Anatomiste de talent, Bartolomeo
Eustachi a fait progresser cette science dans la
seconde moitié du XVIe siècle. Outre la
fameuse trompe d'Eustache, il a
révélé l'existence de la valvule qui
porte son nom, des surrénales, du canal
thoracique.
Le grand oeuvre de Bartolomeo Eustachi devait
être un traité d'anatomie « De
dissensionibus ac controvesiis anatomicis ». Il
devait comporter 47 planches anatomiques,
dessinées avec l'aide de Pier Matteo Pini,
richement détaillées et
légendées. Seulement 8 planches furent
publiées de son vivant. Les 39 autres, perdues,
ont été longtemps recherchées. Elles
ont été retrouvées 162 ans plus tard
chez un descendant de Pier Matteo Pini. Publiées
en 1714 sous le titre « Tabulae anatomicae
Bartolomaei Eustachi quas a tenebris tandem vindicatas
» (illustrations anatomiques de Bartolomeo Eustachi
sauvées de l'obscurité), elles font de leur
auteur, avecVésale, l'un des pères de
l'anatomie moderne.
The influence of
yawning on the variations of air pressure in the tympanal
cavity
In healthy adults, swallowing and yawning with
radiopaque contrast dye at the Eustachian Tube (ET)
orifice allowed it to enter the middle ear, as evidenced
by the presence of residual contrast dye visualized by CT
scan (Computed Tomography (CT) imaging, also known as
"CAT scanning").
Under natural conditions, nasopharyngeal
secretions/fluid may overlie the orifice of the ET when
an individual is either supine or lying on his/her side
during sleep. In this study the lateral decubitus
technique, in which there was ambient air pressure at the
orifice during swallowing and yawning, resulted in
deposition of contrast dye in the middle ear. This
suggests that secretion overlying the ET orifice may
reach the middle ear on opening of the ET during sleep in
healthy adults. The effect of viral respiratory
infection, which has been shown to produce ET
dysfunction, on this phenomenon is not known.
Contrast medium was detected in the ears of two out
of three subjects in each positional group, suggesting
that reflux during swallowing and yawning is a
common event. In young children, nasopharyngeal secretion
would be expected to reach the middle ear with even
greater ease because the ET is shorter and straighter
than in adults.
L'infuence du
bâillement dans les variations des pressions dans
la caisse du tympan
Chez l'adulte sain, après déglutitions
et bâillements, il est possible de constater
l'ouverture de la Trompe d'Eustache en visualisant la
présence résiduelle de baryte
d'opacification (au scanner) dans la caisse du
tympan.
Dans des conditions physiologiques, les
sécrétions nasopharyngées peuvent
franchir l'orifice de la Trompe d'Eustache aussi bien en
position debout que couchée (du côté
de l'oreille), en particulier pendant le sommeil. Dans
cette étude, les auteurs ont cherché
à visualiser les conséquences sur la caisse
du tympan de l'ouverture de la Trompe d'Eustache par la
déglutition ou le bâillement.
Ils ont démontré la présence de
dépôts de baryte au fond de la caisse. Ceci
indique que physiologiquement, en particulier pendant le
sommeil, des sécrétions pharyngées
peuvent atteindre l'oreille moyenne chez l'adulte sain.
L'effet d'infections virales nasopharyngées,
réputées perturbées
l'activité de la Trompe d'Eustache, n'est pas
connu.
La présence de baryte chez deux sujets sur
trois indique que ce phénomène de reflux au
travers de la Trompe d'Eustache est banal et courant. Il
est supposé que chez les jeunes enfants, ce flux
pharyngo-auriculaire est encore plus aisé en
raison de la brièveté et de l'aplomb plus
marqué de la Trompe d'Eustache que chez
l'adulte.
Respiratory control and behavior
in humans: lessons from imaging and experiments of
nature
Ravé Moss I.
