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the glottis. Isambert said that in the second period of laryngeal phthisis. he had almost always seen the glottis moved forwards and to the left, and he showed as an exception to this rule the patient who is the subject of Case V, which follows, in whom the glottis was directed forwards and to the right; the patient in Case IV, presents the same deviation.
ETIOLOGY.—We can easily conceive how tuberculosis, by its lesions of the apex of the lungs, and by hypertrophy of the peritracheal glands, may cause inflammation of the recurrents.
The left pneumogastric descends along the internal surface of the apex of the lung three centimeters lower than its congener of the right side, which explains the greater frequency of paralysis of the left cord in tuberculosis. It is moreover, in relation, in front, with the left group of retro-sterno-clavicular glands, which is hypertrophied and may easily compress or stretch it. The left recurrent after its passage under the aorta has nothing more to fear from the lung, but everything from glands. The right pneumogastric is also in relation with the apex of the right lung, but at a less extent than the left; moreover, the groups of larger glands, right lateral tracheal and right pretracheo-bronchial are situated near the nerve lower down than the point of origin of the right recurrent.* Everything, therefore, concurs to render left paralysis more common than right.
PATHOLOGICAL ANATOMY.—The paralysis is the consequence of a neuritis resulting from compression of the pneumogastric or the recurrent by the hypertrophied glands, or by the false membranes which surround them, or produced by a neighboring inflammation, such as a pleurisy at the apex, a growth of tubercles. Autopsies of such cases are rarely related, with respect to the lesions of the nerves of phonation. In an interesting case of M. W. Poyet and Barety † of tracheo-bronchial adenopathy, producing aphonia, it was observed that there were adhesions with thickening and vascularity throughout the whole course, intra- and extra-thoracic, of the pneumogastric and recurrent nerves.
SYMPTOMATOLOGY-Paralysis of the Left Abductor.—The cases most frequently observed, are those where we say there is a paralysis of the left abductor. We then see the left cord remain motionless, or nearly so, in the median line, and the right cord alone makes the movements required for respiration and phonation. When the glottis is widely open, the line which unites the apex of the triangle to the middle of the interarytenoid base, is directed forwards and to the left, whilst normally it should be directed directly forwards. In phonation, the arytenoideus draws the left arytenoid to the right of the median line and gives to the glottic chink this abnormal direction forwards and to the left. This gives the appearance of the trachea being twisted on its axis.
* See Barety De l'adenopathic tracheo-bronchigne. Paris, 1874. † Poyet: Des paralysies du Larynx. Thesè de Paris, 1877.
Paralysis of the Right Abductor.–Paralysis of the right abductor comes next; the glottic chink is then directed forwards and to the right.
Paralysis of Both Adductors. I have reported a case of paralysis of both abductors, characterized by the impossibility of separating the vocal cords more than three to four centimeters.
Paralysis of Both Abductors.-Lürck saw a double paralysis of abductors of the glottis in a tuberculous patient.
Paralysis of Arytenoideus.-M. E. Nicholas-Duranty relates a case of paralysis of the arytenoideus. In paralysis of the abductors, the vocal cords remain separated and cannot come in contact to produce vocal vibrations. In paralysis of the arytenoideus the inter-arytenoid glottis only is able to close, whilst the inter-ligamentous glottis comes in contact in phonation. In all the cases, aphonia is more or less complete, and the change in the voice presents variations, the cause of which we may some day discover.
Pain is absent and difficulty of breathing is only present in cases of paralysis of abductors, when there is more or less intense crowing. The paralysis may be present alone or may co-exist with the various lesions of tubercular laryngitis. Examination of the lungs shows, in the cases under consideration, that the pulmonary tubercular lesion is always on the same side as the laryngeal paralysis.
DIAGNOSIS.—The diagnosis of the paralysis is easy by laryngoscopic examination, if in an aphonic or hoarse patient, we do not limit ourselves to determining changes of color or form in the vocal cords, but study on several occasions their action in respiration and effort.
Etiological Diagnosis is sometimes difficult. Before putting down pulmonary tubercle as the cause, we ought carefully to examine the neck, the heart, and the large vessels, and enquire into the patients antecedents. Tumors of any kind may compress the recurrents, aneurisms of the large arteries at the base of the neck, diseases of the wesophagus, and even of the pharynx, may cause laryngeal paralysis. Hysteria, diphtheria, and cold may also cause the paralysis or paresis of the vocal cords. With respect to differential diagnosis, also, we must be careful not to take for a paralysis an inability of movement of a cord, owing to oedema of an arytenoid, or a cicatrical band, resulting from ulceration; we must not regard as a paralytic duration the change of direction, or even of shape, which occurs in the glottis from the proliferation of fleshy growths, which during effort, lodge in an ulceration of the neighboring cord. The laryngoscope removes all these difficulties of diagnosis.
