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tumour. Dr. Apostoli is aided in his work by two admirableassistants and a most intelligent nurse.

It would obviously be impossible from an observation oftwo short visits to give an opinion of real value as to themerits of Dr. Apostoli’s treatment. I was induced to paymy visits from a desire to learn for myself the details of,applying the electrolysis, especially to cases of uterine

myoma. I have long felt that we want some means otherthan those which we possess for the treatment of manycases of fibroid tumours of the uterus. Hysterectomy, grandand perfect when successful, has even now a larger mor-tality than is desirable, and can be practised only as a lastresort. Will electrolysis ever be able to be a substitute forthe more heroic treatment? It is our duty to answer thisquestion if possible. With this state of mind, therefore, Iam prepared to try the effects of Apostoli’s method, andhope to be able to communicate in due course the results of.such experience.With my present views I thought that some of the cases

a saw could have been cured by abdominal section, and ontelling this to Dr. Apostoli and Dr. Woodham Webb, theyboth seemed to imply in their answers that when 1 knewmore of what electrolysis could accomplish, I should be asenthusiastic in favour of it as themselves, and should sub-stitute it for many cases now calling for abdominal section.The battery and all necessary appliances can be obtained ofM. Gaiffe, 40, Rue St. André-des-Arts, Paris, at a cost in-cluding freight, &c., of about £25. I have much pleasurein testifying to the extreme courtesy of Dr. Apostoli, whoallowed me to see for myself everything connected with hiswork, and explained most fully every detail. I had the

pleasure also of meeting Dr. Woodham Webb, who mostkindly assisted me by explaining what appeared difficult.Birmingham.

BILATERAL PARALYSIS OF THE DILATORMUSCLES OF THE GLOTTIS, WITH

SUBSEQUENT PARESIS OFTHE CONSTRICTORS.

BY PERCY KIDD, M.D., F.R.C.P.,ASSISTANT PHYSICIAN AND PATHOLOGIST TO THE BROMPTON HOSPITAL.

(Concluded from page 110.)

THE following case, which has come under my own obser-vation, illustrates some of the points in dispute: A. R---,aged forty-seven, a carpenter, came to the out-patient de-partment at the Brompton Hospital on Oct. 15th, 1886,complaining of difficulty in swallowing and shortnessof breath. These symptoms had appeared twelve monthspreviously, and for some five or six months he had beenlosing flesh. About three months ago hoarseness de-

veloped, and the dysphagia and dyspnoea became so

much worse that he was able to do very little work. Forthe last week he had been completely laid up owing to in-creasing shortness of breath. There was no history ofsyphilis, but he stated that he had suffered from "rheumaticgout" in the wrists and ankles. Family history unim-portant. The patientwas ansemic and cachectic looking, beingvery thin. Breath extremely offensive. Voice only slightlyhoarse. Marked inspiratory stridor. Neck swollen, owingto the presence of deeply-seated groups of large hardglands in both anterior and posterior triangles, especially inthe former position. Veins at root of neck distended. Therewas scarcely any movement of the larynx up and downwith respiration. A few shotty glands in right axilla. Leftradial pulse smaller than right. Pupils equal. Tongue furred;bowels constipated. On physical examination of the chestthe expansion of the left side was somewhat impaired; therewas slight dulness over the manubrium sterni extending ashort distance to the left, and over this area trachealbreathing. The breath sounds were weaker at the left apexthan the right. No other abnormal signs. The pharynxwas congested and irritable, and the larynx was in the samestate, The vocal cords approximated during phonation tothe normal extent, but on inspiration they did notdiverge more than one-sixteenth of an inch. On verydeep inspiration the cords almost met in the middleline. There was no appearance of tension of the vocal

cords; indeed, they seemed to be more lax than usual.The patient was thought to be suffering from a new growth

! of the cervical and mediastinal glands, possibly secondaryto malignant disease of the oesophagus, implicating the

. recurrent laryngeal nerves. The patient was admitted into, the hospital under my care, through the kindness of Dr.Symes Thompson. After admission he had one or two

