CASE OF BILATERAL PARALYSIS OF THE MUSCLES SUPPLIED BY THE RECURRENT LARYNGEAL NERVE.

399 to destruction in malarial fever. themselves in our wards. Should those conclusions be subKelsch’s1 observations on this subject, though published stantiated, their practical value as regards both diagnosis several years ago, do not appear to have attracted allthe and prognosis is too obvious to require detailed exposition. attention they deserve. They were made at the military (To be continued.) hospital of Philippeville, in Algeria, where every variety of paludal disease is met with in great profusion. In his examinations of the blood he employed the numerator of CASE OF Malassez; unfortunately, no parallel series of chromometric observations was carried out, so that it must remain doubt- BILATERAL PARALYSIS OF THE MUSCLES ful for the present whether the hypocytosis was or was not SUPPLIED BY THE RECURRENT accompanied by a corresponding degree of hypochrosis. The LARYNGEAL NERVE. visibly profound anpemia displayed by the victims of ague, however, renders it highly probable that no sufficient increase BY J. A. ORMEROD, M.B. (OXON.), M.R.C.P. in the value of the corpuscles occurs to counterbalance the in effect of the great reduction their number. CASESof unilateral paralysis of the laryngeal muscles are Numeration was employed in about 70 cases of paludal I in it and of them was suppose, tolerably common. Cases of bilateral paralysi fever, many repeated daily throughout the course of the disease. The cases are grouped under the of individual muscles, as, for instance, the posterior crice three heads of simple fever, malignant fever, and malarial arytenoids, are being recorded in increasing numbers ; bu cachexia. The most striking eflect of the miasma on the bilateral paralysis of all the laryngeal muscles has hitherto corpuscles is manifested when a previously robust and I believe, been but rarely observed. I therefore venture t healthy man is attacked for the first time. Under such circumstances the daily loss of red corpuscles may amount to publish an account of a case at present under my observa several hundred thousand, occasionally to one million per tion, albeit I have been unable to watch it from the com cubic millimetre of blood in every twenty-four hours. This mencement, and the termination of it still remains to bl is during the initial period of the malady, when the sym- seen. ptoms are of a continued or remittent type. The initial Von Ziemssen, in his " Cyclopædia of Medicine,"men period is usually of short duration, and is followed by a tions eleven cases, six observed by himself, the remainde longer one, during which the fever is definitely intermittent by Turck, Traube, and Baumler. In three of thesE (quotidian or tertian), and the number of corpuscles continues the paralysis was Miinck, on both sides; in seven com complete to decrease uninterruptedly, though less rapidly than in the plete on one side, incomplete on the other ; in one (a re first period. A succession of paroxysms will sometimes markable supposed to be caused by the pressure of s bring down the number of discs from the normal proportion distended case, the paralysis was incomplete on bott pericardium) of five or six millions to one million, or even to five hundred sides. The cause was in four cases cancer; in thousand, per cubic millimetre. As the blood is more and one cancer of the thyroid gland, in œsophageal five aneurism. I find more impoverished, the process of destruction grows slower records of three other cases : one1 by Ludwig Brieger in a and slower, until at last, when the disease has entered on the paralysis complete on both sides: phthisical its third period, characterised by irregular febrile exacerba- the cause patient ; (determined post mortem), pressure upon the re tions, with more or less prolonged intervals of apyrexia, the current nerves by enlarged lymphatic glands. And two2 by number of cornuscles simply oscillates to and fro about an Karl Kittler, in the first of which there was complete paraAt this a show minimum. itseli may average stage tendency on the right side, with paresis upon the left, ascribed to a very gradual restoration of the corpuscular elements; 01 lysis to aneurism; in the second, paralysis not quite complete on their number may continue to diminish, though very slowly; the left side, and paresis on the right ; the cause undeor it may remain quite stationary for weeks together, notbut supposed to be catarrh. It appears, therefore, termined, withstanding the energetic use of quinine and iron, and the that in the majority of these fourteen cases the comparative infrequency of febrile paroxysms. This last was incomplete on one side, and that the cause wasparalysis usually cachectic a tumour or aneurism. condition is met with more especially in patients, with great enlargement of the spleen. The symptoms are so well described by Von Ziemssen In the malignant form of paludal fever, the rapidity of that I need only recapitulate them. On laryngoscopic exis to eorpuscular disintegration proportionate the previous amination, the vocal cords are seen to occupy the cadaveric good health of the patient. When he is a robust and well- position, lying midway between the positions of phonation nourished man, the corpuscles disappear at the rate of from and and not altering their position on phoinspiration, deep half a million to one million per cubic millimetre in twenty- nation or If the paralysis is incomplete on one four hours; when his health has been broken by previous side the inspiration. cord of that side moves, but sluggishly and inand he is from malarial ansemia, attacks, already suffering and it does not, as in cases of purely unilateral the daily loss varies from one to two hundred thousand per sufficiently, for the inactivity of its fellow, by paralysis, compensate cubic millimetre. It is a noteworthy fact that the loss may the middle line to meet it. There is absolute aphonia crossing go on, and may even amount to several hundred thousand (at least in cases of paralysis), inability to cough corpuscles per cubic millimetre every day, while the axillary with force, waste of complete breath on coughing or talking, so that continues no it normal ; bearing proportion, as temperature talking puts the patient out of breath. does in fever of the simple type, to the intensity of the prolonged In the observation of the following case I have to acfebrile movement. On recovery from an attack of the knowledge the help of Dr. Felix Semon in pointing out to malignant form, the restoration of the corpuscles is usually me some essential symptoms, and of Dr. de Havilland Hall, pretty rapid. who also saw the case and agreed in the diagnosis. It is clear that in diseases of this class we have to do Esther C-, aged thirty-eight, marked with small-pox with some specific action of the paludal miasm upon the and looking rather out of health, came to me at the Metroformed elements of the blood. Nothing at all resembling in September last, complaining of Free the effects just described has ever been noticed by ourselves politanand lossHospital of voice, and of feeling generally out of sorts. cough or others in even the most acute febrile maladies which we The larynx was seen to be deeply seated, the ventricular have had an opportunity of studying. The destruction of bands were swollen and overhanging, the arytenoid cartithe red corpuscles is not dependent on the pyrexia as such, a little larger than normal, and the right standing on lages though it probably stands in close relation to the melancemia a higher level than the left. The vocal cords were slightly which is so frequent a consequence of the endemic fevers of congested, the right was quite immovable ; the left moved marshy districts. It is to be hoped that those who enjoy but did not reach the right. The pharynx was slightly suitable opportunities for the purpose will not fail to repeat The chest and neck were perfectly normal. She Kelsch’s observations and amplify them by the simultaneous granular. was treated with benzoin inhalation and iodide of potassium use of the chromoaieter. We have not ourselves had a in doses of five to ten grains three times a day. Her appearchance of examining the blood in even a case of ordinary ance and health general improved, but the aphonia remained. ague, and are therefore unable to say how far, if at all, the By November the symptoms of chronic laryngitis had conclusions stated above may be applicable to the very mild subsided, and I was able to examine the patient under more forms of malarial intoxication which now and then present favourable conditions. The following facts were then made

