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Tuberculosis of the nose, throat, and ear
.CRITICAL
REVIEWS
33
CRITICAL REVIEWS. UNDER the above heading it is proposed to publish in this and subsequent issues critical summaries of the more important of recent publications relating to the pathological, clinical, and sociological aspects of tuberculosis. This, it is believed, will be of practical service to all desirous of keeping abreast of the rapidly extending literature of the subject.
TUBERCULOSIS OF THE NOSE, THROAT, A N D EAR. BY G E O R G E ~VILKINSON, B.A., M.B., B.C., F.R.C.S., Horn Surgeon, E a r a n d T h r o a t D e p a r t m e n t , Sheffield Royal Hospital ; Lecturer on Diseases of t h e T h r o a t in the U n i v e r s i t y of Sheffield.
is a fairly common cause of derangement in nose, ear, and t h r o a t . Both as regards pathology and therapeutics much progress is being made. Among the more important subjects recently studied, special attention may be directed to the following :
TUBERCULOSIS
GalvanofPuncture
in Laryngeal Tuberculosis.
Modern views on the pathology of tuberculosis of the larynx have modified to some extent the methods of treatment in favour with laryngologists for this condition. It is now recognized that tuberculosis of the larynx is in practically all cases secondary to tuberculous deposits in the lungs. T h e excellent results Obtained by sanatorium treatment in early cases, and even in those somewhat advanced, are generally recognized. In laryngeal cases, the " s i l e n c e " treatment is of great value as an addition to the usual routine of sanatorium treatment. T h e importance of giving physiological rest to the larynx was first insisted on by Moritz Schmidt, whose views have found a strong supporter in this country in St. Clair Thomson. 1 In consequence, perhaps, of the recognition of the efficacy of these general hygienic measures, there seems to be a tendency amongst laryngologists to limit the employment of active surgical treatment of the tuberculous larynx to those cases in which there is great dysphagia from ulceration of the epiglottis. The employment of deep galvano-caustic I T h o m s o n , St. Clair : Journal of Laryngology, N o v e m b e r , I9oi. 3
34
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
puncture for cases of submucous tuberculous infiltration of the larynx is advocated by St. Clair Thomson, 1 Dundas Grant, ~ and others, in this country, and by Escat ~ (of Toulouse) in France. This method of treatment, though long in occasional use, was first brought prominently before the profession by Grtinwald in 19o3 .4 The rationale of the treatment is to produce cicatrization of the focus in the submucous tissues, without causing a large open wound of the mucous membrane, as is inevitable by the use of the laryngeal curette. Cases showing very encouraging results have been recently exhibitedP Nasal Obstruction and Pulmonary
Tuberculosis.
It might well be surmised on a priori grounds that nasal obstrnction, by inducing mouth-breathing and under-development of the thorax, would be an important predisposing cause of pulmonary tuberculosis. Such seems to be the assumption of many writers on ihe subject. W . G. Rivers 6 has investigated the evidence of statistics, and carefully analyzed recent literature bearing on the subject. He concludes that there is evidence to show that nasal obstruction from all causes is more common in the phthisical than in the rest of the community, and that there can be little doubt that the nasal obstruction is the antecedent condition and a causal factor. He makes the suggestion that the hereditary predisposing factor in the incidence of consumption may be largely an inherited faulty development of the nose and nasopharynx, causing nasal obstruction. He also expresses the opinion that the catarrhal laryngitis s o frequently present in early phthisis is the result of nasal obstruction and catarrh, rather than of irritation of the larynx by coughing~ which is the usually assigned cause fol; this association. He quotes Besan~on's observations on the frequent occurrence of the same deformities of the chest in consumptives as in subjects of nasal obstruction. The presence of these deformities indicates that nasal obstruction, usually from adenoids, has be~n present in early life. Pulmonary
C o l l a p s e a n d I n d u r a t i o n d u e to N a s a l O b s t r u c t i o n .
This condition was first described by Kr6nig, 7 and has been more recently investigated by Bltimel. s It consists of a fibrous induration i Thomson. St. Clair : Jourmtl of Laryngology, June, 1908. Grant, D. : Journal of Laryngology, April, 19o9. 3 Escat : Journal of Lefyngology, September, 19o6. * Griinwald: Mi~nchenerMcdizinische Wochenschvift, June 23, I9o3, quoted in Journal of Laryngology, May, 19o4. " Meeting of LaryngologicalSection, Royal Societyof Medicine,November 5"1.19o9 6 Rivers, W. G. : Lancet, December 27, I9o7• 7 Kr6nig : DeutschKlinik, Band XI., S. 634. 8 Bliimel:Miinchener Medizinische Wochenschrift, July 28, 19o8.