The Canadian Journal of Neurological
Sciences
2005; 32; 3; 287-297
Departments of Pediatrics and
Physiology, McGill University and McGill University
Health Centre Research Institute, Montreal Children's
Hospital and, Montreal Children's Hospital Research
Institute, Montreal, Quebec, Canada
Ochoa-Sepulveda
JJ, Ochoa-Amor JJ report a case of a 34 year old
right handed woman seen at 29 weeks' gestation who
suffered from apnoea of unknown aetiology. Starting at
week 25, her husband noticed she had developed
intermittent brief periods of apnoea only while sleeping,
which lasted as long as one minute but of variable
duration. Her husband awakened her each time she had a
protracted episode of apnoea. She was asymptomatic while
awake. In the 29th week she suffered a more severe
apnoea. She was intubated in the field and taken to the
hospital for an emergency caesarean section. There was no
spontaneous labour. Inability to breathe spontaneously
persisted for two weeks postpartum and a neurological
consultation was requested.
The neurological examination revealed upbeat
nystagmus of small amplitude in the primary position
which did not change with upward or downward gaze. She
had lack of spontaneous breathing. She was fully awake
and cooperative, sitting up in bed with no assistance.
While intubated she had an obvious cough reflex but the
gag reflex was not formally tested. Tongue examination
showed normal movement and power with no evidence of
atrophy or fasciculation. Otherwise, cranial nerve and
sensorimotor examinations were entirely normal. There was
normal tone, with downgoing plantar reflexes and no
evidence of other pyramidal findings. There was no record
of arrhythmia.
No yawning, vomiting, or hiccups were present
during the examination and they were not seen by nursing
staff. It was of interest that this patient had suffered
from apnoea presenting immediately after her first
vaginal delivery two years previously. This was treated
with intubation and resolved spontaneously with
successful extubation approximately four hours later.
Magnetic resonance imaging of the brain, brainstem, and
cervical spinal cord was carried out, and showed a
Chiari
malformation with tonsillar herniation at C2 level
and a cervical syrinx. After posterior cranial fossa
decompression the patient recovered spontaneous breathing
and yawning. She was off any ventilatory support
within six hours. She and her child have been followed
for two years following this event. She remains in good
health with normal polysomnographic testing. This is an
acquired Ondine's syndrom.
Ochoa-Sepulveda
JJ, Ochoa-Amor JJ rapportent l'observation d'une
femme de 34 ans, droitière, qui à la
29° semaine d'une grossesse souffrit d'apnées
de cause mystérieuse. Son mari remarqua
à partir de la 25° semaine l'existence
d'épisodes d'apnées, pendant son sommeil,
durant une minute ou plus. Son mari la réveillait
à chaque épisode. Elle demeurait
asymptomatique dès qu'elle était
réveillée. Une soudaine aggravation,
à la 29° semaine, amena à
l'hospitaliser pour l'intuber et la ventiler. Une
césarienne fut réalisée en l'absence
de travail spontané. La persistance de cette
incapacité à respirer spontanément
conduisit à l'adresser en neurologie deux semaines
après l'accouchement.
L'examen neurologique retrouva un nystagmus vertical
de faible amplitude, en position horizontale, de repos,
et non modifié par le regard vers le haut ou le
bas. Elle avait perdu la capacité de respirer
spontanément involontairement. Elle était
totalement éveillée et coopérative,
capable de s'asseoir, seule et sans aide, dans son lit.
Pendant qu'elle était intubée, elle
présentait un réflexe de toux,
indiscutable. Mais la recherche du réflexe
nauséeux n'a pas été faite. L'examen
de la langue ne retrouvait ni fasciculation ni
déficit de sa motricité. L'examen
sensori-moteur de toutes les paires crâniennes
était normal. Le tonus corporel était
normal et le réflexe plantaire se manifestait en
flexion, sans aucun autre signe d'atteinte pyramidale.
