The Relation of Acute Diseases of the Nose and Throat to Disorders of Digestion. MOREAU R. BROWNX M. D., CHICAGO*'** RKPBINTKD FBOM THX Neto yorfc fHrtical for August 29, 1896. Reprinted from the New York Medical Journal, for August 29, 1896. THE RELATION OF ACUTE DISEASES OF THE NOSE AND THROAT TO DISORDERS OF DIGESTION* By MOREAU R. BROWN, M. D., CHICAGO. Clinical experience demonstrates that there are cer- tain well-defined relations existing between acute in- flammatory conditions of the nose and throat and other disordered organs of the body. In some cases these re- lations are easily explained; while in others they are shrouded in mysteries which pathology has as yet failed to unfold, and which all attempts to account for can be, at present, but matters of theory, not based on the result of completed scientific investigation. Not that the pathologist or laryngologist has been derelict in searching for the aetiological relations, but rather that the limits of science have precluded their discovery. The connection between acute inflammation of the upper air-passages and disorders of digestion, although a mat- * Read before the American Laryngological Association at its eight- eenth annual congress. Copyright, 1896, by D. Appleton and Company. 2 ACUTE DISEASES OF THE NOSE AND THROAT. ter of clinical observation, is no exception to this state- ment, and the surprising fact is that there is such a scant amount of literature bearing on the subject. Bosworth, in his work on Diseases of the Nose and Throat, briefly refers to the changes occurring in the pharyngeal mucous membrane in stomachic disorders, and further calls attention to chronic inflammation of the upper air-passages as being an important aetiological factor in acute inflammation of the same region. He considers the involvement of the pharynx in gastric disorders as due to the fact that the pharynx is a part of the digestive tract, being the point where the air-pas- sages cross it, which may, in some cases, account for the extension of the inflammatory process. In his Lettsomian Lectures, T. Lauder Brunton re- fers to stomach cough as being due to mild inflamma- tory changes in the upper air-passages, plus the digestive disturbances. He cites a case of stomach cough wherein the pharynx was decidedly hyperaemic, and although no laryngeal examination was made, it was concluded from the symptoms that the larynx was similarly involved. The cough and inflammation failed to respond to treat- ment until a blue pill had been administered. The following case, in my own practice, serves to illustrate the condition rather more forcibly: Mr. -, aged about forty-five, restaurant keeper by occupation, a healthy, robust-looking man, fond of rich food, consulted me first about five years ago for a rather severe attack of acute inflammation in the upper air-pas- sages (nose, pharynx, and larynx) accompanied with asthma. As a history, he stated that such attacks were generally preceded by gastro-intestinal disorders, and a few days previous to the present attack he had suffered ACUTE DISEASES OF THE NOSE AND THROAT. 3 considerable digestive disturbance, such as loss of appe- tite, disgust for food, nausea, headache, abdominal dis- tress and pain, eructation of gas, constipation, and men- tal depression. The treatment directed to the inflam- mation of the upper air-passages was carefully carried out for a short time, but failed to give relief until a saline laxative, followed by such treatment as was calculated to restore the digestion, was ordered and taken. After- ward, appropriate treatment, carried on for some time, checked further asthmatic attacks, but I have seen him a few times since with acute inflammation of the upper air-passages which responds readily to remedies directed to the digestive organs. I have searched the medical literature within my reach for other authorities bearing on this subject, and I am able to give the following reports: (Edema of the larynx in the angeioneurotic, con- nected with gastric disturbances generally, is mentioned by Collins, Osler, Lovett, and also by Pryor (Med. Record, July 28, 1894). Nogano (Courrier med., Paris, September 23, 1893) records a case of haemorrhage of the larynx in a forty- five-year-old man who had suffered from cirrhosis of the liver and cardiac disease. Cackle (Medical Times and Gazette, August 4, 1884) records a case with symptoms resembling those of laryn- geal phthisis. Later two attacks of unconsciousness fol- lowed in quick succession, the latter being fatal. At the autopsy, latent hepatic abscess was found, also a small ulcer of the left vocal cord, the nature of which was not stated. No signs of tuberculosis were discovered. Ed. Lori (Die durch anderweitige Erkrankungen be- dingten Verdnderungen des Rachens, des Kehlkopfs und der Luftrohre, Stuttgart, 1885) thinks that " gastro-in- 4 ACUTE DISEASES OF THE NOSE AND THROAT. testinal catarrh may be either the cause or the result of chronic throat and laryngeal catarrhs." He mentions also haemorrhagic affections of the larynx in liver cirrhosis and echinococcus. Ed. Lori (Jahrbuch fiir Kinderheilkunde, xxi, 1884; Centralblatt fiir Laryngologie, i, 360; Orvosi Hetilup, 1884, No. 12; Pest. med. Presse, No. 31), speaking of gas- tric complications of laryngeal disease