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NASAL OBSTRUCTION AND DEFORMITIES OF THE UPPER JAW, TEETH, AND PALATE.
1038
being of considerable importance in the obserstudy of psoriasis. 1. A careful examination, frequently repeated, of the stools, more especially as to odour and consistence. with the view of determining to what extent the intestinal canal may be acting as a focus of absorption of toxic substances: 2. A similar investigation of the urine, especially noting the total amount passed daily, so as to supply evidence as to the renal activity and general Further important evidence on this cardio-vascular tone. latter point is obtained from (3) a study of the capillary
lay
stress
as much as the algebraic formula a;. To substitute for an explanation is a common but undesirable fallacy. To what extent the shape of the teeth and face and upper jaw is affected by a similar condition in the parent is a matter for careful consideration and offers many pitfalls. The same set of circumstances may surround the offspring in the early years of life that surrounded the parent and produce a similar effect, and yet can in no sense be attributed to a hereditary tendency. The environment is a potent factor in reproducing
quantity
as
vation and
reaction of the general skin surface. More information may sometimes be gained from a critical examination of the skin that is apparently healthy than of the skin that obviously diseased. We have pleasure in expressing our indebtedness to Dr. Edward Carmichael for permission to investigate and to record the cases under his care.
a
I
name
isI
NASAL OBSTRUCTION AND DEFORMITIES OF THE UPPER JAW, TEETH, AND PALATE.1 BY MAYO
COLLIER, M.S. LOND., F.R.C.S. ENG.,
PAST SENIOR SURGEON TO THE NORTH-WEST LONDON HOSPITAL; PRESIDENT OF THE BRITISH LARYNGOLOGICAL ASSOCIATION.
THE subject of this paper is the peculiar deformity of the upper jaw, teeth, and palate so commonly associated with obstructed nasal respiration. The diagrams marked A, B, and C taken from casts indicate the commoner types of this deformity. In A the whole range of the maxillary teeth is well inside the range of the mandibular set, or, to be less technical, the arch of the lower jaw is larger and surrounds the arch of the upper jaw. In these cases the lower jaw is prognathous. With the mouth closed the incisors of the lower jaw are well in front of those of the upper jaw, and the molars of the upper jaw rest by their outside edges on the molars of the lower jaw. The cast labeled B shows the whole upper jaw in an extremely atrophic state and the curve of the alveolar arch is less than the curve of that of the lower jaw and the teeth of the upper jaw are just inside the teeth of the lower jaw. In these cases the palate is extremely high and the turbinal bones are closely approximated to the septum. In a third variety, as shown by the casts marked C, the incisor teeth of the upper jaw are in front of the incisor teeth of the lower jaw. The curve of the arch of the upper jaw is altered so that its sides are approximated and the centre of the arch is thrown forwards in front of the incisors of the lower jaw. The incisors of the upper jaw are prominent and overhang those of the lower jaw. Various explanations have been given of these irregular and unsymmetrical conditions of the jaw, teeth, and palate, but none is altogether complete,
satisfactory. object of this communication is to show, place, that in impeded nasal respiration there is
clear,
or
in the first difference in the pressure on the outside and the inside of the walls of the upper jaw and that if this is so this difference in pressure, however small, is capable in the young and growing skull of altering and affecting the curves of the upper jaw and the shape of the face and palate. Next, I shall approach the subject from the experimental point of view and show that in young animals whose nasal cavity or cavities have been obstructed for the purposeof scientific observation a profound alteration takes place in the development of the upper jaw and a marked alteration in the curves of the alveolar arch and position and height of the palate, on all fours with what one observes in every-day life. And lastly, as completely negativing the prevalent and mischievous statement that these cases are" "hereditary, and there is an end to the matter," I have photographs of children whom I have personally seen and known, who were born with beautiful regular faces and symmetrical dental arches. These have become in after life the subjects of the deformities and irregularities outlined by these casts. To say that these cases are hereditary is not The term "hereditary"is an unknown an explanation. The
a
I’
1
Abstract, of Britain on May
paper read before the 1st, 1899. a
Odontological Society of Great
the
peculiarity.