COURSE - DURATION -- TERMINATION.-- Paralysis generally comes on gradually. The voice lessens, little by little, and the patient remains with a hoarseness or aphonia for a variable period. We have seen a paralysis disappear completely, as the result of an hæmoptysis. Whereas, the pulmonary and glandular lesions of tuberculosis have no tendency to disappear, we may conceive that paralysis may remain as long as its causes. Besides, this symptom is only serious in paralysis of the abductors, where death may supervene suddenly from asphyxia; the hoarseness and loss of voice, are more wearisome to the patient than the physician, who sees only the terrible diathesis.
TREATMENT --General and Local. - The most important thing is to treat the general condition. For the treatment of the laryngeal complication, we have revulsive applications under the clavicles, and on the sternal region, and external electrization; for we fear to introduce the rheophone between the vocal cords, lest fits of coughing and hæmoptysis be produced.
The author concludes the paper with a brief narrative of eight cases of laryngeal paralysis due to pulmonary tuberculosis:
(1) Three cases of paralysis of the left abductor, with tubercle in the left apex. (2) Two cases of paralysis of the right abductor, tubercle at the right apex. (3) One case of paralysis of both abductors, tubercle at both apices. (4) One case of paresis of both constrictors, tubercle at both apices. (5) One case of paralysis of the arytenoideus, tubercle at both apices.-Annales des Maladies de L'oreille et du Larynx.
DETROIT MEDICAL AND LIBRARY ASSOCIATION.
STATED MEETING, APRIL 2, 1888.
THE COMPLICATIONS OF SCARLATINA.
The following papers were read on the complications of scarlatina: “The Throat Complications,” Dr. C.G.Jennings; "Scarlatinal Rheumatism," Dr. R. A. Jamieson; "The Ear Complications," Dr. D. M. Campbell.
DISCUSSION. DR. STANLEY G. MINER thought he could only emphasize the remarks of those who had read papers, and endorse the treatment they had advocated. Regarding the nasal complications, the main point was to keep the nose perfectly clean. Scarlatina being a self-limited disease the less we did the better, and our efforts should be confined to keeping the normal secretions established. The majority of cases of acute otitis media were due to the retention of secretions in the middle ear. If the solution known as Dobell's solution, was used with a syringe through the nasal passages, and inhalations of the vapor of oleum petroleum and iodine subsequently used, the dangers from these retained secretions would be considerably lessened. If pain were present the use of cocaine might be advocated. With regard to pharyngitis, the sooner the much used mixture of chloride of iron and chlorate of potash was dismissed from our armamentarium the better. Some years ago he had seen several cases of scarlatina followed by nephritis, and had become convinced that this was due to the toxic effect of chlorate of potash. He had noticed this effect in his own practice, and was confirmed in his views by the opinions of fellow practitioners, and he was satisfied we often get this scarlatinal nephritis from the exhibition of this drug. He agreed to all Dr. Jamieson had said on scarlatinal rheumatism, only taking exception to the value of cold applications. The ear troubles deserved all the attention Dr. Campbell has demanded from them-it was very essential that the Eustachian tubes be kept perfectly clean.
DR. FLINTERMANN observed that he had to-day been called to a case, where the patient was suffering with severe pain in the joints. This is usually seen in children, seldom in those of advanced years. He had seen many cases where these pains
had occurred, accompanied by increased temperature, and relieved by anti-rheumatic remedies, though he did not think this proved any connection with rheumatism. He had seen cases where suppuration had taken place. Usually these cases occurred at the same period as puerperal complications in women, and it might be that it was caused by a poison similar to that causing septic fever. The most serious cases of puerperal fever certainly occurred during epidemics of scarlet fever. The ear complications were often marked by persistent nausea, and he had frequently seen cases where practitioners had exhausted every remedy for vomiting, which was speedily relieved on giving attention to the ear. One complication had not been mentioned this evening-inflammation of the subcellular tissue, in which in many cases, every effort to relieve pain and prevent death are futile. He had seen a case recently where a perfect infiltration of the subcellular tissue of the neck had occurred, and no sign of suppuration presented itself for two weeks. He made an incision and evacuated a few drops of pus, and although the incision was made with every antiseptic precaution, the whole chest and abdomen speedily became involved and the child died. He considered there was no more miserable complication than this. The Doctor very strongly protested against the duty now imposed upon physicians of reporting recoveries. While such an exaction was required, scarlet fever would continue to be imperfectly controlled in the community.
DR. CARSTENS, speaking of scarlatinal nephritis, said he considered it very frequently due to negligence on the part of patients themselves, and often to physicians reporting the cases as recovered too early. He never on any pretense so reported a case under four weeks. He thought it an outrageous thing that the board of health should allow the cards to be removed earlier, when they knew that the disease was a self-limited one, lasting at least four or five weeks. For the treatment of renal troubles he usually used iodide of potash. He kept the skin warm and administered cathartics, usually a compound jalap powder. He must confess that when he heard Dr. Jennings and Dr. Miner speak this evening, he felt himself a sinner; he thought of all the things he had omitted to do for his patients. Some twelve or fifteen years ago, in his “salad days when he was green in judgment,” he had ventured with much trepidation to speak of scarlet fover, and in spite of the skepticism by his audience, to assert that he had never lost a case. To-night, although he was able to quadruple the number of his cases, he