Examination of the Posterior Nares

A. Hodgkinson
1877 BMJ (Clinical Research Edition)  
June 23, ix77.] THE BRITISH MEDICAL 7OURNAL. 77' tation, and pseudo-angina; the disease so induced, however, being devoid of the characteristic pains, and the more aggravated phenomena of fatal angina". I now pass on to my own explanation of the relationship between the pain of true angina pectoris and the arterial contraction; also of the imodus operandi of the nitrite of amyl in these cases. I believe that we have as yet no data which will enable us to give a complete explanation of the pain
more » ... nation of the pain of angina pectoris, whether it be a pure neuralgia with consequent inhibition of the cardiac contractions, or a result of cardiac muscular cramp, or of overdistension of one or more of the heart's cavities, or a combination, in some cases at least, of two or more of these conditions, must remain at present a matter of doubt. It is agreed on all hands, that the pain is often agonising, and that it often radiates into neighbouring sensitive nerves, more especially those of one or both arms. It is a fact ascertained by experiment, that electrical irritation of the central end of a mixed or a sensitive nerve, such as, tor instance, the sciatic or the trigeminal, not only causes severe pain, but also excites by a reflex.influence through the vasomotor centre, a general contraction of the arterioles, with resulting high arterial tension. (See Vulpian, Lefons snir fAppdareil Vaso-.foteur, tome i, p. 237, etc.) I, therefore, venture to suggest that the high arterial tension, when associated with angina pectoris, is a secondary reflex result, and not the primary cause of the cardiac agony i and, further, that the remedial efficacy of the nitrite of amyl is due to its remarkable influence over some forms of neuralgia, and not to its relaxing effect upon the arterioles, except in so far as its antineuralgic power may depend upon its influence on the arterioles. My contention is that, in addition to the centripetal nervous influence which causes the pain of angina, there is an influence reflected from the nervous centre through the vaso-motor nerves, and thus exciting a more or less general contraction of the arterioles. It is probable that the peripheral arterial resistance, although not the primary or the main cause of the pain, yet adds to the distress and the danger of the paroxysm. We have no evidence to prove that in any case of angina there is a general arterial contraction. It may be that the arterial contraction, like the pain, is limited to one or both arms. A true theory of the relationship between angina and arterial contraction, and of the manner in which the nitrite of amyl affords the remarkable relief which it often does, is not without practical utility, more especially as a guide in the selection of cases which are suitable for the employment of the drug. One of the most striking examples of great and permanent relief by the use of nitrite of amyl is afforded by the case of Dr. Herries Madden of Torquay, as recorded by himself. (Prac/ilioner, IS72, vol. ix, p. 33I ; quoted also in Dr. Gairdner's essay, before referred to.) Dr. Madden states, that for a considerable time he had hesitated and neglected to employ the nitrite of amyl, in consequence of his belief that it was suitable only in those cases in which the face is pallid during the paroxysms. " As mine was flushed", he says, " I dismissed front my mind all thoughts of trying it, and paid the penalty of hasty conclusions in the shape of a large amount of acute suffering. The result of a first trial of five drops inhaled during a severe paroxysm "was truly wonderful. The spasm was, as it were, strangled in its birth; it certainly did not last two minutes instead of the old weary ztently, and so it continued. The frequency of the paroxysms was not diminished for some time; but then they were mere bagatelles as compared with their predecessors. Under these improved circumstances, strength gradually returned, the attacks became less and less frequent, and finally ceased." Now, in this case, although the relief from pain was associated with the usual evidence of the physiological action of the drug in relaxing the arterioles, the flushing of the face during the paroxysm forbids the conclusion that a general contraction of the arterioles was the cause of the cardiac distress, and that the relief was due to relaxation of the arterioles. Dr. Talfourd Jones has given some good illustrations of the therapeutic value of the nitrite of amyl, not only in relaxing spasm, but also in rapidly relieving neuralgic pains. (Practitioner, 1871, vol. vii, p. 213.) Dr. Jones's experience has been confirmed by other clinical observers. A few weeks since, I was consulted by a lady who for a fortnight had been suffering from severe facial neuralgia, which had resisted various remedies that had been employed before she came under my care. I advised her to drop five minims of nitrite of amyl on blottingpaper and to inhale