A
different
would
environment
have
by a different result, whereupon the hereditary tendency vanishes, or, perhaps, is not strong enough to assert itself. * An explanation that approaches nearest the truth is the one associated with nasal obstruction and mouth-breathing. Here, undoubtedly, a stream of air passes the palate and tongue to find its way to the lung. The lower jaw is constantly separated from the upper jaw and themasseter mu-cles are constantly put on the stretch. been
followed
-
These facts are patent and mut be admitted, but theinference is incorrect when it is contended that the alveolar arch is dragged down and approximated by the downwardpull of the masseter and that the palate is pushed up and elevated by the impact of the stream of air upon it. The masseter muscle has no attachment to the alveolar arch and could only pull down the malar bone and the
1039 zygoma, and is consequently out of court as an explanaThe buccinator muscle, again, has been put forward as an active agent in these deformities, but it must be quite innocent of harm as its line of pull is at right angles to the line of action required to produce the contended effect. In mouth-breathing the contention is good that the stream of air passing into the mouth is the cause of the deformity of the palate ; but the method of production is not by impact The effect is on the palate of the stream of moving air. produced by this very same stream of air on its way to the larynx and lungs partly abstracting the contents of the nasal chambers and so producing an increa-ed pressure This from without on all the walls of the nasal box. increased pressure not only pushes up and elevates the hard and soft palates but it squeezes and approximates the halves of the upper jaw and so impedes its proper development and expansion and produces the various deformities and irregularities indicated by these drawings. What evidence is there that the stream of air on its passage to the lungs abstracts part of the contents of the nasal chambers and so causes a lessened tension of the air Some have stoutly denied this fact and contents ? attribute i the very idea to a flight of the imagination The same individuals are of the enthusiastic writer. in the habit of using sprays--no doubt constantly-in the treatment of their patients and must be quite that regulates the spray is the unaware that the law same law that regulates the condition of the air contents of the na-al chambers. Any stream of air passing, however slowly and softly, over any opening leading into any chamber whose contents are air or gas abstracts part of the contents and consequently lessens the tension of that gas or air. This law of pneumatics applies to all atoms in a state of mobility. The actual proof that the tension of the air in the nasal chambers is lessened during each oral inspiration can easily be obtained and should be a complete answer to any objection to the accuracy of this contention. If a manometer be connected with the nose and fit accurately, during each oral inspiration the mercury will ascend in the proximal limb. A more absolute proof cannot be offered. One can also actually see the effect of the difference in tension of the air contents by observing the interior of the On inspiration the mucous nose through a Seigle’s aspirator. membrane becomes redder and on expiration paler, due to the decreased or the increased extra-vascular pressure. I do not fear that with the support afforded by this evidence anyone can seriou-ly contend that complete or partial obstruction to nasal respiration is not followed by oral respiration and as an indirect result by lessened tension of the air contents of the nasal chambers. Some will say : " For argument sake we admit the slight difference in ten-ion in the nasal chambers, but we contend that it is not capable of effecting all you claim for it." The on1lS probandi rests with the tion.
