- Email: [email protected]
LARYNGOLOGY.
388
signs of local irritation of the brain. In tuberculous mening- were the result of functional disturbances which might well itis Mr. Stiles was opposed to operation when the diagnosis be of the nature of imperfect coordination. Such imperfect was a matter of certainty, but in cases where a doubt coordination would be the more likely to occur when the existed an operation was justifiable in view of the possibility physiological action of the several parts had not advanced of the discovery of some condition capable of surgical to a stage of stable equilibrium. Dr. JuLES COMBY (Paris) thought Dr. Thomson’s explanarelief. In posterior basic meningitis it had to be remembered that many cases recovered under medical treatment. tion a very ingenious one, though he could not admit that it Surgical measures, such as lumbar puncture, puncture of the was applicable to all cases. lateral ventricle, and drainage of the fourth ventricle were, Mr. STILES referred to successful treatment of congenital however, of distinct value in some cases. Paraplegia, the hypertrophy of the pylorus as advocated by Nicholl of result of Pott’s disease of the spine, was another condition Glasgow and described a case from his own practice. often susceptible of treatment by surgical measures, more Mr. ROBERT JONES (Liverpool) read a paper on particularly when it was due to an abscess bursting into the The Surgical Treatment of Spastic Paraplegia, spinal canal, when laminectomy was indicated. In the more chronic forms laminectomy should not be practised until rest and quoted a large number of cases in which he had secured and extension had been fairly tried. Speaking of the added comfort and increased power of locomotion for his He insisted on the necessity of prolonged postsurgical treatment of epilepsy Mr. Stiles emphasised the patients. and education if good permanent operative supervision dura well as of mater as the bone in the importance removing were to be obtained. I trephining the skull. This secured a permanent gap in the Mr. NOBLE SMITH deplored the neglect by physicians of
results
Itraining
____
.
with
389 a long time, but investigations had shown
known for
recent observations and
his own extraordinarily intimate connexion which doubtless must have special significance. The connexion of the superior laryngeal nerve with the upper cervical ganglion of the sympathetic and with the rami cardiaci superiores which arose from the latter was known, as was also the connexion of the superior laryngeal nerve with the lower cervical ganglion of the sympathetic, the connexion of the external branch of the superior laryngeal being much closer with the upper cervical ganglion of the sympathetic and the superior cardiac nerve. an
cocaine and nitrous oxide gas and the needle was kept in sitir for a week, no plugging being required. Dr. N. C. HAMXG (Manchester) read a paper on chronic
Laryngitis;Correlation of Diagnosis
and
Treatment.
In this communication stress was laid on the various subdivisions of the disease and their diagnostic distinctions. The author pointed out that in order to secure the best treat-ment for each case a more particularised diagnosis than that of "chronic laryngitis" was required. The cases, he said, The external branch of the upper cervical nerve sent off fell into groups fairly well defined according to the extent a direct cardiac branch or connexions to the upper cervical and degree of the congestion, which might vary from intense ganglion of the sympathetic and to the upper cardiac nerve. diffuse redness of the whole organ to localised injection and These anatomical conditions formed in man an exact according to the position and extent of the hyperplasia ; analogue to the depressor nerve found in animals. In the condition might be latent, yielding no symptoms and regard to the inferior laryngeal they knew its connexions only attracting the patient’s attention during- periods of. with the upper cervical ganglion of the sympathetic and exacerbation. It was essential to be able to exclude with the superior cardiac nerve. Of great significance was tuberculosis, syphilis, and early malignant disease in a the observation of Lenhossek, according to which the diagnosis of chronic laryngitis. Speaking of tuberculosis. inferior laryngeal nerve arose from a ganglion, whilst the of the larynx, he said that a considerable zone of ganglion stood in connexion with the pneumogastric by engorgement might extend around a tuberculous ulcer, means of a thin root. The lower laryngeal was connected and an error in diagnosis was easily possible when with the lower cervical ganglion of the sympathetic and, the ulcer occupied a position where it might escape observafurther, with the cardiac branches which took their origin tion. Except trifling surface abrasions it was extremely from the middle and lower cervical sympathetic. He had doubtful whether ulceration ever occurred in simplesucceeded in demonstrating in the horse the anatomical chronic laryngitis. During the course of pulmonary phthisis proof that according to the double function of respiration the irritant products of expectoration often set up a and phonation of the larynx the respiratory and phonatory laryngeal catarrh which had no other connexion with the nerve bundles ran separately in the trunk of the inferior tuberculous lesion. Cases of chronic laryngitis he divided laryngeal nerve and in the trunk of the pneumo- roughly into three classes : (1) systemic ; (2) due to, or gastric. He had demonstrated this for a length of associated with, nasal disease ; and (3) independent of nasal Whilst the phonatory nerve bundle disease. 