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Telltale of Mute Tongues
132
KUPERMAN, KRIEGER AND ROSOMOFF
patterns of potentials of the respiratory pathway in the cervical spinal cord in the dog. J Neurosurg 22:277, 1965 18 Henderson VE, Craigie EH: On the respiratory center. Amer J Physiol 115:520, 1936 19 Hukuhara T, Nakayama S, Okada H: Action potentials in the normal respiratory centers and its centrifugal pathways in the medulla oblongata and spinal cord. Jap J Physiol4:145, 1954
20 Pitts RF, Magoun HW, Ranson SW: Localization of the medullary respiratory centers in the cat. Amer J Physiol 126:673, 1963 21 Nathan PW: The descending respiratory pathways in man. J Neurol Neurosurg Psychiat 26:487, 1963 22 Hugelin A, Cohen MI: The reticular activating system and respiratory regulation in the cat. Ann New York Acad Sci 105:586, 1963 Reprint requests: Dr. Kuperman, Hospital, Albert Einstein College of Medicine, 1600 Tenbroeck Avenue, Bronx 10461
Telltale of Mute Tongues Hemoptysis, slight, moderate or massive, is likely to frighten and alarm the patient and challenge the diagnostic ingenuity and competence of the physician. Discounting pathologic changes in the nasopharynx and upper respiratory tract, hemoptysis may be brought about by a long array of lung diseases of bacterial, viral, rickettsial, parasitic, chemical or allergic origin. Apropos of parasitic infestations, it may be of interest to refer to reports in the literature on pulmonary hirudiniasis (leech endoparasitism) associated with pulmonary hemorrhage (Gonzalez de Vega, N. et al, Iber. Parasitol. 20:31, 1960; Almallah, Z., Brit. J. Dis. Chest 62:215, 1968; etc). Primary or metastatic malignant tumors, benign neoplasms of the lung, perforation of adjacent blood vessels, empyema, mediastinal or subdiaphragmatic abscess, or tumors into the lung, collagen diseases, infarction, pneumoconiosis, migrating broncholiths, aspirated foreign budies may be etiologic factors. Similar role may be played by mitral stenosis, pulmonary hypertension, congenital or acquired aneurysm of pulmonary arteries, hemosiderosis, focal or diffuse necrotizing glomerulonephritis, blood dyscrasias and vitamin deficiency. Other possible etiologic factors include penetrating and nonpenetrating chest trauma, cystic fibrosis and vicarious menstruation. Developmental anomalies may be the underlying cause, such as friable bronchial mucosa, increased capillary fragility, increased capillary permeability and congenital hemorrhagic teleangiectasia ( Rendu-Osler-Weber disease). The triple eponym gives due credit to clinicians of keen perception and valid appraisal. Henri Jules Marie Rendu ( 1844-1902) observed and reported on the combined occurrence of recurrent epistaxis and mucosal angiomas (Bull et Mem Soc Med Hop Paris 13:731, 1896). Subsequently, William Osler (1849-1919) recorded three cases of this disease in two families (Bull Johns Hopkins Hosp 12:333,1901) and acknowledged the priority of Rendu. Frederick Parkes Weber (1863-1962), British physician, confirmed the characteristic manifestations of this clini-
cal entity, with particular emphasis on its being familial and hereditary (Lancet 1 :43,1908). For the sake of historic accuracy it should be mentioned that an article entitled Hereditary Epistaxis was published by B. G. Babington in 1865 (2:362). It has been ascertained that it is inherited as a simple autosomal dominant trait, transmitted by both sexes. In some families, one or two generations may be skipped by the disease. The latter is frequently associated with the expectoration of bloodstreaked sputum. During its course, the patient may have frank pulmonary hemorrhage which may terminate fatally. There are great variations in the intensity of bleeding in the same person. Frequent bleedings may result in severe anemia and chronic invalidism. The disease affects both sexes with equal frequency. Typical lesions are nonpulsatile, purplish, bluish red, slightly raised from pin-point to split-pea sized vascular dilatations. The latter is enclosed ·in thin walls of endothelium. This explains the pronounced tendency to bleeding. A glance at the patient's tongue may reveal a telling clue which may save the doctor a battery of diagnostic tests. Such lesions may be observed on the surface of the tongue, in addition to those on the lips, gingiva and hard palate. On further inspection, one may find them in the skin of the face, ears, chest, arms, fingers and feet. Also, they may be present in the mucous membrane of the air passages, gastrointestinal tract and the genito-urinary system. Occasionally, the conjunctiva, the meninges of the brain and spinal cord may be involved. Frequent slight or severe nose bleed may be encountered with involvement of the nasal mucous membrane. Interestingly, groups of vascular dilatations have a tendency to vary in their number and size and may disappear completely after a number of years. Teleangiectatic lesions may or may not be seen in the larynx, trachea and bronchi on laryngoscopic and bronchoscopic examinations. Gastroscopy and rarely, proctoscopy may detect typical lesions. Andrew L. Banyai, M.D.
