654

5. As the blade of the laryngoscope is passed still further, the
epiglottis comes into view almost end-on and is readily
passed by the beak of the instrument.
6. The whole laryngoscope is now lifted upwards and for-
wards in a direction at right-angles to the axis of the blade
(leverage is not taken on the teeth, or anœsthetist’s thumb)
and the whole length of the vocal cords comes into view.
If the axis of approach is correct, it coincides with that of
the trachea and the tracheal rings are readily seen.
7. The endotracheal tube may now be passed with ease.
The successful performance of direct laryngoscopy
takes very much longer to describe than to carry out,
and is essentially an easy manoeuvre if simple anato-
mical rules are obeyed.
SUMMARY
Direct laryngoscopy has often been regarded as a
difficult technique because incorrect anatomical prin-
ciples have been assumed.
It is a simple manoeuvre if the patient be adequately
anaesthetised, the neck flexed and the head extended that change of posture influenced the headache, while
‘
ventricle cysts, and Bailey (1916) further elaborated
this view.
These cysts are liable to block one or both of the
foramina of Monro, and changes of posture are likely
to shift their position slightly, so that sudden relief of
the headache due to escape of fluid from the distended
lateral ventricle is a characteristic sign, even in the
absence of other physical signs. Tumours further back
in the third ventricle are liable to cause signs of pressure
on the anterior colliculi and the hypothalamus, so that
ocular pareses and pupil changes and evidences of
diencephalic disturbance, such as hypersomnia, obesity,
polyuria and glycosuria, transient blindness and visual-
field contraction from pressure on the chiasma will help
in locating the tumour.
In the last 18 months I have met with two cases of
colloid cysts of the third ventricle blocking one foramen
of Monro, both of which were characterised by parox-
ysmal severe headache with sudden onset and sudden
disappearance. In the first case the patient denied