88 centimetres. In Group 1 local treatment was of little use, could easily be isolated and showed only one con- the appropriate treatment must be directed to the systemic nexion each with the ansa Vieussensii and with the cardiac lesion. In Group 2 the majority of cases of chronio branch it was difficult to isolate the respiratory nerve laryngeal catarrh were found to be associated with nasal bundle, for it was very intimately connected by means of lesions. It was useless to attempt to cure the laryngitis eight branches with the sympathetic and the cardiac without relieving the nasal condition and in many cases branches. The photograph showed this remarkably intimate the relief of the nasal lesion would be almost sufficient as It was known that in the trunks of the the larynx when relieved from irritation tended to recover. connexion. sympathetic, besides the vasomotor and tropbic, there were Nasal affections appeared to influence the larynx in threecerebro-spinal, sensitive, and motor fibres. His investiga- ways : (1) extension of catarrh by continuity of surface;. tions had shown that the cerebro-spinal nerve fibres of the (2) irritation by discharges ; and (3) mouth-breathing caused rami communicantes ran in the trunk of the sympathetic by nasal obstruction. The presence of pharyngitis sicca according to a well-defined system. In the upper part of pointed strongly to the root of the disease being in the nasal the thorax and in the neck the larger part of the cerebro- area. Passing to a consideration of the affected organ itself spinal fibres of the sympathetic ran upwards and only a Dr. Haring said that he had found the following classificasmaller part downwards, whilst in the rest of the thorax and tion of much clinical use : laryngitis chronica superior, in the abdomen just the reverse was the case. The sym- affecting principally the loose glandular tissues above the pathetic constituted the morphological basis in the known cords ; laryngitis chronica media, affecting principally the connexions for the course of the fibres and their inter- cords ; and laryngitis chronica inferior, affecting principally. communication, as they were of different origin and differ- the region below the glottis. In the treatment of the ent destination. Physiology had until now shown the first variety he had found astringent applications of little presence of the depressor fibres and the cardiac branches value ; on the other hand, the galvano-cautery ’applied originating from the superior laryngeal nerve, and his experi- carefully to the hypertrophied tissue had afforded him ments had shown that in the dog the irritation of the sym- satisfactory results. The formation of fissures in the pathetic trunk between the lower cervical and first thoracic inter-arytenoid space was referred to as a troublesome ganglion, as also of the communicating branches of the form of this subdivision. Under laryngitis chronica media brachial plexus, would produce a contraction of the vocal reference was made to cases which presented cords with cords of the same side. Beyond these observations the grey, lustreless, roughened surface and which resembled morphological facts mentioned had received no pathological pachydermia laryngis, but were distinguished from it by or physiological explanation. In particular he drew atten- the absence of the pathognomonic tumours over the vocal tion to the intimate connexion which existed between the processes. The several forms of treatment commonly in use isolated respiratory nerve-fibres of the lower laryngeal nerve were referred to. Under laryngitis chronica inferior it was and the sympathetic and the cardiac branches. The morpho- mentioned that in most cases of chronic laryngitis the portion logical foundation was laid in the above-mentioned facts, below the glottis suffered and that it was owing to the showing an exchange of nerve-fibres of different origin and neglect of this region that local remedies often failed to destination, but the isolation of these fibres and the investi- effect a cure. gation of their destinations formed still a subject for future Dr. W. JoBSOX HORNE (London) agreed that the term inquiry. "chronic laryngitis" had come to be too loosely used, that it Dr. J. DUNDAS GRANT (London) read a paper on was far too comprehensive, and that a more particularised dia- Simplified Operation for Deflection of the Cartilaginous gnosis was required to secure the best treatment. At the same time he could not accept the classification of chronic larynThis consisted in the first instance in straightening the gitis, as suggested by Dr. Haring, into "superior," "media," cartilage by transfixion by means of a strong needle intro- and "inferior." A regional subdivision might be at times duced from the concave side in front of the concavity, clinically useful for purposes of description, but it was not pushed through to the other side, and then back through to permissible on pathological grounds, and, after all, an apprethe concave side behind the deflection. Two cuts were then ciation of the pathology of the various forms of chronic made by means of Moure’s or Asch’s shears through the laryngitis was the only sure way of reaching the most approcartilage, one above and in front of the deflection parallel to priate treatment..de therefore advocated a classification. the nasal ridge, the other horizontally below parallel to the which specified the causes and was based upon pathology. floor of the nose but not meeting. The cartilage was then Dr. HARING replied that the subdivisicns which he had were intended to be clinical aids to carrying out manipulated so as to bring about over-riding of the segments at the lines of incision. The operation could be done under Irthe treatment of parts most affected in particular cases.