objectors. As affording
a
further remarkable
proof,
if
one can
be
con-
requisite, I will place before you the result of certain experiments carried out by Professor Ziem of Dantsic, whose investigations on this subject are worth the fullest consideration. The experiments of Professor Ziem, although instituted and carried out for a totally different purpose, are completely in support of my contentions. He has proved by direct experiment on animals that every obstruction to the nose when acting for some considerable time exerts widely spread consequences on the development of the skull in young animals in which the nostrils (one or both) are completely blocked up for a long time. Not only the upper jaw sidered
but the whole of
the frontal bone was affected. There deviation of the interaxillary bone and the sagittal suture towards the shut-up side ; also a lesser length of the nasal bone, of the frontal bone, and of the horizontal plate of the palate bone. The palate bone as compared with the other side was distinctly atrophied. The na-al bone and the frontal bone were atrophied and the sutures were displaced from the mid-line towards the atrophied side. There was less steep elevation of the alveolar processes. There was a smaller distance between the anterior surface of the bony auditory capsule and the alveolar processes, also between the zygomatic arch and the supra-orbital border, and smaller size and asymmetrical position of the vascular and nerve canals on the closed side of the nose. The distance of the two orbits from the mid-line was unequal, which, as has been observed in men, leads to asthenopia, astigmatism, and strabismus. The orbit itself was smaller on the closed-up side and the frontal bone, the was
seen
a
I
ear, and the whole
side of the face
were
arrested in their
development. The theoretical explanation I have propounded, together with the practical experiments of Professor Ziem, should be quite sufficient to impress the most sceptical with the belief that although many of these cases may be produced by other causes the disarrangement of the natural pressures on the exterior and interior of the nasal chambers is capable of producing a very serious alteration in the development, shape, and appearance of the whole upper jaw. The experiments of Professor Ziem are again corroborated by the results obtained in these cases of restoring the normal nasal respiration. If the deformity is not too marked and the age of the patient is below that where complete ossification has taken place much improvement in the size, shape, and symmetry of the upper jaw can be effected by simply restoring the normal calibre of the nasal In several cases of marked deformity (two of passages. which occurred in my own family) the deformity has been arrested by restoring the full measure of nasal breathing and much has taken place subsequently in the size, shape, and symmetry of the upper jaw and face. The object of making these remarks on the subject of maxillary and dental deformities is to stimulate the study of the same from a purely etiological point of view. I have endeavoured to point out that it is not only possible, but easy, to predict the course of such cases and to adopt effective measures for their prevention, for more especially in these cases is prevention better than cure.
improvement
Harley-street,
W.
CANCER OF THE ŒSOPHAGUS WITHOUT OBSTRUCTION. BY J. G.
EMANUEL, M.D., B S, B. SC., M.R C.P.,
PATHOLOGIST, GENERAL HOSPITAL, BIRMINGHAM.
Ix the following paper are described six cases of cancer of the aeòophagus without obstruction which occurred at the City of London Hospital for Diseases of the Chest, Victoria Park, E., in the years 1897 to 1899 inclusive, during my tenure of the posts of house physician and resident medical officer. In all these cases the common symptom of cancer of the oesophagus, dysphagia, was either altogether absent or else it was obscured by other more prominent symptoms. In three of the cases the symptoms for the relief of which the patient sought admission to the hospital were laryngeal (hoarseness or aphonia), and in two of these pulmonary symptoms (cough and expectoration) were present as well. In a fourth case the patient was admitted on account of shortness of breath, cough, and expectoration, and the pleural cavity had to be aspirated immediately after admission. Hasmoptysis accounted for the admission of another case, and in only one was there vomiting which was apparently due to a simple gastritis and which was certainly not accompanied by any difficulty in swallowing. Even in those cases in which the history brought out some trouble in deglutition the difficulty was not one associated with trying to get food through a stenosed cesophagus, but was caused by the oesophageal growth perforating either the trachea, the left bronchus, or the lung itself, and bringing on a reflex spa=m of coughing immediately after taking food. This paroxysm was sometimes so violent that the food was returned through the nose as well as through the mouth. It is very important to recognise this form of dysphagia, this reflex paroxysm of cough immediately after swallowing. It differs from the ordinary form of dysphagia, by which, in cancer of the 03sophag)is at all events, is meant difficulty of getting food through a narrowed tube, and by this symptom some stricture of the oesophagus is indicated. But a com"cough immediately after swallowing" munication between the’ oesophagus and the air passages ; and the importance of recognising this symptom is obvious, for although the patient may succeed in getting part of the food, enough to maintain life, past the growth into the stomach, some will find its way into the air passages and sooner or later set up an inhalation broncho-pneumonia. And patients in whom this symptom is present should be advised against taking food through the mouth and should be fed by nutrient enemata, an oesophageal tube, or by means of a gastrostomy.