’ severe attacks of dyspnoea, and preparations were made fortracheotomy, but, after a consultation with Mr. Godlee, the

operation was deferred, although dyspnoea continued to bea prominent symptom. The patient was able to swallowliquids with difficulty, but not solids, and the dysphagia didnot increase much for the first four or five days. The tem-perature varied between 98’ and 1000 as a rule, and did notrise above 1005° at any time. Sphygmographic tracingsseemed to confirm the idea that the left radial pulse wassmaller than the right. On Oct. 21st Mr. Godlee kindlyexamined the patient’s oesophagus, and reported as follows :"Bougie (No. 9, Alackenzie’s) stops at seven inches anda half from incisor teeth. The man struggles very much,so attempts had to be short. No blood. The finger willnot reach beyond the tip of the epiglottis." A few dayslater a marked improvement took place in the breathing,and on Oct. 26th 1 found that, although the dyspnoeawas decidedly less, the patient’s voice was now very weakand high pitched. The man could not swallow either liquidsor solids, and had wasted rapidly. " Foetor ex ore" wasmore marked than ever. On laryngoscopic examination theopening of the glottis was distinctly wider. When attemptswere made to phonate, the cords approached one another tosome extent, but in a faltering manner. This imperfectadduction could not be sustained as in singing, but after amomentary movement towards, but not quite up to, themiddle line, the vocal cords diverged and took up a positionmidway between that of quiet inspiration and phonation.No further opening of the glottis occurred on the deepestinspiration. The impression gained was that the constric-tors of the glottis acted in a weak, irregular manner, whilethe dilators were completely paralysed. Recourse was nowhad to nutrient enemata, but the patient continued to wastewith great rapidity. Mr. Godlee again saw the patient,and suggested gastrostomy, more as a means of postponingthe end than with any hope of long-continued relief. Thechances of the operation were put before the patient, andhe decided to have it done. Gastrostomy was performedby Mr. Godlee on the afternoon of Oct. 30th. The pulsefailed somewhat during the operation, but improved again,and the man appeared to rally somewhat afterwards. Thisimprovement, however, was only temporary, and he

gradually sank without any rise of temperature, and diedthe next morning at 9 A.M. No change was noticed in thelaryngoscopic appearances after the 26th, but no examina-tion was made after the 29th. The voice preserved itsweak, high-pitched character to the end.Abstract of necropsy.—Large nodular masses of new

growth were found in both anterior and posterior trianglesof the neck, being most abundant towards the middle thirdof the neck. These masses, which were hard and white, laymainly beneath the sterno-mastoid muscles, and were mattedtogether, forming a nodular chain continuous with a similargrowth in the posterior mediastinum. There were only afew small nodules in the anterior mediastinum, though theconnective tissue here was very dense and obviously thick-ened. The common carotid arteries were pushed forwardsand inwards by the growth, which lay to their outer side,and the left subclavian artery was somewhat compressed.On the right side the vagus was not at all pressed upon, butopposite the cricoid cartilage the nerve presented a largefusiform swelling like a ganglionic enlargement. The rightrecurrent laryngeal nerve was traced round the subclavianartery to its entrance into the larynx, and was not impli-cated. On the left side the vagus was buried in the can-cerous material at the level of the upper third of the

thyroid cartilage. On dissection, the nerve could be tracedwith ease through the growth, and, though it was some-what flattened, it did not appear to be infiltrated.Below this point the nerve was thinner than the vagustrunk on the other side. The left recurrent nerve passedfreely round the aortic arch, but was embedded in thegrowth along the lower part of the trachea. The superiorlaryngeal nerve, with its external branch, was quite free oneach side. The oesophagus, from a point one inch below thecricoid cartilage down to its termination, was infiltrated andbhickened. Opposite the junction of the upper and middle

160

third of the trachea the gullet was extensively ulcerated, ttand there was a ragged oval perforation of the trachea one tlinch and a half in length. There was a similar growth in qthe mucous membrane of the trachea from this point almost o:

down to its division, with slight ulceration in places. The tllower part of the pharynx contained a few miliary nodules fton its mucous membrane, one just above the left border of Mthe cricoid cartilage, but there was no infiltration of sub- d

jacent structures. The larynx was quite free from disease. s(

The vocal cords lay in the cadaveric position, and could be u

moved freely to and from the middle line. There was no in- dterference with the crico-arytenoid articulation. On remov- If