about the atlanto-occipital joint. in the second the relief of the pain was dramatic when
Leverage on the upper teeth, and consequent risk of the head was lowered.
damage to these, is unnecessary and is condemned. CASE 1.—A man of 48, seen at the Maida Vale Hospital on
Diagrams and X-ray photographs illustrate correct Sept. 3, 1942, with a 12 months’ history of attacks of vertigo,
and incorrect methods. recurring weekly, associated with sagging of the legs. He
We are indebted to Dr. F. H. Kemp for the X-ray records, also complained of paroxysmal severe headaches for a few
to Messrs. Ilford Ltd. for making the prints from them, and minutes at a time, with sudden onset and sudden disappear-
to the patient who volunteered to be the subject. ance, and just before I first saw him he had a much longer
attack of headache. for several hours. His memory was much
REFERENCES
affected, but there were no pyramidal signs or ataxy. There
Flagg, P. J. (1939) The Art of Anesthesia, Philadelphia. were early choked discs, and lumbar puncture showed a
N.
Gillespie, A. (1941) Endotracheal Anesthesia, Madison, Wisconsin.
Gwathmey, J. T. (1925) Anesthesia, New York. pressure of 220 mm. of water in the cerebrospinal fluid. The
Hadfield. C. F. (1931) Practical Anæsthetics, London. paroxysmal headache, with its sudden variations, was sug-
Hewitt, F. W. (1922) Anæsthetics and their Administration, London.
Jackson, C., Jackson, C. L. (1937) The Larynx and its diseases, gestive of intermittent blocking of one or both foramina of
Philadelphia. (1934) Bronchoscopy, Esophagoscopy and Gas- Monro, and he was transferred to Mr. Wylie McKissock’s
troscopy, Philadelphia. neurosurgical unit at ’Leavesden Hospital. Ventriculo-
Macintosh, R. R., Bannister, F. B. (1943) Essentials of General
Anæsthesia, Oxford. graphy, on Nov. 18, disclosed a globular filling defect in the
Minnitt, R. J. (1940) Handbook of Anæsthetics, Edinburgh. upper and anterior part of .the third ventricle, resembling
Nosworthy, M. D. (1935) The Theory and Practice of Anæsthesia, a colloid cyst. Operation on the same day through a small
London.
Rood, F. S., Webber, H. N. (1930) Anæsthesia and Anæsthetics, right-sided hypophyseal flap ; a circle of right frontal lobe
London. was excised and the lateral ventricle entered. At the foramen
of Monro the bluish wall of a cyst was seen immediately, and
PAROXYSMAL AND POSTURAL HEADACHES by gentle dissection it was eventually delivered into the right
lateral ventricle, the pedicle clipped and the tumour removed
FROM INTRAVENTRICULAR CYSTS AND intact-a colloid cyst measuring 2-5 by 1-5 cm. Recovery was
TUMOURS slow but satisfactory, and when I saw him on Jan. 13, 1944,
he was quite strong and well. The optic discs would have,
WILFRED HARRIS, M D CAMB., F R C P
PHYSICIAN, MAIDA VALE HOSPITAL FOR NERVOUS DISEASES
passed for normal, bdt his memory was still very treacherous
which made it difficult for him to undertake any work.
AND ST. MARY’S HOSPITAL, LONDON
Probably his denial that his headaches were relieved by
ACCOUNTS of only 49 tumours or cysts in the third change of posture was due to his unreliable memory.
ventricle had been published up to 1936 ; yet it is CASE 2.-I saw a more striking case on May 4, 1943. A
probable that these represent only a small proportion girl of 22, an aircraft worker, was sent to me, at St. Mary’s
of actual cases, for I have personally met with 4. In Hospital, for severe intermittent headaches, getting worse
many of the recorded instances of third and lateral for the past two-years, and continuous for the past 3 weeks.
ventricle cysts and tumours no physical signs have been There was’papilloedema with 4D swelling. She stated that
found beyond the so-called classical triad of headache, her headaches were liable to start suddenly and to disappear
vomiting and papilloedema, and sudden death has been suddenly, and that she could sometimes stop them by throwing
common. It is therefore probable that many tumours her head back. She was almost delirious with pain on the
and cysts of the third ventricle and lateral ventricle have night of her admission, throwing her head about in the effort
never come to autopsy, and that their incidence is much to get relief. On the following morning when laid on her
greater than the published records indicate. As Dandy side for lumbar puncture she at once exclaimed " My headache
stated in 1933, " Not the least of the reasons for suspect- has gone." Her CSF pressure was 220 mm. of water, which
ing a tumour of the third ventricle is,... their silence." I considered too high to be followed safely with an air ence-
Paroxysmal headaches, with sudden onset and perhaps phalogram ; but the evidence of postural headache made it
equally sudden disappearance, have been recorded in clear that there was a valvular block of one foramen of Monro.
most such cases, but even more characteristic is sudden Next day Mr. Dickson Wright did ventriculography, which
relief of the pain by sudden change of posture. This demonstrated an enormously dilated left lateral ventricle,
has been observed by Fulton and by Stookey, and was bulging slightly across the middle line. No air could be
striking in 3 of the 4 cases that I have met with. Indeed transferred into the right ventricle, and no air was visible
it was this sudden variation of the headaches with in the third ventricle ; the diagnosis of 3rd ventricle tumour
change of posture that enabled me to diagnose a pedun- or cyst seemed established. Mr. Wright operated on May 10.
culated tumour blocking one foramen of Monro in 3 under local anaesthesia by the transfrontal route on the left
cases which showed no other physical signs than the side, exposing the cortex in front of the fissure of Rolando.
classical triad. A small circle of left frontal lobe was excised in the premotor
Pedunculated tumours growing from the wall of a. area, the ventricle entered, and a colloid cyst as large as a
lateral ventricle may be ependymal in origin, whereas small cherry was seen protruding through the left foramen of
the tumours growing in the third ventricle are often Monro. This was ruptured in the effort to deliver it into
colloid cysts. These cysts are paraphyseal" in origin, the lateral ventricle, a thick creamy fluid like condensed
according to McLean (1936), and grow downwards from milk escaping into the ventricle. The fluid was evacuated
the anterior end of the roof of the third ventricle from and the cyst walls completely removed. The patient made
the paraphysis, a vestigial sense-organ. Sjovall (1909) a quick and uneventful recovery except for slight pyrexia
first suggested the paraphyseal origin of these third from May 11to 17, reaching 102° F. on three days, but falling
 655
’

