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CONGENITAL DIAPHRAGM OF THE LARYNX.
764 rather than
an infection, if one can judge from the rapid disappearance of symptoms when the tick is entirely removed, whereas if only the head of the parasite is left in the skin the paralysis may persist and even progress. If the possibility of the presence of a tick be not borne in mind the condition might be mistaken for simple convulsions or for infantile paralysis. ____
THE
EFFECTIVENESS
OF TOOTH-WASHES.
THERE are few persons now who have not the conviction that the scientific cleansing of the teeth and gums is very valuable, and the business in antiseptic dentifrices is obviously increasing, judging from the numerous public advertisements which appear in the daily press setting forth the merits of a great number of these preparations. Generally speaking, they are so composed as to render them well adapted for the purpose, and we have submitted a number of them to analytical examination. The choice of antiseptic is commonly confined to carbolic acid, thymol, peppermint, boric acid, benzoic acid, eucalyptus and other essential oils, distributed in vehicles containing as an agent of attrition non-gritty chalk and as an alkaline medium soap. Experiments are actual as to the germicidal usually quoted value of these preparations in vitro, but of course it would be more satisfactory to have evidence of their real effect in the mouth where very different conditions must as a matter of fact exist. The use of a tooth-wash does not approach the conditions of a laboratory test, though there can be little doubt that a good deal of germicidal work in the mouth is done by the vigorous application of the toothbrush, and it may be pointed out that the tongue may well be included in the process. To be effective, however, the action of all antiseptics takes time, according to the vitality of the organisms they encounter, and usually the tooth-brushing process does not occupy many seconds. This question of time-exposure is important, but it is very generally overlooked, and consequently the antiseptic treatment of the teeth falls short of that effectiveness which is shown to be the case The tooth-washing in laboratory experiments. be more should prolonged and the process antiseptic wash allowed to remain in contact with the teeth and gums for some minutes instead of seconds before finally washing the mouth clear of antiseptic with plain water.
During phonation the membrane almost disappeared, but enough remained to prevent approximation of the cords. The Wassermann reaction was negative. Congenital diaphragm of the larynx was diagnosed because of the history normal.
of hoarseness since birth, the absence of any illness which would account for such a condition, the appearance of the diaphragm, and the otherwise normal larynx. With a laryngeal knife the membrane was split down the centre from the free margin to the anterior commissure. As the knife approached the anterior commissure there was increased resistance on account of the greater thickness of the membrane. Although measures were taken to prevent it, adhesion of the cords at their anterior part occurred. After the reaction from the operation the voice was slightly improved and breathing easier. As to the origin of such membranes, Ganghofner has shown that the larynx is developed from two symmetrically placed ridges which bound a small fissure. At a certain stage of development these ridges lie close to each other and are attached by epithelial adhesions. The membrane is due to the persistence of these adhesions. Heredity seems to play a part, though in the present case there was no family history of such a condition. A case has been recorded in which the father and sister of a patient had similar formations, and a case in which the mother of a patient had congenital adhesions of the cords at the anterior commissure. Other congenital deformities-shortening of the fraenum linguas and coloboma of the upper lid-have been found associated with congenital laryngeal diaphragm. Microscopic sections have shown the presence of mucous glands and muscle fibres in the diaphragm. Flat epithelial cells were present on the upper surface and cylindrical epithelial cells on the under surface similar to those of the cords. A congenital diaphragm of the larynx is usually in the anterior part, but two cases have been reported in which it was in the posterior part. The diaphragm varies in size from a simple rounding of the angle of the anterior commissure to that present in the case described above. Rounding of the anterior commissure is not an infrequent finding in the examination of the larynx. Treatment, as a rule, has been unsatisfactory, because the raw surfaces of the anterior commissure unite again. Improvement of the voice usually is not marked, although the breathing is easier. ____
PITUITARY STANDARDISATION.
CONGENITAL DIAPHRAGM OF THE LARYNX.
ACCORDING to Sir StClair Thomson there are but 20 cases of congenital diaphragm of the larynx on record. In the Saint Paul Medical Journal for February Dr. G. B. New has reported the following A case from the Mayo Clinic, Rochester, Minn. 27 had and years, well-developed healthy man, aged been hoarse since birth with no apparent change of voice. On exertion, such as running up stairs, he had slight difficulty in breathing. Laryngeal examination showed a thin membrane extending between the margins of the true vocal cords for two-thirds of their extent anteriorly with a concave margin towards the lumen of the glottis. The membrane was pale grey, gradually fading into the margins of the cords, which were rounded and slightly reddened. It appeared thinnest in the median line and at its free margin, and did not show any scarring. The larynx was otherwise
PHYSIOLOGICAL standardisation has for many years been a subject of controversy, and many efforts were made to induce the General Medical Council to adopt this method in the current British Pharmacopoeia. It has been urged that this test affords the only certain method of obtaining uniformity of strength for various galenical preparations. Since the General Medical Council has not thought fit to introduce this innovation, it is not necessary to recount the various arguments adduced in its favour. It must be admitted that the latest contributionis certainly not encouraging. It recounts experiments conducted with a view of comparing the physiological activity of some commercial pituitary preparations, and after a careful description of a large series of experiments the writer (George B. Roth) concludes that in a general way it may be said that the claims of the 1
Hygienic Laboratory Bulletin, No. 100, November, 1914,Washington.
an infection, if one can judge from the rapid disappearance of symptoms when the tick is entirely removed, whereas if only the head of the parasite is left in the skin the paralysis may persist and even progress. If the possibility of the presence of a tick be not borne in mind the condition might be mistaken for simple convulsions or for infantile paralysis. ____
THE
EFFECTIVENESS
OF TOOTH-WASHES.
