PARALYSIS OF RECURRENT LARYNGEAL NERVE.

BY R. V. WOOLEN, M. D., INDIANAPOLIS.

August 3, 1886, I received a letter from the hands of a patient, sent me by my good friend Dr. Charlton, of Seymour, from which I extract the following:

"DEAR SIR-This will introduce Mr. Jas. B————, the gentleman of whom I spoke to you, who has been working for the railroad at night for the past fourteen years, and finally some six years (1880) ago was confined to his house some several months during the winter and spring from bronchitis complicated with pleurisy. Finally he got so much better that he went to work in the yards again. Since that time was tolerably well until February, 1885, when he lost his voice for a time. Afterwards was better again until the following July, when the trouble returned, since which time it has remained very much as you now find him. I have not given him any treatment since last spring a year, and he tells me he has not taken any."

Upon examination I found the patient to be fifty-three years of age, five feet nine inches high, weighing 148 pounds, nervo-bilious temperament; native of England; occupation, railroad watchman; stating his throat difficulty was of one and a half year's duration; general condition not good, seemed somewhat emaciated and was nervous in demeanor, and had an anxious expression of countenance. Nutritive organs fairly active. Respiration forced and prolonged and easily disturbed. Prolonged inspiratory sound. Loud sibilant rales over both lungs, especially in case of left; right more normal, rather increased respiratory sound. Dullness on percussion over left side of chest. Thirteen respirations per minute. Voice stridulous, harsh and discordant. Functions of nose normal. Examination of mouth revealed appearance of former phar

yngitis; uvula somewhat elongated-nothing special. Ante- and post-rhinoscopic views same.

Laryngoscopic examination showed general congestion of interior of larynx, increased at evening examination and much relieved next morning. Left vocal cord immovable, and in "cadaveric position" i. e. midway between adduction and abduction. Slightly bowed right vocal cord meeting left in phonation by extra adduction, i. e. crossing over median line, but not meeting so as to form perfect glottis, too elliptical and apparently not abducting as freely as it should. Hence discordant voice, due to the unequal vibration of the vocal cords and abnormal way in approximation. In further search for cause of this laryngeal paralysis it was found that the patient's heart was quickly and greatly disturbed by violent exercise or excitement. Pulse almost imperceptible at left wrist, normal at right, 108 evening, 102 in morning. Temperature 100 evening, 98 morning. Called his attention to coldness of hands, especially left, which he had noticed before.

Difficulty of swallowing had been noticed for the last two or three months, which seems low down in oesophagus. Sleeps with head high and on right side. Complains of pain through center and in the left side of chest, running through to back.

Bowels and kidneys and other functions normal so far as known to patient; has no hereditary rheumatism or syphilis, and has lived a temperate life. Patient's chest was stripped and was found symmetrical, except undue prominence over top of sternum, which extends downward to its middle and beyond the median line on each side, one inch and half to the right and two inches to the left. There was marked dullness over this space; also marked increase of heart sounds, which were not distinct over usual space. Distinct aneurismal bruit and thrill to the ear unaided by stethoscope, but wanting with stethoscope. Same condition found of lungs as already recorded, only left lung seemed more engorged with lower percussion note.

The chest was mapped out with ink as to site of tumor, which was determined by inspection, palpation, percussion and auscultation, and returned to his physician with a duplicate of this examination, and letter of explanation, of which the following is a copy:

"DEAR DOCTOR C.-The above record, as you see, is of Mr. B., whom you sent to me, and is most interesting-painfully so. He has paralysis of left recurrent laryngeal nerve from pressure of an aneurism of the arch of the aorta, as it seems certain to me. There is no laryngitis, as suggested by you in our former conversation, and only congestion from strain in the effort to use right vocal cord in speaking, which compensates loss of function of left by crossing over to meet it, as imperfectly shown in diagrams. The loud, sighing, sibilant rales are caused by want of tension of vocal cords, as you will notice by placing stethoscope over patient's larynx. The patient's general appearance is most misleading, and his condition can only be arrived at by careful use of laryngoscope. I wish I could hope I was mistaken, but by careful exclusion of all other possibilities I am forced to the diagnosis which is given. If this is correct the line of treatment is obvious. Cure being out of the question, palliating and sustaining measures to be relied upon. The galvanic and faradic currents through the larnyx will sustain his voice and help retain nutrition of parts and subdue congestion. A very quiet and orderly life, free-very free-from violent exertion, etc. Anodyne inhalation if larynx is irritable and cough

troublesome."