the vapour. The pain was rapidly and completely subdued. In a few hours it returned in a milder degree, and it was again promptly removed by the amyl vapour, and, after three or four repetitions of the dose, the cure was complete. It would be interesting, and it might be instructive, to observe, whether during a severe attack of facial neuralgia or sciatica, there is any evidence of contraction of the arterioles, with resulting tension of the arteries. In conclusion, I repeat the expression of my belief that the relief which is often afforded by nitrite of amyl during a paroxysm of angina pectoris, is due to its antineuralgic power, and not directly to its rerelaxing influence on the muscular arterioles. OPHTHALMOLOGY IN ITS RELATION TO PRAC-TICAL MEDICINE. By II. IACNAUGCITON JONES, M.I)., M.Ch., ..C.S.I.&E., Surgeon to the CJrk Ophthalmic and Aural Hospilta, etc. WHIILE I was perusing the valuable and lucid exposition of Dr. Hughlings Jackson, on the relationship which at times exists between ocular motor disturbance and megrim, or it may be certain psychological phenomena, the following case presented itself to my notice. The man came to the extern department of the Cork South Infirmary and County Hospital. He is a very intelligent man, and the annexed description of his case is principally reported from his own statement of his past history and present symptoms. The interest which just now is taken in such cases, and the bearing of this one on the subject dealt with by Dr. Jackson, must be my excuse for here detai ing tha. particulars. WV. A., smith by trade, aged 48, twenty-four years since, when living in London, fell into the hold of a vessel. iHe was removed to St. Thomas's Hospital. Mr. Solly, he says, pronounced his case to be one of "concussion of the spinal cord", with " displacement of the vertebrae" in the cervical region. lie was insensible f.-r some time after the injury; he had difficulty of feciing and inability to open the mouth; there was apparently no aphasia; lie was salivated at the time; he remained in the hospital about eleven weeks. The right side was paralysed, with absence of sensation; the right extremities were useless. He was subsequently subjected to treatment by electricity, and became paraplegic; and both arms and legs were completely paralysed for the space of one year. Ile then recovered gradually, with a halting in the right leg, which remained ever since, and a difficulty in raising the right arm. He got a thelmatic attack about two years since, when the right eye became affected. At present, he has almost complete ptosis of the right eyelid; the pupil of the right eye is dilated; he has divergent strabismus of the same eye, pointing to paralysis of the third nerve. lie can count fingers at any distance with the right eye. Vision 2, (Snellen), with + 60 = o ' nearly; I have not examined with prisms. When he walks with lJoth eyes open, there is a peculiar halting gaitand staggering of the right limb; with thesotund eyelid closedl with adhesive plaister, he gets complete megrim, and cannot walk (would fall); with the affected eyelid closed, lie can walk much more steadily. There is ankylosis of the spinous processes of the third anl fourth cervical vertebrae, with considerable enlargement of this region at the seat of the old injury. Op/hl/almoscopic Examination.-The fundus of the left eye is in every respect normal. The optic disc of the rigllt eye is hyperaemic; the arteries are small and attenuated ; the retina is otllerwise normal. Pscho/ogical PIhnoenat. -When "alone for any time, or violent', he sees visions of "men, women, and children, and animals of all sorts"; these gradually go on maltiplying, and, when they "arc .t their height", he "fancies he sees the devil". lie cannot describe al! the shapes and forms he sees; they arc so numerous. When this sta e has lasted for some time, he must lie or .si down. A feetin. of nausea sometimes comes on, and he gets a sense of faintness; lie never hlas had a fit. When he ntbs the right side of the face with his hands, l:e says he gets a sensation as if le were subj._cted to an electric sllock. The urine is of specific gravity Iot5; no cloudin-ss, tnodeosit, no albumen. Honorary Physician to the Hospital for Consumption and Dis.a ecs of tile Throat Mauchester. SINCE the invention, or at least discovery, by Czrrenak of tlie art of examining the nasal portiol of the pharynx anid thll niial fossae by means of a mirror placed at the back of the throat, the art of rhinoscopy has established for itself a reputation not merely ai an aid to diagnosis, but also as a means of facilitating treatment, which its daily. employment only serves to enhance. Experience brings the rhinosccipist into contact with a class of cases in which the relations of the velum paliti to the pharynx and toague necessitate artificial displacement of the former, whi.s excessive irritability of the parts with which the "palat.-hoak" co ne; into conta:t
doi:10.1136/bmj.1.860.771-a fatcat:u4uxrjwrd5c4fmwi4lbw6vv5na