ing the mucous membrane covering them the crico-aryte- ftnoidei postici looked pale and thin, but not more so than the vmuscles generally. The crico-arytenoidei laterales pre- Esented no abnormal appearance. The lower lobe of the hleft lung contained one small nodule, and there were afew enlarged glands behind the stomach and liver. bThe gastrostomy wound looked quite healthy, and there Iwas no peritonitis. The rest of the abdominal cavity was dfree from disease. The brain with its vessels and membranes a

appeared quite healthy. Microscopical examination showed tthat the growth was a carcinoma (squamous epithelioma). dIn sections of the fusiform enlargement of the right vagus tit was seen that almost all the nerve bundles had been v

destroyed, but the outlines of the bundles were still visible. dThe nerve fibres were replaced by an opaque granular v

material, which exhibited indistinct circular markings like s

those of the original fibres, but without any trace of axis 1:

cylinder or medullary sheath. Every section showed two c

or three small bundles of healthy nerve fibres, situated in teach case peripherally-i.e., immediately beneath the epi- c

neurium. The epithelial growth could be seen between the Inerve bundles, and in many cases lying inside the peri- c

neurium. In a very few places scattered epithelial cells iwere seen between the individual nerve fibres. Sections of tthe left vagus below the point of compression showed an t

opaque granular condition of the nerve fibres, with completeloss of axis cylinder and medullary sheath. Here and there ta few healthy nerve fibres were seen lying scattered among f

the degenerate fibres, and not collected into bundles. Bothrecurrent laryngeal nerves were in much the same state. Afew healthy fibres were seen here and there, but there was lthe same widespread granular transformation of themedullary sheath and axis cylinder, and in places the nuclei iof the neurilemma were increased in number, and connective-tissue development appeared to be going on. The crico-arytenoidei postici and the right crico-arytenoideus lateraliswere examined, and presented the following appearances.Most of the muscular fibres were normal and distinctlystriated, but in all three muscles some of the fibres werethinner than the others and were slightly granular anddevoid of striation. Mere degenerate fibres were notnumerous in any of the muscles, but were more abundant inthe postici than in the lateralis muscle.The bearing of the present case on the subject of abductor

paralysis is obvious. The patient presented at first the

appearances of bilateral paralysis of the dilators to whichwas added subsequently paresis of the constrictors of theglottis. It is difficult to say how long the paralysis of thedilators had existed when the patient was first seen, but weknow that this condition was present during the last fort-night of his life, and paresis of the constrictors onlydeveloped four or five days before death. The anatomicalrelations of the new growth found after death quite explainthe succession of clinical symptoms. Both vagus nerveswere compressed above the origin of the recurrent laryngealnerves, one of these nerves being also involved in thedisease. The first muscles to feel the effects of the graduallyincreasing pressure of the growth on the motor nerveswere the crico-arytenoidei postici, the adductors showingno loss of power till a much later date. It is remarkablethat in spite of the very decided pressure on the nerveswhich existed, the laryngeal muscles showed comparativelyso little evidence of degeneration. It must be remembered,however, that some few healthy nerve fibres were found ineach recurrent laryngeal nerve. Possibly, too, the completeimmunity of both superior laryngeal nerves may have hadsomething to do with the maintenance of nutritionin the muscles, for Exner’s investigations teach us thatthis nerve takes more parts than was previously thought inthe innervation of the laryngeal muscles. Krause wishes toexclude cases like that above described so as to avoid the

possibility of a direct invasion of the muscles or their

terminal nerves by the growth. But, as Rosenbach urges,these cases are specially suited for the elucidation of the.question, illustrating as they do the uncomplicated effectsof pressure on the nerves. In Rosenbach’s, as in my case,the larynx itself was quite free from the growth, and thefact that in his case the necropsy was made by ProfessorMarchand is an ample guarantee of the correctness of thedescription which Rosenbach quotes. Cases like these andsome of Dr. Semon’s contradict Tervaert’s assertion that no,uncomplicated case is recorded in which paralysis of thedilators passed into complete paralysis of the recurrentlaryngeal nerve. Krause lays himself open to a serious.fallacy when he compares his experimental studies in animals.with the affection known as abductor paralysis in man.Electrical stimulation of the laryngeal nerves of a dog can,hardly be said to come within the same category asthedegene-rative processes set up in the corresponding human nervesby the slowly-increasing pressure of a carcinomatous growth,The same must be said of his attempts to imitate this slowdegenerative process by his experiments with the cork. Theappearances described in the nerves which he subjected tothis treatment are those of acute neuritis, not chronicdegeneration. Even granting that he really did produce atonic contracture of the adductor muscles, which is some-what doubtful, the difference between the method of pro-duction of his artificial contracture and the affectionswhich occasion a similar position of the human vocalords is so great as to forbid any analogy being drawnbetween the two conditions. It is strange that the closureof the glottis resulting from electrical stimulation ofthe nerve ceased when inspiration occurred, in spiteof the irritation being maintained, whereas the medianposition of the cords produced by the pressure of thecork was unaffected by inspiration; and yet - in bothinstances Krause ascribes the approximation of the cordsto contraction of the adductors resulting from irritation ofthe motor nerves.