notice, is their liability

profoundly

1 Contribution à 1’Anatomie Pathologique des Maladies Palustres. Par A. Kelsch. Arch. de Physiologie, vol. ii., 1875.

I

1 2

Virchow, Hirsch, Jahresbericht, 1878. Schmidt, Jahrbuch., vol. clxxix., p. 167.

40C out :-There was nothing abnormal in the mouth, tongue, or fauces. The epiglottis was thickened, and there were some white spots of ulceration on it. The right vocal cord lay in the cadaveric position, and there was little, if any, appreciable movement of it, or of its arytenoid cartilage, during inspiration or phonation. The left vocal cord to be a little more during quiet respiration abducted than the right. On deep inspiration the left cartilage and cord moved outwards to a certain extent. On phonation the left cartilage appeared to move inwards, the cord also made a slight motion inwards, but not to an extent corresponding with the motion of the cartilage ; it

appeared

appeared

to become lax and

bulge in its central part;

it did There

right cord, or even the middle line. ansesthesia. of fauces or larynx. The epiglottis acted perfectly. The paralysis was entirely confined to the muscles supplied by the recurrent nerves. Prolonged patient out of breath. The chest and neck the were re-examined, and again with a negative result. She gave the :-In November, 1877, she had a severe cold, cough, and hoarseness, and felt constitutionally ill. She was treated at the Ratcliff Cross Dispensary, and subsequently at the London Hospital, and improved; but in April, 1878, she caught small-pox, and during convalescence from this her voice got much worse. She also stated (but in answer to questions) that at the beginning of her illness she had a swelling in the left side of her neck, such as could be felt externally; and that swallowing food or liquid would cause choking and sneez ing. Before her illness she had a particularly strong voice. No history of syphilis could be obtained. There was, therefore, very little from which to conjecture the cause of the disease. The swelling in the throat (an important item ii it could have been verified by physical examination) only occurred to her recollection on being cross-questioned, and might, indeed, have been a simple tonsillitis. The laryngeal symptoms, so far as could be made out, had preceded thE small-pox, though worse after it. The condition of the epiglottis was suggestiveof syphilis, and the patient’f general health had improved under iodide of potassium. II seemed right, therefore, to give this drug a fair trial, and she took it combined with tincture of nux vomica in dose, increasing till half a drachm three times a day was reached, The induction current was also applied (percutaneously for the most part) twice a week. This treatment was continued till the middle of January. The result has been negative. The patient, indeed, thinks herself in better health, and maintains that her voice is improved, but to me it sounds as whispering as before, and there is scarcely any altera tion in the laryngoscopic appearances. Upper Wimpole-street, W. not reach the