THERE are few persons now who have not the conviction that the scientific cleansing of the teeth and gums is very valuable, and the business in antiseptic dentifrices is obviously increasing, judging from the numerous public advertisements which appear in the daily press setting forth the merits of a great number of these preparations. Generally speaking, they are so composed as to render them well adapted for the purpose, and we have submitted a number of them to analytical examination. The choice of antiseptic is commonly confined to carbolic acid, thymol, peppermint, boric acid, benzoic acid, eucalyptus and other essential oils, distributed in vehicles containing as an agent of attrition non-gritty chalk and as an alkaline medium soap. Experiments are actual as to the germicidal usually quoted value of these preparations in vitro, but of course it would be more satisfactory to have evidence of their real effect in the mouth where very different conditions must as a matter of fact exist. The use of a tooth-wash does not approach the conditions of a laboratory test, though there can be little doubt that a good deal of germicidal work in the mouth is done by the vigorous application of the toothbrush, and it may be pointed out that the tongue may well be included in the process. To be effective, however, the action of all antiseptics takes time, according to the vitality of the organisms they encounter, and usually the tooth-brushing process does not occupy many seconds. This question of time-exposure is important, but it is very generally overlooked, and consequently the antiseptic treatment of the teeth falls short of that effectiveness which is shown to be the case The tooth-washing in laboratory experiments. be more should prolonged and the process antiseptic wash allowed to remain in contact with the teeth and gums for some minutes instead of seconds before finally washing the mouth clear of antiseptic with plain water.
During phonation the membrane almost disappeared, but enough remained to prevent approximation of the cords. The Wassermann reaction was negative. Congenital diaphragm of the larynx was diagnosed because of the history normal.
of hoarseness since birth, the absence of any illness which would account for such a condition, the appearance of the diaphragm, and the otherwise normal larynx. With a laryngeal knife the membrane was split down the centre from the free margin to the anterior commissure. As the knife approached the anterior commissure there was increased resistance on account of the greater thickness of the membrane. Although measures were taken to prevent it, adhesion of the cords at their anterior part occurred. After the reaction from the operation the voice was slightly improved and breathing easier. As to the origin of such membranes, Ganghofner has shown that the larynx is developed from two symmetrically placed ridges which bound a small fissure. At a certain stage of development these ridges lie close to each other and are attached by epithelial adhesions. The membrane is due to the persistence of these adhesions. Heredity seems to play a part, though in the present case there was no family history of such a condition. A case has been recorded in which the father and sister of a patient had similar formations, and a case in which the mother of a patient had congenital adhesions of the cords at the anterior commissure. Other congenital deformities-shortening of the fraenum linguas and coloboma of the upper lid-have been found associated with congenital laryngeal diaphragm. Microscopic sections have shown the presence of mucous glands and muscle fibres in the diaphragm. Flat epithelial cells were present on the upper surface and cylindrical epithelial cells on the under surface similar to those of the cords. A congenital diaphragm of the larynx is usually in the anterior part, but two cases have been reported in which it was in the posterior part. The diaphragm varies in size from a simple rounding of the angle of the anterior commissure to that present in the case described above. Rounding of the anterior commissure is not an infrequent finding in the examination of the larynx. Treatment, as a rule, has been unsatisfactory, because the raw surfaces of the anterior commissure unite again. Improvement of the voice usually is not marked, although the breathing is easier. ____
PITUITARY STANDARDISATION.
CONGENITAL DIAPHRAGM OF THE LARYNX.
ACCORDING to Sir StClair Thomson there are but 20 cases of congenital diaphragm of the larynx on record. In the Saint Paul Medical Journal for February Dr. G. B. New has reported the following A case from the Mayo Clinic, Rochester, Minn. 27 had and years, well-developed healthy man, aged been hoarse since birth with no apparent change of voice. On exertion, such as running up stairs, he had slight difficulty in breathing. Laryngeal examination showed a thin membrane extending between the margins of the true vocal cords for two-thirds of their extent anteriorly with a concave margin towards the lumen of the glottis. The membrane was pale grey, gradually fading into the margins of the cords, which were rounded and slightly reddened. It appeared thinnest in the median line and at its free margin, and did not show any scarring. The larynx was otherwise
PHYSIOLOGICAL standardisation has for many years been a subject of controversy, and many efforts were made to induce the General Medical Council to adopt this method in the current British Pharmacopoeia. It has been urged that this test affords the only certain method of obtaining uniformity of strength for various galenical preparations. Since the General Medical Council has not thought fit to introduce this innovation, it is not necessary to recount the various arguments adduced in its favour. It must be admitted that the latest contributionis certainly not encouraging. It recounts experiments conducted with a view of comparing the physiological activity of some commercial pituitary preparations, and after a careful description of a large series of experiments the writer (George B. Roth) concludes that in a general way it may be said that the claims of the 1
Hygienic Laboratory Bulletin, No. 100, November, 1914,Washington.