signifies
being of considerable importance in the obserstudy of psoriasis. 1. A careful examination, frequently repeated, of the stools, more especially as to odour and consistence. with the view of determining to what extent the intestinal canal may be acting as a focus of absorption of toxic substances: 2. A similar investigation of the urine, especially noting the total amount passed daily, so as to supply evidence as to the renal activity and general Further important evidence on this cardio-vascular tone. latter point is obtained from (3) a study of the capillary
lay
stress
as much as the algebraic formula a;. To substitute for an explanation is a common but undesirable fallacy. To what extent the shape of the teeth and face and upper jaw is affected by a similar condition in the parent is a matter for careful consideration and offers many pitfalls. The same set of circumstances may surround the offspring in the early years of life that surrounded the parent and produce a similar effect, and yet can in no sense be attributed to a hereditary tendency. The environment is a potent factor in reproducing
quantity
as
vation and
reaction of the general skin surface. More information may sometimes be gained from a critical examination of the skin that is apparently healthy than of the skin that obviously diseased. We have pleasure in expressing our indebtedness to Dr. Edward Carmichael for permission to investigate and to record the cases under his care.
a
I
name
isI
NASAL OBSTRUCTION AND DEFORMITIES OF THE UPPER JAW, TEETH, AND PALATE.1 BY MAYO
COLLIER, M.S. LOND., F.R.C.S. ENG.,
PAST SENIOR SURGEON TO THE NORTH-WEST LONDON HOSPITAL; PRESIDENT OF THE BRITISH LARYNGOLOGICAL ASSOCIATION.
THE subject of this paper is the peculiar deformity of the upper jaw, teeth, and palate so commonly associated with obstructed nasal respiration. The diagrams marked A, B, and C taken from casts indicate the commoner types of this deformity. In A the whole range of the maxillary teeth is well inside the range of the mandibular set, or, to be less technical, the arch of the lower jaw is larger and surrounds the arch of the upper jaw. In these cases the lower jaw is prognathous. With the mouth closed the incisors of the lower jaw are well in front of those of the upper jaw, and the molars of the upper jaw rest by their outside edges on the molars of the lower jaw. The cast labeled B shows the whole upper jaw in an extremely atrophic state and the curve of the alveolar arch is less than the curve of that of the lower jaw and the teeth of the upper jaw are just inside the teeth of the lower jaw. In these cases the palate is extremely high and the turbinal bones are closely approximated to the septum. In a third variety, as shown by the casts marked C, the incisor teeth of the upper jaw are in front of the incisor teeth of the lower jaw. The curve of the arch of the upper jaw is altered so that its sides are approximated and the centre of the arch is thrown forwards in front of the incisors of the lower jaw. The incisors of the upper jaw are prominent and overhang those of the lower jaw. Various explanations have been given of these irregular and unsymmetrical conditions of the jaw, teeth, and palate, but none is altogether complete,
satisfactory. object of this communication is to show, place, that in impeded nasal respiration there is
clear,
or
in the first difference in the pressure on the outside and the inside of the walls of the upper jaw and that if this is so this difference in pressure, however small, is capable in the young and growing skull of altering and affecting the curves of the upper jaw and the shape of the face and palate. Next, I shall approach the subject from the experimental point of view and show that in young animals whose nasal cavity or cavities have been obstructed for the purposeof scientific observation a profound alteration takes place in the development of the upper jaw and a marked alteration in the curves of the alveolar arch and position and height of the palate, on all fours with what one observes in every-day life. And lastly, as completely negativing the prevalent and mischievous statement that these cases are" "hereditary, and there is an end to the matter," I have photographs of children whom I have personally seen and known, who were born with beautiful regular faces and symmetrical dental arches. These have become in after life the subjects of the deformities and irregularities outlined by these casts. To say that these cases are hereditary is not The term "hereditary"is an unknown an explanation. The
a
I’
1
Abstract, of Britain on May
paper read before the 1st, 1899. a
Odontological Society of Great
the
peculiarity.