In answer to my communication, subsequently, the doctor stated he had not examined the patient for eighteen months previous to sending him to me, and said he had examined him since his return and was "satisfied it must be aneurism of aorta, or a tumor, occupying the region described and pressing against and surrounding the artery, of malignant character; but that it is aneurism seems to be correct." Then, after some references to laryngoscopic description sent him, he stated he had put him on tonic and sustaining measures, sedative and astringent inhalations, with moderate exercise.

Three weeks later the doctor wrote that the patient had "improved steadily and gained some strength and flesh, but for the last week he has expectorated small amounts of blood after coughing some time, and this evening, while eating supper, was attacked with profuse hemorrhage, and in less than twenty minutes lost over a pint of blood, before I could see him. I found his pulse feeble, but regular; heart impulse strong and but very little inspiratory murmur over left side; still coughing some blood. I gave ergot, whisky and digitalis." Next day the doctor reports the patient "very feeble; pulse, 96 to 100; respiration, 24;

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temperature, scant 98; did not have any further hemorrhage, but still coughs up some coagula. Gave a little morphine last evening and continued other treatment and supporting measures."

Three days later, August 31st, the doctor writes: "Mr. B., although confined to bed, is much better, and his strength and color are returning; appetite also. On Sunday I satisfied myself the hemorrhage all came from his left lung, which has almost cleared up, and his breathing is attended with less oppression than before the hemorrhage, and there is less dullness on percussion on right side and up to middle of the sternum. He is in good spirits again."

September 25th. The doctor writes he is going to bring Mr. B. up soon "if he keeps as well as he is now, having improved very well of late."

September 30th. The doctor couldn't come, and sent patient with note saying he had examined patient but once of late on account of his own illness, "and at that time there was less dullness on percussion than at any time since you saw him, and the area of dullness more circumscribed. Voice much stronger and clearer."

After the hemorrhage he was greatly prostrated and was not able to sit up for two weeks, since which his improvement has been very satisfactory. Appetite and digestion good, bowels regular. Sleeps very well and coughs but little. He still takes malt with small quantity of glycerine, pepsin and muriatic acid after meals. Between meals and at bed-time a capsule of cinchonid. sulph., muriate hydrastin and nux vomica." The following is an extract of letter I sent the doctor after visit of patient:

* * * * "I was, as you doubtless have learned from him, greatly pleased and somewhat surprised at the apparent great improvement made in his case. I hope it has proven real. There certainly was considerable decrease in size of tumor and area of dullness on percussion over its side at top of sternum. The vast change in left lung also was a surprise, and I can not help feeling it was result of the hemorrhage both as to the reduction of the size of tumor and clearance of lung, although it almost cost him his life at the time.

"I think I can see how it would allow collapse of the aneurism and act as a drain on the engorged lung, so that nature could re-establish her processes before the parts are replenished with blood

which were distending in the one case and engorging in the other. Then your very wise management has led to such recuperation as to allow healthful activity to occur, so that it is greatly to be hoped, and I may say expected, that consolidation of the aneurism and a cure will occur. If so it will certainly be one of the most interesting cases which I know of on record. As Mr. B. has told you, I have nothing to add as to treatment. 'Nothing succeeds so much as success.

This improvement continued so that patient went on a visit to Ohio for a short time, and returned expecting to resume his former occupation as watchman. Subsequently the doctor wrote me:

"In regard to Mr. J. B., who died November 23, 1886, at 9 o'clock A. M., I will say that he returned from his visit in Ohio very much improved in his general health, but unfortunately came home on a late train about midnight, and his house, which had been closed for two or three weeks and unoccupied, was cold and damp, and he contracted a severe cold, which was followed by cough, oppressed breathing, soreness in the chest and face, so that he was compelled to quit his job as watchman at the railroad depot, and take his bed. This was about the 7th of November, and from this time he was confined to his house, and much of the time had some fever, and continued to cough and complain of oppression in breathing and soreness through the left lung. His appetite, which had been good after recovery from the first profuse hemorrhage, the date of which you have, left him and we had to urge him to take even small quantities of food. I think it was on the 20th of November he had a slight hemorrhage from his lungs, in which he lost about one-half pint blood, which exhausted him very much, and from this time until his death he continued to cough up small quantities of blood with mucus. On the morning of the 23d he seemed as well as usual, but while his wife was in the kitchen, only for a moment, he sprang out of his bed and rushed into the dining-room with a spittoon in hand, and there, seated on an arm-chair, she found him, with the hemorrhage so profuse that he died in two or three minutes. That evening you were present at post-mortem and have your record.”

December 1st. Autopsy twelve hours after death. Body yet slightly warm, very exsanguine, well nourished, an increase of adipose tissue manifest since first examinations four months ago. Fullness over top of sternum, site of former enlargement almost gone. On opening chest left lung was collapsed, scarcely half