It will be seen from the various criticisms already quotedthat the general opinion is adverse to Krause’s views,and, as Professor Fraenkel says, the hypothesis of a primaryneuropathic contracture merely adds to our difficulties.The fact that in the case described above both superiorlaryngeal nerves were unaffected may be claimed byTervaert as supporting his view. But his theory quitefails to account for cases of abductor palsy dependent oncentral disease, and cannot therefore be regarded as ad-mitting of general application. Seifert’s cases do not throwmuch light on the subject. For the larynx was onlyexamined anatomically in one case, and the account givenis not complete. Whether the laryngeal paralyses describedby Seifert can be credited to the influence of lead mustremain at present a matter of doubt.

It seems, then, that Semon and Rosenbach have provedtheir point as to the vulnerability of the abductor nervefibres, but an explanation is still wanting. It is hard to say

, whether the vulnerability attaches to the nerves alone or toi both nerves and muscular fibres. Dr. Semon, I believe,

inclines to the latter view. Simanowski’s observations arei interesting, as pointing to structural differences in laryngeali muscles. If the terminal motor nerves and their end organs are less abundant in one group of muscles than. another, it is easy to conceive that any disease of thecorresponding nervous tract, whether central or peripheral,would react more disastrously on this set of muscles1than on another group more richly supplied with nervousfilaments.1 The writer of a leading article in THE LANCET, June 5th,.

1886, endeavours to account for the vulnerability of thedilators by a mechanical explanation suggested by Dr.Gowers-viz., that the abductors are inserted at an acuteangle into the muscular process of the arytenoid cartilage,

0and therefore act at a disadvantage as compared with thes adductors, which are inserted into the same process almosty at a right angle. There are, however, strong objections to

the acceptance of this theory, plausible as it seems at firstn sight.e Mr. Horsley and Dr. Semon1 have found that if the larynxd be excised from animals immediately after death, and then elecrical current be applied directly to the muscles them-,t selves, the crico-arytenoidei postici lose their excitabilityn long before the adductors. Again, some experiments ofo Dr. Hooper2 of Boston, published in 1885, and confirmed and

1 Brit. Med. Journ., Aug. 28th and Sept. 4th, 1886.2 Transactions of American Laryngological Association, vol. vii.

161

amplified by Horsley and Semon,3 show that the degree of- ether or chloroform narcosis determines whether the dilatorsor constrictors shall react to electrical stimulation of therecurrent nerve. When the anaesthesia was slight, irritationof the nerve produced adduction of the vocal cord; whenthe anmsthesia was more profound, stimulation of thenerve caused abduction of the cord from the middleline. The differentiation obtains when the peripheral end ofthe divided nerve is excited, pointing to the action of theanaesthetic being peripheral and not central. Facts such asthese do not fit in well with the mechanical explanation.suggested above, nor with the idea of the preponderance ofthe adductors assumed .by Krause.Brook-street, W.

ON LATERAL CURVATURE OF THE SPINE.

BY RICHARD BARWELL, F.R.C.S.,SENIOR SURGEON, CHARING-CROSS HOSPITAL.

III.