A
different
would
environment
have
by a different result, whereupon the hereditary tendency vanishes, or, perhaps, is not strong enough to assert itself. * An explanation that approaches nearest the truth is the one associated with nasal obstruction and mouth-breathing. Here, undoubtedly, a stream of air passes the palate and tongue to find its way to the lung. The lower jaw is constantly separated from the upper jaw and themasseter mu-cles are constantly put on the stretch. been
followed
-
These facts are patent and mut be admitted, but theinference is incorrect when it is contended that the alveolar arch is dragged down and approximated by the downwardpull of the masseter and that the palate is pushed up and elevated by the impact of the stream of air upon it. The masseter muscle has no attachment to the alveolar arch and could only pull down the malar bone and the
1039 zygoma, and is consequently out of court as an explanaThe buccinator muscle, again, has been put forward as an active agent in these deformities, but it must be quite innocent of harm as its line of pull is at right angles to the line of action required to produce the contended effect. In mouth-breathing the contention is good that the stream of air passing into the mouth is the cause of the deformity of the palate ; but the method of production is not by impact The effect is on the palate of the stream of moving air. produced by this very same stream of air on its way to the larynx and lungs partly abstracting the contents of the nasal chambers and so producing an increa-ed pressure This from without on all the walls of the nasal box. increased pressure not only pushes up and elevates the hard and soft palates but it squeezes and approximates the halves of the upper jaw and so impedes its proper development and expansion and produces the various deformities and irregularities indicated by these drawings. What evidence is there that the stream of air on its passage to the lungs abstracts part of the contents of the nasal chambers and so causes a lessened tension of the air Some have stoutly denied this fact and contents ? attribute i the very idea to a flight of the imagination The same individuals are of the enthusiastic writer. in the habit of using sprays--no doubt constantly-in the treatment of their patients and must be quite that regulates the spray is the unaware that the law same law that regulates the condition of the air contents of the na-al chambers. Any stream of air passing, however slowly and softly, over any opening leading into any chamber whose contents are air or gas abstracts part of the contents and consequently lessens the tension of that gas or air. This law of pneumatics applies to all atoms in a state of mobility. The actual proof that the tension of the air in the nasal chambers is lessened during each oral inspiration can easily be obtained and should be a complete answer to any objection to the accuracy of this contention. If a manometer be connected with the nose and fit accurately, during each oral inspiration the mercury will ascend in the proximal limb. A more absolute proof cannot be offered. One can also actually see the effect of the difference in tension of the air contents by observing the interior of the On inspiration the mucous nose through a Seigle’s aspirator. membrane becomes redder and on expiration paler, due to the decreased or the increased extra-vascular pressure. I do not fear that with the support afforded by this evidence anyone can seriou-ly contend that complete or partial obstruction to nasal respiration is not followed by oral respiration and as an indirect result by lessened tension of the air contents of the nasal chambers. Some will say : " For argument sake we admit the slight difference in ten-ion in the nasal chambers, but we contend that it is not capable of effecting all you claim for it." The on1lS probandi rests with the tion.