CRITICAL
REVIEWS
35
and shrinkage of the apices of the lungs, with flattening of the chest wall over the apices, first manifest on the right side, in patients ;¢¢h0 are the subject of nasal obstruction. BKimel regards it as secondary to mouth-breathing and dust-inhalation, with resulting catarrhal conditions of the air-passages. It is a non-tuberculous affection, though doubtless a condition predisposing t o tuberculous infection of the lungs. T h e diagnosis between this condition and early phthisis depends on absence of tubercle bacilli from the .expectoration, and want of reaction to tuberculin tests. •T h e
Diagnostic
Use
of Tuberculin.
Lafite-Duport and Moulinier 1 (Bordeaux) have added one more to the number of tuberculin diagnostic methods at present in use. T h e serum used seems to be identical with Callnette's~i.e., a i per cent. solution, in sterile water, of dried tuberculin, previously purified by precipitation with alcohol. T h e novelty of the method consists in applying the serum on small cotton swabs to the mucous membrane of the septum of the nose, to w h i c h it is kept applied for ten minutes. Reaction follows in eighteen to forty-eight hours, and is manifested b y congestion of the muucosa, followed b y an exudate at the site of application. A crust forms later, which separates on the fourth to sixth day. If the reliability of the test be established, the selection of the nasal nmcous m e m b r a n e as the site of application, in place of the conjunctiva, has certain obvious advantages. A good many cases of painful and even serious inflammations of the conjunctiva and cornea have been recorded as the result of excessive reaction to Calmette's ophthalmic instillation test. Excessive .reaction will probably be attended w i t h less danger and discomfort on the less sensitive nasal mucous membrane. Another advantage is that the rhino-reaction can be applied without the patient understanding its significance or being conscious of t h e r e s u l t obtained. W e have n o w six methods of applying t h e tuberculin test to choose from : the hypodermic injection method, yon Pirquet's scarification method, Moro's 2 Ointment inunction, W o o d c o c k ' s 8 blister~ing method, Calmette's ophthalmoreaction, and the most recent rhino-reaction. An extended trial is required to determine the relative reliability and convenience of the various methods. 1 Lafite-Duport and Moulinier: Xnnales des Mal~tdies de l'Oreille et du Larynx, May; i9o9, quoted in Journal of Laryngology, November, 19o9. '2 Miinchene# Medizinische Wochenschrifl, February 4, I9o8. British Medical Journal, March 28, I9o8.
REVIEWS
33
CRITICAL REVIEWS. UNDER the above heading it is proposed to publish in this and subsequent issues critical summaries of the more important of recent publications relating to the pathological, clinical, and sociological aspects of tuberculosis. This, it is believed, will be of practical service to all desirous of keeping abreast of the rapidly extending literature of the subject.
TUBERCULOSIS OF THE NOSE, THROAT, A N D EAR. BY G E O R G E ~VILKINSON, B.A., M.B., B.C., F.R.C.S., Horn Surgeon, E a r a n d T h r o a t D e p a r t m e n t , Sheffield Royal Hospital ; Lecturer on Diseases of t h e T h r o a t in the U n i v e r s i t y of Sheffield.
is a fairly common cause of derangement in nose, ear, and t h r o a t . Both as regards pathology and therapeutics much progress is being made. Among the more important subjects recently studied, special attention may be directed to the following :
TUBERCULOSIS
GalvanofPuncture
in Laryngeal Tuberculosis.
Modern views on the pathology of tuberculosis of the larynx have modified to some extent the methods of treatment in favour with laryngologists for this condition. It is now recognized that tuberculosis of the larynx is in practically all cases secondary to tuberculous deposits in the lungs. T h e excellent results Obtained by sanatorium treatment in early cases, and even in those somewhat advanced, are generally recognized. In laryngeal cases, the " s i l e n c e " treatment is of great value as an addition to the usual routine of sanatorium treatment. T h e importance of giving physiological rest to the larynx was first insisted on by Moritz Schmidt, whose views have found a strong supporter in this country in St. Clair Thomson. 1 In consequence, perhaps, of the recognition of the efficacy of these general hygienic measures, there seems to be a tendency amongst laryngologists to limit the employment of active surgical treatment of the tuberculous larynx to those cases in which there is great dysphagia from ulceration of the epiglottis. The employment of deep galvano-caustic I T h o m s o n , St. Clair : Journal of Laryngology, N o v e m b e r , I9oi. 3
34
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
puncture for cases of submucous tuberculous infiltration of the larynx is advocated by St. Clair Thomson, 1 Dundas Grant, ~ and others, in this country, and by Escat ~ (of Toulouse) in France. This method of treatment, though long in occasional use, was first brought prominently before the profession by Grtinwald in 19o3 .4 The rationale of the treatment is to produce cicatrization of the focus in the submucous tissues, without causing a large open wound of the mucous membrane, as is inevitable by the use of the laryngeal curette. Cases showing very encouraging results have been recently exhibitedP Nasal Obstruction and Pulmonary
Tuberculosis.