AT some future opportunity, and in some method which.affords to me a greater amount of space than can beallotted in the columns of a journal, I shall discuss the

exceedingly difficult and much controverted etiology of,curves primarily dorsal; here I must confine myself toaemeiology and treatment. From whatever cause it mayarise, the first advent of dorsal curvature, though occasionallypretty rapid, is in the vast majority of instances insidiousand slow. The early changes of form are indicated, not byany aberration in the line of the spinous processes, but bycertain alterations due in the beginning solely and entirelyto rotation, and this, although the vertebrae as a whole,more especially their bodies, may have considerablydeviated. This apparent paradox is due to the fact that bythe very act of rotation the spinous processes of the aberrantvertebrae are carried towards the concavity of the curve,and that therefore a certain amount of deviation is, as far as’the tips of the spinous processes are concerned, compensatedby the rotation itself. But the ribs having a long sweepoutwards from the spine, act as indices which show-even a very small degree of rotation, a much smaller

degree than can be detected by any examination ofthe spine itself, as, for instance, at the loins.l Hence changesof form produced by such twist can be verified by notingjust about and outside the line of insertion of the longissi-mus dorsi tendons, the exaggerated backward projectionof the ribs on one side, their diminished protuberance onthe other. lioreover, the scapula lie on and are supportedby the ribs, and must change their position and the direc-tion of their surfaces with any alteration in the planesand forms of the bed on which they lie, hence certainchanges in the shape of the shoulders are aids in thediagnosis, and are usually the special point which firstattracts the attention of parents, and generally con-

tinues throughout the case to be the chief object of theirsolicitude.Thus considered, it will be plain that diagnosis depends

on a subtle perception of form, or rather of deviations fromnatural and healthy symmetry, which I will do my best toexplain. Dorsal curvature is usually, though by no meansexclusively, to the right. We will therefore suppose, for thepurposes of description, a curve convex in that direction.’The earliest sign, before any lateral deviation can befound, and before any obvious change in the positionof the scapule takes place, is a greater fulness and round-ness of the posterior aspect of the right side of the chest,and a certain flatness on the left side around and about thelower angle of the scapula, as also between that point andthe spine. A most useful and instructive method is to in-vestigate the form from above, either by letting the patientsit on a low stool, or better by the surgeon standing on onewhile the patient remains erect. Whichever of these twoplans be chosen, the chiefly important point is to look

straight down the spine, noting also the conformation of the’bordering parts, thus obtaining, if I may so express myself, abird’s-eye view of the patient’s torso. The annexed series

3 Loc. cit.1 In my treatise on Lateral Curvature, I have shown that the ribs,

besides being indices to mark, are levers to produce rotation.

of outlines (see Fig. 7) are diagrams of the forms as thusseen, the head being omitted as likely to confuse thesketches, which were in each instance taken from life. Thefirst is the normal form, showing absolute symmetry of leftand right sides-the next three show the progressive changesof the back and shoulders in cases of increasing severity;the fifth depicts in a severe case the changes of back,shoulders, and chest. Now, to explain the last four outlinesThe depression near the middle of the figure is the placeof the vertebral groove. On the left of this (concave side)the outline is slightly flattened, and the slight projection, alittle further out (the posterior border of the scapula),lies pretty near the spine and the shoulder blade itself ;the line still further out beyond the slight projectionis the spine of that bone, looks too directly backward.On the right (convex) side the line from the vertebralgroove outward becomes in increasingly severer cases moreand more rounded, the posterior costa of the scapula recedesfurther from the spine, and the hinder surface of that bonelooks abnormally outward.

Thei3e outlines and description form a key to the backview, in which, by careful lighting2 these positions, theprojections and depressions can be well studied, and thedistances of the scapulae from the spine measured. More-over, it will be found that the right one sits close to,

and pretty firmly on, the ribs; the left lies looser, evena little way off the ribs, so that the surgeon can passbetween them-that is, under the venter of the scapula-the ends of his fingers. Hence while the right shoulder isboth thick and high, the left one is flat, flaccid, and low. Inall but very early cases the line of the spinous processes iscurved towards the right, but the proportion between theamount of curvature and the amount of rotation varies indifferent cases. Soon after the appearance of the dorsaldeviation the lumbar spine begins to assume a secondary orcompensating curve to the left, and the marks and signs oflumbar curvature, described in my former paper, are super-added to the above changes-namely, the deeper incurvationon one side (left) of the waist, the apparent sideways shift-ing of the upper part of the figure on the pelvis, the dis-parity of the two rounded angles between the iliac and thedorsal halves of the trunk. Moreover, about this period-sometimes a little earlier, sometimes a little later-evidenceof alteration in the form and position of the ribs may beobserved, though a little careful study will show that theanatomical changes must have begun some time beforethey were clinically perceptible. They are shortly describedas follows. The angles of those on the convex side of the

2 A light direct from above has many advantages.