objectors. As affording
a
further remarkable
proof,
if
one can
be
con-
requisite, I will place before you the result of certain experiments carried out by Professor Ziem of Dantsic, whose investigations on this subject are worth the fullest consideration. The experiments of Professor Ziem, although instituted and carried out for a totally different purpose, are completely in support of my contentions. He has proved by direct experiment on animals that every obstruction to the nose when acting for some considerable time exerts widely spread consequences on the development of the skull in young animals in which the nostrils (one or both) are completely blocked up for a long time. Not only the upper jaw sidered
but the whole of
the frontal bone was affected. There deviation of the interaxillary bone and the sagittal suture towards the shut-up side ; also a lesser length of the nasal bone, of the frontal bone, and of the horizontal plate of the palate bone. The palate bone as compared with the other side was distinctly atrophied. The na-al bone and the frontal bone were atrophied and the sutures were displaced from the mid-line towards the atrophied side. There was less steep elevation of the alveolar processes. There was a smaller distance between the anterior surface of the bony auditory capsule and the alveolar processes, also between the zygomatic arch and the supra-orbital border, and smaller size and asymmetrical position of the vascular and nerve canals on the closed side of the nose. The distance of the two orbits from the mid-line was unequal, which, as has been observed in men, leads to asthenopia, astigmatism, and strabismus. The orbit itself was smaller on the closed-up side and the frontal bone, the was
seen
a
I
ear, and the whole
side of the face
were
arrested in their
development. The theoretical explanation I have propounded, together with the practical experiments of Professor Ziem, should be quite sufficient to impress the most sceptical with the belief that although many of these cases may be produced by other causes the disarrangement of the natural pressures on the exterior and interior of the nasal chambers is capable of producing a very serious alteration in the development, shape, and appearance of the whole upper jaw. The experiments of Professor Ziem are again corroborated by the results obtained in these cases of restoring the normal nasal respiration. If the deformity is not too marked and the age of the patient is below that where complete ossification has taken place much improvement in the size, shape, and symmetry of the upper jaw can be effected by simply restoring the normal calibre of the nasal In several cases of marked deformity (two of passages. which occurred in my own family) the deformity has been arrested by restoring the full measure of nasal breathing and much has taken place subsequently in the size, shape, and symmetry of the upper jaw and face. The object of making these remarks on the subject of maxillary and dental deformities is to stimulate the study of the same from a purely etiological point of view. I have endeavoured to point out that it is not only possible, but easy, to predict the course of such cases and to adopt effective measures for their prevention, for more especially in these cases is prevention better than cure.
improvement
Harley-street,
W.
CANCER OF THE ŒSOPHAGUS WITHOUT OBSTRUCTION. BY J. G.
EMANUEL, M.D., B S, B. SC., M.R C.P.,
PATHOLOGIST, GENERAL HOSPITAL, BIRMINGHAM.
Ix the following paper are described six cases of cancer of the aeòophagus without obstruction which occurred at the City of London Hospital for Diseases of the Chest, Victoria Park, E., in the years 1897 to 1899 inclusive, during my tenure of the posts of house physician and resident medical officer. In all these cases the common symptom of cancer of the oesophagus, dysphagia, was either altogether absent or else it was obscured by other more prominent symptoms. In three of the cases the symptoms for the relief of which the patient sought admission to the hospital were laryngeal (hoarseness or aphonia), and in two of these pulmonary symptoms (cough and expectoration) were present as well. In a fourth case the patient was admitted on account of shortness of breath, cough, and expectoration, and the pleural cavity had to be aspirated immediately after admission. Hasmoptysis accounted for the admission of another case, and in only one was there vomiting which was apparently due to a simple gastritis and which was certainly not accompanied by any difficulty in swallowing. Even in those cases in which the history brought out some trouble in deglutition the difficulty was not one associated with trying to get food through a stenosed cesophagus, but was caused by the oesophageal growth perforating either the trachea, the left bronchus, or the lung itself, and bringing on a reflex spa=m of coughing immediately after taking food. This paroxysm was sometimes so violent that the food was returned through the nose as well as through the mouth. It is very important to recognise this form of dysphagia, this reflex paroxysm of cough immediately after swallowing. It differs from the ordinary form of dysphagia, by which, in cancer of the 03sophag)is at all events, is meant difficulty of getting food through a narrowed tube, and by this symptom some stricture of the oesophagus is indicated. But a com"cough immediately after swallowing" munication between the’ oesophagus and the air passages ; and the importance of recognising this symptom is obvious, for although the patient may succeed in getting part of the food, enough to maintain life, past the growth into the stomach, some will find its way into the air passages and sooner or later set up an inhalation broncho-pneumonia. And patients in whom this symptom is present should be advised against taking food through the mouth and should be fed by nutrient enemata, an oesophageal tube, or by means of a gastrostomy.
signifies