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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![paralysis not only is there palsy of the vocal cords, but likewise of the palate, lips, and tongue, owing to the 7th and 9th as well as the spinal accessory nerves being involved. In our case, how- ever, there are no head symptoms, nor is there paralysis of any other part than the vocal cords, so that in all probability the lesion is not central; it must therefore be peripheral^ in which case either the pneumogastric nerves or their recurrent branches must be involved. [Dr Anderson tlien referred to a variety of morbid states, such as diseases of the oesophagus and thyroid gland, which have been known to produce paralysis of the vocal cords by pressure upon these nerves, and then proceeded as follows.] What peripheral lesion, then, has given rise to the paralysis in this case? The history having pointed to symptoms of catarrh of the larynx at the outset, it was hoped at first that this was the cause of the paralysis, but a careful examination of the patient's chest has led me to take a much more gloomy view of his case. You will observe that the apex beat of the heart is displaced very much downwards and to the left, being situated in the 6th space, 3J inches below the nipple and 2 inches to the left of the nipple line, and that the cardiac dulness is proportionately displaced downwards. Secondly, the breath sounds are much more feeble over the left than over the right lung, especially at the apex • and perhaps the left side of the chest is rather flatter than the right. There is no other evidence of disease of the lungs, except that slight musical rhonchi are to be heard at times over the greater part of the chest on both sides. Thirdly, you will observe that the veins on the left side of the neck and left infra-clavicular region are a little fuller than those on the right. There must, therefore, be a something within the chest which has pushed the heart down- wards and to the left, and which is interfering with the free entrance of air into the left lung, and the free return of venous blood from the veins on the left side of the neck. It is reasonable, there- fore, to conclude that we have here to deal with an intrathoracic tumour which is pressing on one or both of the recurrent laryngeal nerves, and thus producing the paralysis of the vocal cords. I say one or both, because it has been shown that bilateral paralysis may result from pressure upon one pneumogastric nerve, and which Dr George Johnson believes to result from reflex paralysis, while Mackenzie thinks it more probable that central disease is set up, the nuclei of the spinal accessory nerves (from which the pneumo- gastric receives most of its motor fibres) becoming actually diseased. What, then, is the nature of the tumour ? Upon this point I desire to speak with more reserve, although the evidence, as far as it goes, is rather in favour of aneurism. There is an absence of the cachexia of malignant disease, which is by far the most common form of solid tumour within the chest, while, on the other hand, the patient's age (49) is quite in accordance with the aneurismal](https://iiif.wellcomecollection.org/image/b21457554_0007.jp2/full/800%2C/0/default.jpg)