Septum.
mentioned I
signs of local irritation of the brain. In tuberculous mening- were the result of functional disturbances which might well itis Mr. Stiles was opposed to operation when the diagnosis be of the nature of imperfect coordination. Such imperfect was a matter of certainty, but in cases where a doubt coordination would be the more likely to occur when the existed an operation was justifiable in view of the possibility physiological action of the several parts had not advanced of the discovery of some condition capable of surgical to a stage of stable equilibrium. Dr. JuLES COMBY (Paris) thought Dr. Thomson’s explanarelief. In posterior basic meningitis it had to be remembered that many cases recovered under medical treatment. tion a very ingenious one, though he could not admit that it Surgical measures, such as lumbar puncture, puncture of the was applicable to all cases. lateral ventricle, and drainage of the fourth ventricle were, Mr. STILES referred to successful treatment of congenital however, of distinct value in some cases. Paraplegia, the hypertrophy of the pylorus as advocated by Nicholl of result of Pott’s disease of the spine, was another condition Glasgow and described a case from his own practice. often susceptible of treatment by surgical measures, more Mr. ROBERT JONES (Liverpool) read a paper on particularly when it was due to an abscess bursting into the The Surgical Treatment of Spastic Paraplegia, spinal canal, when laminectomy was indicated. In the more chronic forms laminectomy should not be practised until rest and quoted a large number of cases in which he had secured and extension had been fairly tried. Speaking of the added comfort and increased power of locomotion for his He insisted on the necessity of prolonged postsurgical treatment of epilepsy Mr. Stiles emphasised the patients. and education if good permanent operative supervision dura well as of mater as the bone in the importance removing were to be obtained. I trephining the skull. This secured a permanent gap in the Mr. NOBLE SMITH deplored the neglect by physicians of
results
Itraining
____
.
with
389 a long time, but investigations had shown
known for
recent observations and
his own extraordinarily intimate connexion which doubtless must have special significance. The connexion of the superior laryngeal nerve with the upper cervical ganglion of the sympathetic and with the rami cardiaci superiores which arose from the latter was known, as was also the connexion of the superior laryngeal nerve with the lower cervical ganglion of the sympathetic, the connexion of the external branch of the superior laryngeal being much closer with the upper cervical ganglion of the sympathetic and the superior cardiac nerve. an
cocaine and nitrous oxide gas and the needle was kept in sitir for a week, no plugging being required. Dr. N. C. HAMXG (Manchester) read a paper on chronic
Laryngitis;Correlation of Diagnosis
and
Treatment.
In this communication stress was laid on the various subdivisions of the disease and their diagnostic distinctions. The author pointed out that in order to secure the best treat-ment for each case a more particularised diagnosis than that of "chronic laryngitis" was required. The cases, he said, The external branch of the upper cervical nerve sent off fell into groups fairly well defined according to the extent a direct cardiac branch or connexions to the upper cervical and degree of the congestion, which might vary from intense ganglion of the sympathetic and to the upper cardiac nerve. diffuse redness of the whole organ to localised injection and These anatomical conditions formed in man an exact according to the position and extent of the hyperplasia ; analogue to the depressor nerve found in animals. In the condition might be latent, yielding no symptoms and regard to the inferior laryngeal they knew its connexions only attracting the patient’s attention during- periods of. with the upper cervical ganglion of the sympathetic and exacerbation. It was essential to be able to exclude with the superior cardiac nerve. Of great significance was tuberculosis, syphilis, and early malignant disease in a the observation of Lenhossek, according to which the diagnosis of chronic laryngitis. Speaking of tuberculosis. inferior laryngeal nerve arose from a ganglion, whilst the of the larynx, he said that a considerable zone of ganglion stood in connexion with the pneumogastric by engorgement might extend around a tuberculous ulcer, means of a thin root. The lower laryngeal was connected and an error in diagnosis was easily possible when with the lower cervical ganglion of the sympathetic and, the ulcer occupied a position where it might escape observafurther, with the cardiac branches which took their origin tion. Except trifling surface abrasions it was extremely from the middle and lower cervical sympathetic. He had doubtful whether ulceration ever occurred in simplesucceeded in demonstrating in the horse the anatomical chronic laryngitis. During the course of pulmonary phthisis proof that according to the double function of respiration the irritant products of expectoration often set up a and phonation of the larynx the respiratory and phonatory laryngeal catarrh which had no other connexion with the nerve bundles ran separately in the trunk of the inferior tuberculous lesion. Cases of chronic laryngitis he divided laryngeal nerve and in the trunk of the pneumo- roughly into three classes : (1) systemic ; (2) due to, or gastric. He had demonstrated this for a length of associated with, nasal disease ; and (3) independent of nasal Whilst the phonatory nerve bundle disease. 