in children, says: " Laryngeal disease may affect the stomach by continu- ity, by swallowing secretions of ulcerated sores, cankers, etc., and gastric disturbances are often produced in a reflex way from the larynx. Especially do we frequently observe meteorism and anorexia with inflammatory dis- ease of the posterior laryngeal walls, and also gastric dilatation and vomiting." Turck has also recently demonstrated the bacterial origin of stomachic disorders from nasopharyngeal in- fection, finding similar micro-organisms in both regions, and the former relieved after relieving the latter. Fur- ther bacteriological research may be able to demonstrate the reverse of this position, and establish that stomach disorders are causal factors of laryngeal inflammations, though, as far as I can learn, no one has undertaken the task. Steffin (von Ziemssen's Cyclopaedia) says spasm of the glottis may be favored by elevation of the diaphragm, owing to overfilling of the stomach, or by overdisten- tion of the intestines by faecal masses, or by serous swell- ing of the liver. Among the conditions found present in spasm of the glottis are swelling, and yellow or yel- low-gray color of the liver, and a considerable deposit of fat within its cells. Ariza (Madrid, Laringismo gastrico, Centralblatt, ii, ACUTE DISEASES OF THE NOSE AND THROAT. 5 446; El Distancen, No. 44, p. 211, May 20, 1885) cites a case (Virchow's Annalen) Qi aphonia from indigestion relieved by an emetic. He distinguishes three varieties of laryngeal disturbance from gastric disorders: 1. Laryngeal hypersesthesia, with normal aspect of the fauces and larynx, the patients complaining of burn- ing sensations, pain, etc. All these patients suffer from dyspepsia. He reported cases at the Laryngological Con- gress at Milan. 2. " Laringismo gastrico plastico." The vocal cords and surroundings are hypersemic and painful, and vary with the gastric disorder. This form especially occurs with chronic gastric disease. 3. " Laringismo gastrico paralitico." He says that he can not explain the aphonia and dysphonia in cholera cases, except by a temporary reflex paralysis of the larynx. He finds, however, in the literature, no laryngoscopic observations, and thinks they would be difficult to make. Kispert, who abstracts his paper, says that Matterstock made some good observations of this'kind in the Wurz- burg epidemic, and found this paralysis frequent, es- pecially on the left side. So much for authorities. The explanation of the conditions of the simultaneous occurrences is not easy, but the following may be suggested: In oedema of the larynx, occurring during the course of liver disorders, it is apparent that we must look to the obstruction of the portal circulation as a cause, and in the inflamma- tion produced by the imbibition of alcohol rather to the venous stasis which follows its use. This is particularly the case in oedema of the upper air-passages ensuing upon a debauch, as shown by the rapidity with which it disappears on taking further liquor early the next day, 6 ACUTE DISEASES OF THE NOSE AND THROAT. and the subsequent increase of the oedematous condition, or by the more rapid recovery following an evacuation of the gastro-intestinal tract. In acute catarrhal inflammation of the nose and throat, supervening on disorders of digestion, we have an entirely different element to deal with. In offering an explanation for this condition we must largely theo- rize. It has been, in times past, the custom to call to our aid the old theory of reflexes, and it may not be unreasonable to suppose that these views are not en- tirely without foundation. It is a recognized fact, as so aptly put by M. Gross (New York Medical Journal, May 4, 1895), that " every affection of the stomach is re- flected back on the other organs; and inversely, every dis- order of the organs reacts upon the stomach." Yet in the present day of bacteriological research, when the micro-organism theory of inflammation is generally rec- ognized, we must agree with Bosworth, who, in a paper read before this association last year, states: "I think that as we become more familiar with the disorders of the upper air tract we shall in many cases be able to abandon this somewhat indefinite and obscure term ' re- flex,' and adopt the theory that many of the so-called ' reflexes ' are the direct result of morbid action upon either the nerve centres or the tissues involved in the inflammatory process" (jVew York Medical Journal, No- vember, 1859, page G55). What bacteriological research has failed to fully es- tablish is demonstrated clinically-namely, that an acute inflammation of the upper air-passages will create disorders of digestion by direct infection through the mass of muco-purulent secretion, loaded with bacteria, which finds its way into the stomach. But, as to the ACUTE DISEASES OF THE NOSE AND THROAT. 