It might well be surmised on a priori grounds that nasal obstrnction, by inducing mouth-breathing and under-development of the thorax, would be an important predisposing cause of pulmonary tuberculosis. Such seems to be the assumption of many writers on ihe subject. W . G. Rivers 6 has investigated the evidence of statistics, and carefully analyzed recent literature bearing on the subject. He concludes that there is evidence to show that nasal obstruction from all causes is more common in the phthisical than in the rest of the community, and that there can be little doubt that the nasal obstruction is the antecedent condition and a causal factor. He makes the suggestion that the hereditary predisposing factor in the incidence of consumption may be largely an inherited faulty development of the nose and nasopharynx, causing nasal obstruction. He also expresses the opinion that the catarrhal laryngitis s o frequently present in early phthisis is the result of nasal obstruction and catarrh, rather than of irritation of the larynx by coughing~ which is the usually assigned cause fol; this association. He quotes Besan~on's observations on the frequent occurrence of the same deformities of the chest in consumptives as in subjects of nasal obstruction. The presence of these deformities indicates that nasal obstruction, usually from adenoids, has be~n present in early life. Pulmonary
C o l l a p s e a n d I n d u r a t i o n d u e to N a s a l O b s t r u c t i o n .
This condition was first described by Kr6nig, 7 and has been more recently investigated by Bltimel. s It consists of a fibrous induration i Thomson. St. Clair : Jourmtl of Laryngology, June, 1908. Grant, D. : Journal of Laryngology, April, 19o9. 3 Escat : Journal of Lefyngology, September, 19o6. * Griinwald: Mi~nchenerMcdizinische Wochenschvift, June 23, I9o3, quoted in Journal of Laryngology, May, 19o4. " Meeting of LaryngologicalSection, Royal Societyof Medicine,November 5"1.19o9 6 Rivers, W. G. : Lancet, December 27, I9o7• 7 Kr6nig : DeutschKlinik, Band XI., S. 634. 8 Bliimel:Miinchener Medizinische Wochenschrift, July 28, 19o8.
CRITICAL
REVIEWS
35
and shrinkage of the apices of the lungs, with flattening of the chest wall over the apices, first manifest on the right side, in patients ;¢¢h0 are the subject of nasal obstruction. BKimel regards it as secondary to mouth-breathing and dust-inhalation, with resulting catarrhal conditions of the air-passages. It is a non-tuberculous affection, though doubtless a condition predisposing t o tuberculous infection of the lungs. T h e diagnosis between this condition and early phthisis depends on absence of tubercle bacilli from the .expectoration, and want of reaction to tuberculin tests. •T h e
Diagnostic
Use
of Tuberculin.
Lafite-Duport and Moulinier 1 (Bordeaux) have added one more to the number of tuberculin diagnostic methods at present in use. T h e serum used seems to be identical with Callnette's~i.e., a i per cent. solution, in sterile water, of dried tuberculin, previously purified by precipitation with alcohol. T h e novelty of the method consists in applying the serum on small cotton swabs to the mucous membrane of the septum of the nose, to w h i c h it is kept applied for ten minutes. Reaction follows in eighteen to forty-eight hours, and is manifested b y congestion of the muucosa, followed b y an exudate at the site of application. A crust forms later, which separates on the fourth to sixth day. If the reliability of the test be established, the selection of the nasal nmcous m e m b r a n e as the site of application, in place of the conjunctiva, has certain obvious advantages. A good many cases of painful and even serious inflammations of the conjunctiva and cornea have been recorded as the result of excessive reaction to Calmette's ophthalmic instillation test. Excessive .reaction will probably be attended w i t h less danger and discomfort on the less sensitive nasal mucous membrane. Another advantage is that the rhino-reaction can be applied without the patient understanding its significance or being conscious of t h e r e s u l t obtained. W e have n o w six methods of applying t h e tuberculin test to choose from : the hypodermic injection method, yon Pirquet's scarification method, Moro's 2 Ointment inunction, W o o d c o c k ' s 8 blister~ing method, Calmette's ophthalmoreaction, and the most recent rhino-reaction. An extended trial is required to determine the relative reliability and convenience of the various methods. 1 Lafite-Duport and Moulinier: Xnnales des Mal~tdies de l'Oreille et du Larynx, May; i9o9, quoted in Journal of Laryngology, November, 19o9. '2 Miinchene# Medizinische Wochenschrifl, February 4, I9o8. British Medical Journal, March 28, I9o8.