CHEST, VOL. 59, NO. 2, FEBRUARY 1971
KUPERMAN, KRIEGER AND ROSOMOFF
patterns of potentials of the respiratory pathway in the cervical spinal cord in the dog. J Neurosurg 22:277, 1965 18 Henderson VE, Craigie EH: On the respiratory center. Amer J Physiol 115:520, 1936 19 Hukuhara T, Nakayama S, Okada H: Action potentials in the normal respiratory centers and its centrifugal pathways in the medulla oblongata and spinal cord. Jap J Physiol4:145, 1954
20 Pitts RF, Magoun HW, Ranson SW: Localization of the medullary respiratory centers in the cat. Amer J Physiol 126:673, 1963 21 Nathan PW: The descending respiratory pathways in man. J Neurol Neurosurg Psychiat 26:487, 1963 22 Hugelin A, Cohen MI: The reticular activating system and respiratory regulation in the cat. Ann New York Acad Sci 105:586, 1963 Reprint requests: Dr. Kuperman, Hospital, Albert Einstein College of Medicine, 1600 Tenbroeck Avenue, Bronx 10461
Telltale of Mute Tongues Hemoptysis, slight, moderate or massive, is likely to frighten and alarm the patient and challenge the diagnostic ingenuity and competence of the physician. Discounting pathologic changes in the nasopharynx and upper respiratory tract, hemoptysis may be brought about by a long array of lung diseases of bacterial, viral, rickettsial, parasitic, chemical or allergic origin. Apropos of parasitic infestations, it may be of interest to refer to reports in the literature on pulmonary hirudiniasis (leech endoparasitism) associated with pulmonary hemorrhage (Gonzalez de Vega, N. et al, Iber. Parasitol. 20:31, 1960; Almallah, Z., Brit. J. Dis. Chest 62:215, 1968; etc). Primary or metastatic malignant tumors, benign neoplasms of the lung, perforation of adjacent blood vessels, empyema, mediastinal or subdiaphragmatic abscess, or tumors into the lung, collagen diseases, infarction, pneumoconiosis, migrating broncholiths, aspirated foreign budies may be etiologic factors. Similar role may be played by mitral stenosis, pulmonary hypertension, congenital or acquired aneurysm of pulmonary arteries, hemosiderosis, focal or diffuse necrotizing glomerulonephritis, blood dyscrasias and vitamin deficiency. Other possible etiologic factors include penetrating and nonpenetrating chest trauma, cystic fibrosis and vicarious menstruation. Developmental anomalies may be the underlying cause, such as friable bronchial mucosa, increased capillary fragility, increased capillary permeability and congenital hemorrhagic teleangiectasia ( Rendu-Osler-Weber disease). The triple eponym gives due credit to clinicians of keen perception and valid appraisal. Henri Jules Marie Rendu ( 1844-1902) observed and reported on the combined occurrence of recurrent epistaxis and mucosal angiomas (Bull et Mem Soc Med Hop Paris 13:731, 1896). Subsequently, William Osler (1849-1919) recorded three cases of this disease in two families (Bull Johns Hopkins Hosp 12:333,1901) and acknowledged the priority of Rendu. Frederick Parkes Weber (1863-1962), British physician, confirmed the characteristic manifestations of this clini-
cal entity, with particular emphasis on its being familial and hereditary (Lancet 1 :43,1908). For the sake of historic accuracy it should be mentioned that an article entitled Hereditary Epistaxis was published by B. G. Babington in 1865 (2:362). It has been ascertained that it is inherited as a simple autosomal dominant trait, transmitted by both sexes. In some families, one or two generations may be skipped by the disease. The latter is frequently associated with the expectoration of bloodstreaked sputum. During its course, the patient may have frank pulmonary hemorrhage which may terminate fatally. There are great variations in the intensity of bleeding in the same person. Frequent bleedings may result in severe anemia and chronic invalidism. The disease affects both sexes with equal frequency. Typical lesions are nonpulsatile, purplish, bluish red, slightly raised from pin-point to split-pea sized vascular dilatations. The latter is enclosed ·in thin walls of endothelium. This explains the pronounced tendency to bleeding. A glance at the patient's tongue may reveal a telling clue which may save the doctor a battery of diagnostic tests. Such lesions may be observed on the surface of the tongue, in addition to those on the lips, gingiva and hard palate. On further inspection, one may find them in the skin of the face, ears, chest, arms, fingers and feet. Also, they may be present in the mucous membrane of the air passages, gastrointestinal tract and the genito-urinary system. Occasionally, the conjunctiva, the meninges of the brain and spinal cord may be involved. Frequent slight or severe nose bleed may be encountered with involvement of the nasal mucous membrane. Interestingly, groups of vascular dilatations have a tendency to vary in their number and size and may disappear completely after a number of years. Teleangiectatic lesions may or may not be seen in the larynx, trachea and bronchi on laryngoscopic and bronchoscopic examinations. Gastroscopy and rarely, proctoscopy may detect typical lesions. Andrew L. Banyai, M.D.
CHEST, VOL. 59, NO. 2, FEBRUARY 1971