to normal after sulphathiazole was given. By May 19 she

was very well, and left hospital on May 27. On June 28 I . DEFICIENCY DISEASES IN HONG-KONG
showed her at a clinical meeting of the Medical Society of P. B. WILKINSON, M B LOND., M R C P
London held at the hospital; she was perfectly well, and the MEDICAL OFFICER IN THE COLONIAL SERVICE.
papillcedema had almost entirely disappeared. In answer POVERTY and polished rice are responsible for much
to a follow-up letter she wrote on Jan. 11, 1944, that she was
very well, and back at work at the aircraft factory. of the disease seen in south China, and before making a
I wish to lay emphasis on the character of the headache diagnosis it is essential to find out in every case what
in these cases, the suddenness of onset, and the equally the patient earns, how much he spends on food, what
sudden disappearance. If also an alteration of posture sort of food he buys, and how he cooks it. Today
brings about a sudden change, either in starting or poverty is probably more widespread and more devas-
arresting the headache, the diagnosis of a valvular tating in its effects in China than anywhere else in the
intraventricular lesion is almost certain, such as a pedun- world. The war has laid waste great tracts of the
culated ependymal tumour in the lateral ventricle, or a country and has created many millions of refugees
colloid cyst or tumour in the third ventricle. who are often dependent for their existence on what
I have seen two other cases of this type of pedunculated they can carry with them. Most of these refugees are
farmers or farm workers whose diet at the best of
ependymal tumour, in which the clear history of sudden times is probably a defective one judged by western
onset and sudden disappearance of headache enabled
me to make the diagnosis. standards, and since the outbreak of the war quantita-
tive deficiencies have been added to the normally
The first I saw in consultation in the north of London
32 years ago, where the local doctor, now dead, had made a occurring qualitative ones.
The staple foods differ markedly in north and south
diagnosis of hysteria in a woman school-teacher of about 40,
China, a point which has always to be borne in mind
who had been suffering for some months with headaches of
in taking case-histories. In the north the staple food
this type. She was semicomatose when I saw her, with
is millet, a grain which is usually eaten in the form of
choked discs, and she died on the following day. It did not
coarse ground flour.
occur to me at that time that surgery was possible, but with
Very often soya-bean flour is
-

modern methods her life might have been saved, since

added to the millet flour, and this mixture contains
an adequate amount of vitamin Bl and valuable proteins.
autopsy showed us an intraventricular ependymal tumour Vegetables are freely eaten and vary with the season.
plugged in the right foramen of Monro. -

Fats are obtained almost entirely from the vegetable

The other case I saw several years ago at Maida Vale
oils in which the vegetables are cooked. In the south,
Hospital, the characteristic feature of sudden onset and on the other hand, polished rice of an inferior grade is
sudden disappearance of violent headache being present.
the staple food. Soya-bean flour is scarcely known
Even then surgery was considered impossible. and is not liked by the southern Chinese. Vegetables
With modern methods of ventriculography and surgical are eaten throughout the year, often cooked in vegetable
approach most of these cases could undoubtedly be oils such as groundnut oil and sesame oil. Meat,
saved, since the cysts and most of such tumours are chicken, duck and fish are eaten, mixed with rice and
benign, and there is little or. no danger of recurrence. vegetables if -the family income permits, but dairy
Although paroxysmal headaches, with. sudden onset products such as milk, butter and cheese are unknown.
and sudden disappearance have been recorded by most Eggs are eaten infrequently by the masses because
authors as characteristic of a ball-valve blocking of the they are too expensive.. Fresh fruit of any sort is not
foramen of Monro by a third ventricle tumour or popular.
’

