Clinical medicine : cases / by Dr. M'Call Anderson.

  • Thomas McCall Anderson
Date:
1881
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Licence: Public Domain Mark

Credit: Clinical medicine : cases / by Dr. M'Call Anderson. Source: Wellcome Collection.

Provider: This material has been provided by The University of Glasgow Library. The original may be consulted at The University of Glasgow Library.

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    From these symptoms the experienced observer might have a shrewd suspicion of the general character of the lesion which produced them, but certainty could not be attained without a laryngoscopic examination, wliich shows that both vocal cords are paralyzed. Now there are three forms of bilateral paralysis :— 1. Paralysis of the Abductors, in which condition the vocal cords do not separate on inspiration. This is the paralysis of the vocal cords with central fixture of Mackenzie; it is generally the result of a cerebral lesion, and demands a prompt resort to tracheo- tomy, else the patient is very apt to die of suffocation. 2. Paralysis of the Adductors, when the vocal cords are widely open, and do not approximate on phonation—Mackenzie's bilateral paralysis with lateral fixture. This condition is most frequently met with in hysterical subjects, and is then to be relieved by the direct application of the induced current to the vocal cords, 3. Paralysis of both Abductors and Adductors, when the vocal cords remain in the cadaveric position, i.e., midway between complete closure and complete opening of the glottis. This last is probably the rarest variety of all, and it is that which is present in our patient. Apart from the laryngoscopic examination, the symptoms which he presents are quite in accordance with those which are usual in such cases, as the following quotation from Morell Mackenzie's admirable work on Diseases of the Tliroat and Nose shows':—No dyspnoea is present in such cases (when at rest, I presume he means), and the voice may be weak or reduced to an almost inaudible whisper. In any case there is constant waste of breath present, and speaking is attended by a great increase in the amount of effort normally required, the excessive size of the glottis necessitating a greater degree of pressure to throw the vocal cords into vibration. The muscles of expiration, especially the abdominal, are therefore unusually strained, discomfort is felt at their thoracic attachments, and the patient quickly becomes exhausted. He cannot cough, expec- torate, or speak properly, because in these acts it is necessary to close the glottis, and this he cannot accomplish. On forced in- spiration a stridulous sound is often produced, which appears to depend on the'arytenoid cartilages, the ary-epiglottic folds or flaccid vocal cords being thrown into coarse vibrations. So far our diagnosis is perfectly clear; but a still more important, and often more difficult, question remains to be considered, viz., the cause of the paralysis, and the nature of the lesion which has pro- duced it. It may be either central or peripheral. If central, the lesion is probably situated in the medulla oblongata, or so as to implicate the roots of the pneumogastric and spinal accessory nerves. In that case we should probably have, not only laryn- geal, but likewise head symptoms, such as pain, etc., perhaps optic neuritis, and usually other nerves ai-e implicated. Thus in bulbar » Vol. i. p.440.
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