88 centimetres. In Group 1 local treatment was of little use, could easily be isolated and showed only one con- the appropriate treatment must be directed to the systemic nexion each with the ansa Vieussensii and with the cardiac lesion. In Group 2 the majority of cases of chronio branch it was difficult to isolate the respiratory nerve laryngeal catarrh were found to be associated with nasal bundle, for it was very intimately connected by means of lesions. It was useless to attempt to cure the laryngitis eight branches with the sympathetic and the cardiac without relieving the nasal condition and in many cases branches. The photograph showed this remarkably intimate the relief of the nasal lesion would be almost sufficient as It was known that in the trunks of the the larynx when relieved from irritation tended to recover. connexion. sympathetic, besides the vasomotor and tropbic, there were Nasal affections appeared to influence the larynx in threecerebro-spinal, sensitive, and motor fibres. His investiga- ways : (1) extension of catarrh by continuity of surface;. tions had shown that the cerebro-spinal nerve fibres of the (2) irritation by discharges ; and (3) mouth-breathing caused rami communicantes ran in the trunk of the sympathetic by nasal obstruction. The presence of pharyngitis sicca according to a well-defined system. In the upper part of pointed strongly to the root of the disease being in the nasal the thorax and in the neck the larger part of the cerebro- area. Passing to a consideration of the affected organ itself spinal fibres of the sympathetic ran upwards and only a Dr. Haring said that he had found the following classificasmaller part downwards, whilst in the rest of the thorax and tion of much clinical use : laryngitis chronica superior, in the abdomen just the reverse was the case. The sym- affecting principally the loose glandular tissues above the pathetic constituted the morphological basis in the known cords ; laryngitis chronica media, affecting principally the connexions for the course of the fibres and their inter- cords ; and laryngitis chronica inferior, affecting principally. communication, as they were of different origin and differ- the region below the glottis. In the treatment of the ent destination. Physiology had until now shown the first variety he had found astringent applications of little presence of the depressor fibres and the cardiac branches value ; on the other hand, the galvano-cautery ’applied originating from the superior laryngeal nerve, and his experi- carefully to the hypertrophied tissue had afforded him ments had shown that in the dog the irritation of the sym- satisfactory results. The formation of fissures in the pathetic trunk between the lower cervical and first thoracic inter-arytenoid space was referred to as a troublesome ganglion, as also of the communicating branches of the form of this subdivision. Under laryngitis chronica media brachial plexus, would produce a contraction of the vocal reference was made to cases which presented cords with cords of the same side. Beyond these observations the grey, lustreless, roughened surface and which resembled morphological facts mentioned had received no pathological pachydermia laryngis, but were distinguished from it by or physiological explanation. In particular he drew atten- the absence of the pathognomonic tumours over the vocal tion to the intimate connexion which existed between the processes. The several forms of treatment commonly in use isolated respiratory nerve-fibres of the lower laryngeal nerve were referred to. Under laryngitis chronica inferior it was and the sympathetic and the cardiac branches. The morpho- mentioned that in most cases of chronic laryngitis the portion logical foundation was laid in the above-mentioned facts, below the glottis suffered and that it was owing to the showing an exchange of nerve-fibres of different origin and neglect of this region that local remedies often failed to destination, but the isolation of these fibres and the investi- effect a cure. gation of their destinations formed still a subject for future Dr. W. JoBSOX HORNE (London) agreed that the term inquiry. "chronic laryngitis" had come to be too loosely used, that it Dr. J. DUNDAS GRANT (London) read a paper on was far too comprehensive, and that a more particularised dia- Simplified Operation for Deflection of the Cartilaginous gnosis was required to secure the best treatment. At the same time he could not accept the classification of chronic larynThis consisted in the first instance in straightening the gitis, as suggested by Dr. Haring, into "superior," "media," cartilage by transfixion by means of a strong needle intro- and "inferior." A regional subdivision might be at times duced from the concave side in front of the concavity, clinically useful for purposes of description, but it was not pushed through to the other side, and then back through to permissible on pathological grounds, and, after all, an apprethe concave side behind the deflection. Two cuts were then ciation of the pathology of the various forms of chronic made by means of Moure’s or Asch’s shears through the laryngitis was the only sure way of reaching the most approcartilage, one above and in front of the deflection parallel to priate treatment..de therefore advocated a classification. the nasal ridge, the other horizontally below parallel to the which specified the causes and was based upon pathology. floor of the nose but not meeting. The cartilage was then Dr. HARING replied that the subdivisicns which he had were intended to be clinical aids to carrying out manipulated so as to bring about over-riding of the segments at the lines of incision. The operation could be done under Irthe treatment of parts most affected in particular cases.
Septum.
mentioned I