Aucune arythmie cardiaque n'a été
notée.
Aucun bâillement, aucun vomissement,
aucun hoquet ne furent observés tant pendant les
examens que par l'équipe soignante. Il est
intéressant de noter que, deux ans auparavant,
lors de la délivrance de son
précédent accouchement, une apnée
avait obligé à une intubation avec reprise
d'une ventilation spontanée et extubation possible
quatre heures plus tard. Une IRM fut
réalisée, visualisant une malformation d'
Arnold Chiari, avec hernie de l'amygdale
cérébelleuse jusqu'au niveau de C2 et une
cavité syringomyélique. Après une
décompression chirurgicale de la fosse
postérieure, la patiente retrouva une respiration
spontanée et ses bâillements. Revue
deux ans plus tard, elle allait bien sans
récidive. Il s'agissait donc d'un syndrome
d'Ondine acquis.
"Ondine's curse" is a term used to denote a rare
neurological condition causing failure of automatic
respiration. The patients are no longer capable
ofbreathing spontaneously-they must consciously and
voluntarily force themselves to do so. Ondine (also known
as "Undine"), a mythological figure of European
tradition, was a water nymph or sprite who could become
human only when she fell in love with a mortal man.
However, if the mortal was unfaithful to her, he was
destined to forfeit his life. In the 16th century,
Paracelsus coined the term "Undine" to describe the
spirit that inhabited the element of water. Baron de la
Motte-Fouque wrote the story of Undine in the late 18th
century. It has since become a popular subject for
theater productions. Jean Giraudoux, the French
playwright, introduced the concept of the loss of
automaticity of all functions as the "curse of Ondine."
The legend was popularized in the form of the fairy tale
"The Little Mermaid" by Hans Christian Andersen and as an
animated motion picture by Walt Disney Productions. In
this study, we look at the origins of this eponymous
term, the personalities intertwined with its popularity,
and its misrepresentations in the medical
literature.
Le
syndrome d'Ondine tire son nom de la
pièce écrite par Jean
Giraudoux en 1939. Nymphe amoureuse d'un chevalier,
Ondine accepte qu'il soit condamné, s'il lui est
infidèle, à mourir en oubliant de respirer
pendant son sommeil. Une origine
génétique à cette "
malédiction d'Ondine " mythologique a
été découverte en 2003 pour la forme
pédiatrique primitive ou maladie d'Ondine. Le cas
présenté ici est secondaire à une
malformation.
Le syndrome
d'Ondine et le syndrome de
désafférentation motrice (locked-in
syndrome) distinguent les mécanismes
régulateurs du tronc cérébral des
mécanismes supramédullaires chez l'humain:
les premiers comportent une perte du contrôle
respiratoire neuro-végétatif et la survie
dépend alors de la respiration volontaire et les
derniers impliquent la perte des voies corticospinales ou
corticobulbaires nécessaires à la
respiration volontaire, mais préservent le
contrôle respiratoire
neurovégétatif.
Abstract: The purpose of this review is to
demonstrate that respiration is a complex behavior
comprising both brainstem autonomic control and
supramedullary influences, including volition. Whereas
some fundamental mechanisms had to be established using
animal models, this review focuses on clinical cases and
physiological studies in humans to illustrate normal and
abnormal respiratory behavior.
To summarize, central respiratory drive is generated
in the rostroventrolateral medulla, and transmitted to
both the upper airway and to the main and accessory
respiratory muscles. Afferent feedback is provided from
lung and muscle mechnoreceptors, peripheral carotid and
aortic chemoreceptors, and multiple central
chemoreceptors. Supramedullary regions, including cortex
and subcortex, modulate or initiate breathing with
volition, emotion and at the onset of exercise. Autonomic
breathing control can be perturbed by brainstem pathology
including space occupying lesions, compression,
congenital central hypoventilation syndrome and sudden
infant death syndrome. Sleep-wake states are important in
regulating breathing.
