritating the nasal fossæ. In the pharynx boththe sensory. and the motor nerves may be affected. Allvarieties of sensorial disturbance may occur-viz., anaesthesia,hyperaesthesia, and parassthesia. On the motor side theremay be paralysis or spasm with contraction. The mucousmembrane of the larynx, like that covering the pharynx,may be the seat of anæsthesia, hyperæsthesia, or paræsthesia.On the motor side three kinds of affections are seen in thelarynx as a result of tabes—(1) spasm of the adductors ; (2)paralysis of the abductors ; and (3) incoordination of the

laryngeal muscles. The last mentioned of these laryngealaffections of tabes is a true ataxy of the vocal cords, and isperhaps one of the earliest laryngeal signs of tabes.

(Dr, de Havilland Hall here made short references toSyringomyelia, Paralysis Agitans, Labio-glosso-laryngealParalysis, and Reflex Epilepsy of Nasal Origin.]

HYSTERIA.The neuromimetic conditions affecting the upper air

passages are so numerous that I can only briefly describesome of the most important. It has been stated that a

regular attack of hysteria may be produced by the irritationof certain parts of the nasal mucous membrane, the so-called hystero-genetic zones, and that after the applicationof the galvano-cautery to these areas the attacks haveceased to occur. Though I have been examining the interiorof noses for the last twenty years, and have constantly usedthe probe, I have never succeeded in starting off an attack ofhysteria. The motor neuroses of the pharynx may be due tospasm or paralysis. The so-called globus hystericus isnothing more or less than spasm of the pharyngeal muscles.Hysterical paralysis of the muscles of the pharynx may, bycausing dysphagia, give rise to the suspicion of malignantdisease, especially if the patient is middle-aged ; the

diagnosis is readily effected by means of the cesophagealbougie. A curious condition to which the term inspiratoryspasm or perverted action of the vocal cords has beenapplied is occasionally seen in hysterical persons. In thisaffection the voice remains normal, but on attempts at

inspiration the vocal cords, instead of separating, approxi-mate in a convulsive manner. Sometimes they come incontact and cause grave interference with respiration ; atother times they remain in the cadaveric position, givingrise to inspiratory stridor. Another form of spasm is thebarking cough of puberty."

NEURASTHENIA AND MELANCHOLIA.The subject of the various reflex nasal neuroses has

received much attention of late years and there has been atendency, I think, to exaggerate the effect of the variousintra-nasal lesions. As I frequently examine the noses ofpatients-no matter what their complaint - have comeacross numerous instances of deilected septa, nasal crests,and spurs in patients in whom there is no symptom of anynasal or reflex nasal affection. On the other hand, there is nodoubt that these same conditions in neurotic or neurasthenic

patients would produce symptoms of a reflex character curableby local treatment in conjunction with suitable general treat-ment. Some patients become quite hypochondriacal as tothe state of the nose and are constantly craving for anapplication of some kind or the other to be made to it.I have recently had under my care a lady, forty years of age,who, on account of paroxysmal sneezing," suffered manythings in the way of removal of bone, cautery, &0." Shecertainly lost the sneezing, but since it disappeared she hassuffered from flatulent dyspepsia, acidity, intestinal catarrh,and constipation, accompanied by neuralgia and varioussensations referred to the pelvic viscera. She has lost flesh,is terribly depressed, and is a typical example of neu-

rasthenia. She dates all her present symptoms from thetime she ceased to sneeze, and attributes them to the shockof the numerous and severe operative procedures carried outin her nose. Her medical man takes the same view, and Iam disposed to agree with him.

HEADACHE.There is hardly any nasal affection but has headache for a

symptom. Hence a careful examination of the nose andaccessory cavities should be carried out before headache is

.

regarded as being of a neurasthenic or neuralgic origin.Chief among the naal causes of headache may be mentionedhypertr’ phy of the turbinals giving rise to nasal stenosis ;

deflection of the septum may also have a similar effeFurthermore, I should here like to direct attention to thepain referred to the nape of the neck and the occipital regionradiating towards the ear, which is met with in some

pharyngeal affections.

[Dr. de Havilland Hall here referred briefly to Meningitis,Cerebral Abscess, Cerebral Haemorrhage, and Epistaxis.] ]

CONCLUDING REMARKS.I have purposely refrained from saying anything about

diphtheria because the subject is too wide to be treated in anadequate manner in the time I could devote to it. Moreover,it is somewhat outside the limits I laid down for my own.guidance when I commenced writing these lectures. Forsimilar reasons I have not discussed the manifestations of £tubercle, syphilis, and malignant disease in the nose andthroat, as these are well described in the various text-bookson the subject. The plan I proposed to myself was,to grouptogether the various affections of the upper air-passages asthey may occur in connexion with general or local diseases,and also to point. out the diseases of remote organs whichmay arise as a result of affection of the upper iespiratorytract. A secondary object I had constantly before me was toaccentuate the importance of a systematic examination ofthe nose, naso-pharynx, pharynx, and larynx. I am quiteconscious that I have omitted many points of interest, but.tbe task of selection is rendered difficult by the veryabundance of material.

CHRONIC INTERSTITIAL NEPHRITIS INCHILDHOOD.1

BY LEONARD G. GUTHRIE, M.A., M.D.OXON.,M.R.C.P.LOND.,

PHYSICIAN TO THE REGENT’S PARK HOSPITAL FOR PARALYSIS;PHYSICIAN TO OUT-PATIENTS AT THE PADDINGTON-

GREEN CHILDREN’S HOSPITAL AND THENORTH-WEST LONDON HOSPITAL.

(Concluded from page 588.)

PHYSICAL SIGNS AND SYMPTOMS (continued).’ Mental characteristics.-Children suffering from this com-plaint seem to be shrewd, precocious, and intelligent beyondtheir years. This was noted particularly in Dr. Barlow’s fatalcase. In my own fatal case there was a peculiar mentalperversity. The patient apparently soon discovered that shewas an object of interest, and did all she could to attractattention. She would scream incessantly and feign uncon-sciousness during the friends’ visiting hour at hospital, butafterwards would confess that she knew all that was goingon. She would beg that poison might be given her anddisturb the whole building by her shrieks at night, butwould be quiet directly she had succeeded in having thehouse physician called up to see her. It was difficult toascertain whether she were actually in pain or only counter-feiting it.

I have observed in other cases that intelligence appears tobe above the average. It is possible that the active cerebralcirculation in such cases due to cardio-vascular hypertrophymay conduce to premature mental development. There may ,

be more truth than W. S. Gilbert supposed in his ballad con-cerning the precocious child, who died "an enfeebled olddotard at five."

Cerebral symptoms.-Headache and vomiting were pro-minent features in four of these fatal cases. In twcheadaches were frequent, but there is no mention of vomit-

ing. In one vomiting was frequent, but not headache.Vertigo and amaurosis accompanied headache and vomitingin my own fatal case. The localisation of headaches is of novalue ; it is usually frontal, but may be occipital, coronal, orlateral. They resemble those of migraine in their periodicity,severity, and association with visual disturbance or vertigo,and in being often relieved by vomiting. Also, at first theycommonly occur on waking in the morning, as in migraine,though later they may happen at any time of the day. I

1 A paper read before the Harveian Society of London on Nov. 19th1896.