the splint, and also padded. The apparatus may be worn in bed, during sleep, or when riding in a perambulator. It has been found effectual, after repeated trials, in restoring the normal contour of the bones in cases of external curvature, or rather cases in which the on the outer side of the limb.

convexity of

Wirkaworth.

A Mirror HOSPITAL PRACTICE, OF

was no

talking put

the curvature was

BRITISH

AND

FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morbomm et dissectionum historias, turn aliorum, turn proprias collectas habere, et inter se compare.—MORGAGNI De Sed. et Caul. Morb., lib. iv. Proœmium.

following history

GUY’S HOSPITAL. SURGICAL CASES ILLUSTRATING WOUND TREATMENT AND REPAIR.

(Under the care of Mr. BRYANT.) THE subjoined report is continued from p. 364. Solid Bursce Patellce ; Excision ; Recovery. (From notes taken by Mr. Row.)-Susan B-, aged twenty-nine, was admitted into Lydia ward on Dec. 1st, 1879. Eight years before she had noticed a swelling on the top of the right knee. It was painted with iodine, and washed with a lotion, and got better ; but a hard swelling, about the size of a filbert, remained. Eight months before admission the patient walked ten miles, and a few days after found the same knee very tender and slightly swollen. On her admission she had a hard swelling, about the size of a walnut, just below the patella, freely movable, and not attached to skin or patella. On Dec. 2nd, under chloroform, an incision an inch and a half in length was made along the outer edge of the patella, and the tumour was removed. The wound was washed with iodine, and dressed with terebine. The dressing was kept on for forty-eight hours, and a back splint applied. The bursa on section was nearly solid, having a good deal of yellow material in the centre. On the 4th the wound was dressed. There was some suppuration, but no burrowing. There was a good deal of pain in the wound and up and down the leg. The bowels were confined. On the l7th she was discharged well. The

wound was firmly closed. The temperature never rose above 98’8° F. Congenital Myxomatous Tumour of the Hand ; Partial DESCRIPTION OF AN APPARATUS FOR THE RemovalRelieved. (From notes taken by Mr. Dashwood.) TREATMENT OF DEFORMITIES OF THE Albert E. P-,aged six months, was admitted into Lydia ward on June 27th, 1879. He was a healthy child, but had LEGS IN RICKETY CHILDREN. a congenital tumour on the left hand, involving the thumb, BY WILLIAM WEBB, M.D., F.R.C.S. ENG. & EDIN. back of the hand, and the first and second fingers, as well as the front of the wrist. The tumour had bled slightly THE apparatus consists (as will be seen in the diagram) of twice during the last two or three weeks, and had increased in size. The tumour was elastic, and on the thumb was a foot-piece (A), into the middle of which is firmly fixed, by movable. screws, at right angles, a splint (B), which is well padded on On July 3rd the temperature was 104.1°, but fell to 97’S’ both sides, and covered with flannel. To this splint the legs next day. On the 8th, under chloroform, an incision was made into the tumour parallel to the metacarpal bone of the thumb ; the tumour was dissected out in pieces, and was found to be of a fibrous nature, containing fat. The edges were brought together with sutures. There was very little bleeding. On the 15th the wound was completely healed without constitutional or local disturbance. ,

Ossifying Cartilaginous

Tumour

growing from Ungual

Phalanx of Great Toe ; Excision; Recovery. (From notes taken by Mr. L. Stokes.)-Arthur J. W-, aged fifteen, was admitted into Job ward on May 22nd, 1879. About a year before the nail of the right great toe began to grow in, and the patient from time to time cut away the in-growing Three months before admission a swelling came beneath the nail and gradually pushed the nail up. The nail came off, and the swelling increased in size. On admission the right great toe was considerably swollen and inflamed opposite the last phalanx. The bed of the nail was occupied by a hard round swelling, about half the size of a marble.

portion.

are

bound

the

more

on either side by a light bandage, which can hei readily adapted and kept in position by the aid of the cross-supports (c), which are firmly screwed to the back oi