7 reverse process, is it probable that the upper air-passages become inoculated directly by the stomach contents? The irritation of the larynx and pharynx, or, less often, the nasopharynx, from the eructation of the contents of the stomach, is to be ascribed more to the direct irri- tant effect of the secretion than to inoculation. Yet the irritating effect may be so intense and prolonged that acute inflammation follows. In this case it may be that the secretion furnishes a proper soil for the bacteria which light up the inflammation. J. E. Free {New York Medical Journal, December 7, 1895) states: " If there is a morbid process at work in the stomach, there will be established in it colonies of bac- teria in abundance, the toxines may be absorbed, and nourishment to the tissues thus contaminated, and every tissue of the body compelled to feed on this contaminated blood." Warren, in his Surgical Pathology (page 122), says: " Van Buren explains catching cold ' by arrest of the function of the skin as an emunctory, whereby certain effects, and presumably noxious materials which should be eliminated, are retained and act as blood poisons? This view of auto-infection is used to explain any febrile and inflammatory disturbances due to ptomaine absorp- tions arising from gastric and intestinal disorders." We know that the presence in the circulatory blood of certain toxic products of some micro-organisms favors the development of foci of inflammation, and the site of a chronic inflammation seems sufficient to predispose to infection. Orloff (Materialien zur Frage uber die Ein- trittswege der Mikroben in den thierischen Organis- mus, Centralblatt f. Bacteriologie u. Parasitenkunde, Bd. cxi, No. 15) fed pure culture of staphylococcus to 8 ACUTE DISEASES OF THE NOSE AND THROAT. six healthy animals. He then made a subcutaneous fracture in all six animals, and found that suppuration ensued at the point of fracture. This demonstrates that bacteria and toxines in the stomach will infect any weak point in the system. We may therefore surmise that in this manner the nose and throat may be infected through disorders of digestion. Another explanation of this condition might be that digestive disorders would lower the vitality to such a degree that the patient would become more liable than the healthy to attacks of acute inflammation, and this would be more apt to occur at points weakened by chronic inflammatory changes, such as we find in the upper air-passages of the majority of individuals. There is one disease of the gastro-intestinal tract in which laryngeal complications have been extensively studied, and while typhoid fever may not be consid- ered as falling within the scope of my subject, yet the inference is legitimate that if typhoid fever does pro- duce laryngeal complications, so also may gastritis have an analogous influence on the larynx and other upper air organs. Laryngeal complications occurring in typhoid fever have attracted no little attention, and literature abounds with reports of cases and theories advanced as to the re- lation they have to each other. The laryngeal changes vary from a slight degree of hyperaemia to rather exten- sive loss of tissue. In some cases there is what appears to be a simple catarrhal laryngitis, or there may be oedema, infiltration of tissue, ulceration, or perichon- dritis. The larynx is, at times, left in a state of ex- tensive deformity. The changes may occur at almost any stage of the typhoid period, occasionally ushering ACUTE DISEASES OF THE NOSE AND THROAT. 9 in the disease. Voltolini (Archives of Laryngology, vol. i) describes a case where a patient, after exposure to wet and cold, had a severe laryngitis; in the course of a few days regular typhoid fever set in, and, running its usual course, the laryngeal condition progressed rapidly to the stage of ulceration. The laryngeal complications seem to bear no rela- tion to the typhoid symptoms. The deeper tissues are seldom involved in the early stages of the disease; ulcera- tion, oedema, and perichondritis occur in the latter stages or during convalescence, sometimes as late as two months after the onset of the disease (Union med., March 10, 1892). As may be surmised, the symptoms may be serious from stenosis, or from the dangers of necrosis. The condition, in some cases, may result in loss of life; tracheotomy or intubation may be required; and the resulting deformities may necessitate the indefi- nite retention of the tube. The lesions generally in- volve the epiglottis, arytsenoids, and cricoid cartilages. Lucatela (Gazzetta degli Ospedali, 70, 132) and others report finding Eberth's bacilli in the larynx in fatal cases. Brieger and Frankel failed to demonstrate the presence of typhoid bacilli in these laryngeal ulcers (Kanthack and Drysdale, Journal of Laryngology, April, 1896), but the weight of evidence seems to favor the specific origin of laryngeal ulcers in typhoid. Taken alone, the argument from analogy is not convincing, but it seems to be plausible enough to infer that if the typhoid bacilli can infect the larynx, so may other forms of bacilli, which have their origin in the stomach, be able to invade and infect, likewise, the upper air-passages. To sum up the subject, then, I would say that no proof has yet been presented of the direct causation of 10 ACUTE DISEASES OF THE NOSE AND THROAT. acute inflammatory processes in the upper air-passages by stomach disorders; but that clinical observation is abun- dant in favor of such causation, and that the hope may be entertained that the bacteriologists will soon be able to supply direct proof. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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