Thus, respiratory control abnormalities are most
often evident during sleep, or during transition from
sleep to wakefulness. Previously undiagnosed structural
brainstem pathology may be revealed by abnormal breathing
during sleep. Ondine's
curse and 'the locked-in
syndrome' serve to distinguish brainstem from
supramedullary regulatory mechanisms in humans: The
former comprises loss of autonomic respiratory control
and requires volitional breathing for survival, and the
latter entails loss of corticospinal or corticobulbar
tracts required for volitional breathing, but preserves
autonomic respiratory control.
Résumé: Contrôle et
comportement respiratoire chez l'humain : leçons
tirées de l'imagerie et des expériences
naturelles. Le but de cette revue est de démontrer
que la respiration est un acte complexe impliquant un
contrôle neuro-végétatif provenant du
tronc cérébral et des influences
supramédullaires, entre autres la volonté.
Alors que les mécanismes fondamentaux ont dû
être établis grâce à des
modèles animaux, cette revue est axée sur
des cas cliniques et des études physiologiques
chez l'humain afin d'illustrer le comportement
respiratoire normal et anormal.
En résumé, la stimulation respiratoire
centrale origine de la moelle
rostro-ventro-latérale et elle est transmise aux
voies aériennes supérieures et aux muscles
respiratoires principaux et accessoires. La
rétroaction afférente provient de
mécanorécepteurs pulmonaires et
musculaires, de chémorécepteurs
périphériques à la carotide et
à l'aorte et de multiples
chémorécepteurs centraux. Des
régions supramédullaires corticales et
sous-corticales jouent un rôle dans la modulation
ou le déclenchement de la respiration par la
volonté, l'émotion et en début
d'exercice.
Le contrôle neuro-végétatif de la
respiration peut être perturbé par une
pathologie du tronc cérébral, soit par une
lésion expansive, une
compression, le syndrome congénital
d'hypoventilation alvéolaire central et le
syndrome de la mort subite du nourrisson. Les
états de sommeil et d'éveil sont importants
dans la régulation de la respiration. Des
anomalies du contrôle respiratoire sont plus
souvent évidentes pendant le sommeil ou pendant la
période de transition du sommeil à
l'éveil. Une respiration anormale pendant le
sommeil peut révéler une pathologie
structurale du tronc cérébral encore non
détectée.
Gschwend J Yawning in a
case with transsecting glioma of the pons
Fortschr. Neurol. Psychiat 1977; 45;
652-655
Crumley
RL The opercular syndrome - diagnostic trap in facial
paralysis The laryngoscope 1979; 89;
361-365
Bauer G et al
Involuntary motor phenomena in the locked-in syndrome
J. Neurol. 1980; 223; 191-198
Bauer G et
al stimulus evoked oral automatismsin the locked-in
syndrome Arch Neurol1982; 39;
435-436
Laurent-Vannier
A Syndrome de Foix Chavany Marie d'origine
traumatique Rev Neurol 1999; 155; 5;
387-390
Ghika J,
et al Dissociated preservation of automatic-voluntary
jaw movements in a patient with biopercular and
unilateral pontine infarcts Eur Neurol
2003, 50; 185-188
Krasnianski M, et
al Yawning despite trismus in a patient with
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Too little is known for this article to end with a
dazzling intellectual flourish and a Grand Unified Theory
of Yawning. It is customary at this point, though, to
suggest a need for further study, and indeed I see much
potentia in using yawning to develop and test theories of
mind and to better understand certain neuro- and
psychopathologies. Here I have attempted to describe the
yawn, when we do it and its promise for study, without
speculating about function.