pedunculated growth in-the lateral ventricle, I have Both the northern and the southern diets are defective;
found only three references to change of posture causing the northern in calcium, vitamins A, B1, C and prob-
the sudden changes in intensity of the pain (Stookey 1934, ably D ; the southern in first-class protein, vitamins A,
Dandy 1933, Fulton and Bailey 1929). Weisenburg B1, B2 and possibly D. As a result of these deficiencies,
(1910) first described intermittent sudden loss of vision night-blindness, hyperkeratosis, infantile and adult
dependent on changes of posture in cases of third rickets (osteomalacia), scurvy and pellagra are all
ventricle colloid cysts. found in northern China, though beriberi is rare except
The headaches in these cases occasionally- last for in the ports, and in southern China beriberi abounds
ten years or more before vomiting, dizziness, faintings, and coexists with pellagra and certain other syndromes
sudden falls from collapse of the legs, and papulcodema probably caused by lack of part of the B complex. But
develop. Sudden falls from the legs giving way might scurvy and rickets are distinctly uncommon in, south
suggest the cataplectic attacks in narcolepsy, but the China, and the skin and eye changes found in vitamin-A
characteristic somnolence is absent, while the pr sence of deficiency are not common. The cost of living rose steadily
headache, vomiting or papillœdema will decide the in Hong-Kong during the 3 years before the Jap invasion,
diagnosis of intercranialoftumour. An instructive case and many of the poor -Chinese undoubtedly had to
isrecorded by Dandy a lady aged 37, who never
suffered from headache except when she had attacks of
exist on a diet defective not only in quality but also in
quantity. These defects in diet are responsible for an
dizziness accompanied by shooting pain from the occiput immense amount of disease in China, and the well-
over the top of the head to the forehead. These were marked differences between European and Chinese diets
apt to occur with sudden change of posture, as on standing may account for some of the peculiarities in the
up or stooping to the ground. Otherwise she was perfectly incidence of disease.
well, and could play tennis most of the day, but not golf, Another most important point is the method of
owing to stooping to pick up the ball starting an attack. preparation of the food. The Chinese methods of cook-
There were no other neurological sign.’3-, and Dandy mistook ing polished rice make an already defective food more
the case at first for " functional." Ultimately operation so, and there is no doubt that much vitamin C is lost
disclosed a benign tumour in the third ventricle which he in the cooking of vegetables in oil. Poverty and
successfully removed. polished rice, then, are the two outstanding factors in
SUMMARY the production of deficiency disease in south China.
Intermittent headaches, sometimes persisting even
for ten years, may be due to intraventricular cysts and BERIBERI
tumours. Their onset and disappearance are often Beriberi we have always with us in south China.
sudden, and, especially if changes of posture produce or The number of cases in Hong-Kong rose enormously
relieve the headache suddenly, this is a pathognomonic during the three years before the Japanese occupation
sign of the ball-valve action of such cysts or tumours as the population increased and the standard of living
blocking one or both foramina of Monro.
Third ventricle colloid cysts appear to be the commoner
DR. HARRIS : REFERENCES
variety, and grow from the anterior part of the roof of
the third ventricle. Bailey, P. (1916) J. comp. Neurol, 26, 79.
Dandy, W. E. (1933) Benign Tumours in 3rd Ventricle, Baltimore.
They are non-malignant, and when approached Fulton, J. F., Bailey, P. (1929) J. nerv. ment. Dis. 69, 18.
through a hypophyseal flap, opening the lateral ventricle, McLean, A. J. (1936) Arch. Neurol. Psychiat., Chicago, 36, 485.
are not difficult to remove completely. Sjövall, E. (1909) Beitr. path. Anat. 47, 248.
Stookey, B. P. (1934) Bull. neurol. Inst., NY, 3, 475.
References at foot of next column Weisenburg, T. H. (1910) Brain, 33, 236.