Yawning appeared very early in vertebrate history,
with contagiousness evolving much later. Yawning hasmany
consequences, including opening of the eustachian tube,
tearing, inflating the lungs, stretching and signaling
drowsiness, but these may be incidental to its primal
functionÑwhich may something as unanticipated as
sculpting the articulation of the gaping jaw during
embryonic development. Selecting a single function from
the many options may be an unrealistic goal. However,
reviewing the disparate facts, I'm impressed that yawning
is associated with the change of behavioral
stateÑwakefulness to sleep, sleep to wakefulness,
alertness to boredom, threshold of attack, sexual
arousal, switching from one kind of activity to
another.
Yawning is a vigorous, widespread act that may stir
up our physiology and facilitate these transitions, with
the motor act becoming the stimulus for the more recently
evolved contagious response. Consider the Bakairi people
of central Brazil as observed by their first European
visitor, 19th-century ethnologist Karl von den Steinen.
Irenäus Eibl-Eibesfeldt recalls in his 1975 book
Ethology that Steinen reported: "If they seemed to have
had enough of all the talk, they began to yawn
unabashedly and without placing their hands before their
mouths. That the pleasant reflex was contagious could not
be denied. One after the other got up and left until I
remained with my dujour.
Among all members of our species, the chain reaction
of contagious yawning synchronizes the behavioral as well
as the physiological state our tribe. Yawning is a
reminder that ancient and unconscious behavior lurks
beneath the veneer of culture, rationality and language,
continuing to influence our lives.
Dans la collection des clichés de Pierre
Marie en 1921, ce patient pseudo bulbaire au
rire et pleurer spasmodique, avec une parésie des
4 membres, bouge les doigts droits lors de son
bâillement !
(a) Hiccough is mentioned merely because discussion
of its relationship with epidemic encephalitis would be
beyond the scope of this paper.
(b) Yawning. Involuntary opening of the mouth is
not an uncommon feature in the post-encephalitic
Parkinsonian syndrome: during the last three months,
three patients out of twenty-five observed by ourselves
showed this symptom. Occasionally "mouth opening" occurs
in paroxysms, is sustained for a few seconds and amounts
in degree to a wide gape. Such a manifestation is
tantamount to a yawn and may be included amongst the
respiratory tics of post-encephalitic nature. An extreme
instance is recorded in our third case and is illustrated
by photograph. Other cases have been reported by Sicard
and Paraf, Pardee, Hinds Howell, Abrahamson and Farquhar
Buzzard.
(c) "Soufflement." The French writers have used this
word to denote tic-like expiration of air through the
nose as though in order to dislodge a foreign body.
(Babinski and Charpentier.)
(d) Spasmodic cough. One of the most distressing
post-encephalitic "tics" consists in a constant, short,
hacking, dry cough which persists during the daytime and
often throughout the night. Pierre Marie gives the term
"toux coqueluchoïde "to this cough. There are no
pulmonary physical signs and examination of the larynx
and pharynx is negative. This cough may be succeeded
later by some other respiratory disorder as in Case 1 of
our series.
These respiratory tics are particularly common in
children after encephalitis. They tend to persist through
the daytime, but show an increased frequency towards
nightfall.
From the study of the recorded cases it is apparent
that respiratory phenomena may arise at any stage of
epidemic encephalitis. It does not seem possible to trace
any association between the symptomatology of the
original attack and the subsequent onset of respiratory
disorders. Thus cases which were originally characterized
by insomnia or delirium do not tend to develop subsequent
respiratory disorders any more than cases showing
lethargy. The myoclonic variety is known also to be
followed occasionally by disorders of breathing.
MUSEE DES ENFANTS.
Paris, Société Saint Augustin
Desclée de Brouwer, sans date (autour de
1880).
Ouvrage relié de format in-4. Ouvrage
édifiant et divertissant pour la jeunesse qui
comprend des chansons avec partitions, des récits
et anecdotes, des concours littéraires, des
portraits de saints et textes de catéchisme.
" The love of science, unbounded patience in long
reflecting over any subject, industry in observation and
collecting facts and a fair share of invention as well as
of common sense"
