1249

sputum which contains numerous micro-organisms and

their products in addition to the tubercle bacillus.
In
the absence of other distinctive signs a uniform redness of
both vocal cords should not be diagnosed as tuberculous,
but if one cord be affected markedly in excess of the other
tuberculosis may be strongly suspected.
The subjects of
active phthisis often complain of much dryness and discomfort in the throat, especially at night, even when there is
no obvious nasal obstruction.
This appears to be the result
of the nocturnal pyrexia and the consequent rapid respiration which makes nasal breathing insufficient. A drink of
hot milk or a demulcent lozenge diminishes the sense of disPatients in quite an early stage of phthisis sometimes complain of painful sensations about the throat which
The cause of this
on examination appears perfectly normal.
is obscure ; it may, perhaps, be that the pain is referred from
the pulmonary disease to the most sensitive part of the
respiratory system. Be that as it may, the symptom is not
very uncommon, and I would suggest that the patient who
complains of pain about the larynx for which no cause can
be found should be submitted to a careful examination of
the chest.
Pachydermia laryngis is also disproportionately common
indeed,
among the subjects of pulmonary phthisis ;
Gougenheim] considered the majority of cases of pachydermia to be tuberculous. I personally consider the affecBrook-street, W.
tion as an extreme form of chronic laryngitis and due to the
same causes; it is therefore natural that it should be
frequent in the larynges of consumptives exposed to the
mechanical irritation of coughing and the chemical irritation
of the sputum without, of necessity, any entrance of the
AND
MEDICAL,
bacillus tuberculosis into the tissues.
The firm white,
THERAPEUTICAL.
almost cornified, appearance of a typical case is very
different from the soft semi-translucent granulations of
tuberculous laryngitis. On several occasions I have removed
A NOTE ON SOME NON-TUBERCULOUS THROAT
the pachydermatous thickening from the posterior commissure
COMPLICATIONS OF PHTHISIS.
of consumptive patients and have failed to find any sign of
BY HAROLD S. BARWELL, M.B. LOND., F.R.C.S. ENG., tuberculosis on
microscopical examination.
SURGEON FOR DISEASES OF THE THROAT, ST. GEORGES HOSPITAL;
It is well known that in cases of tuberculous laryngitis the
SURGEON TO THE THROAT AND EAR DEPARTMENT, HAMPSTEAD
voice is readily lost and is generally much weaker than it
GENERAL HOSPITAL; LATE LARYNGOLOGIST, MOUNT
VERNON HOSPITAL FOR CONSUMPTION, ETC.
would be with a similar extent of lesion due to another
cause, such as syphilis. But apart from any laryngeal affecTUBERCULOUS laryngitis is by far the most important of tion, functional aphonia is very common among consumptive
those complications of phthisis which affect the upper patients. The feeble respiration, the general weakness, and
respiratory tract, so much so, indeed, that it is apt to over- the tendency to catarrh and discomfort of the throat all
shadow all the others and to receive the exclusive attention conduce to this affection, which is found in male as well as
of the laryngologist as well as of the physician. Never- female consumptives, though more frequently in the latter.
theless, other complications are very frequently encountered It is so frequent that an examination of the chest is
and are of sufficient importance to claim some consideration. advisable in every case of intractable functional aphonia.
A " pre-tuberculous " condition of the larynx has often been True paralysis of a vocal cord is also a recognised complicadescribed, and this expression seems to mean an abnormal tion of pulmonary phthisis. It is due to pressure on the
condition, consisting of anaemia, congestion, or swelling of recurrent laryngeal nerve, and is therefore of the abductor
the larynx of a phthisical patient but without as yet any type. Paralysis of the left cord is the result of pressure on
true tuberculous deposit, and it is implied that this is the left recurrent laryngeal nerve by enlarged bronchial or
a precursor of tuberculous infiltration.
The use of this tracheal glands, but the right nerve passes very close to the
for
there are no apex of the right pleura and is thus sometimes directly
expression appears highly unscientific,
grounds for the view that there is any distinctive state involved in an infiltration of the lung on this side. This is,
of the larynx which is always, or frequently, followed perhaps, the commonest cause of paralysis of the right vocal
by tuberculosis. There is also a very general opinion cord, therefore the possibility of pulmonary phthisis should
that pallor of the larynx is a characteristic feature always occur to the mind of the observer who discovers this
of tuberculous laryngitis, but this opinion requires qualifica- lesion on laryngoscopic examination.
Thus, other complications of pulmonary phthisis occur in
tion. Many consumptives are anaemic, and in such cases the
throat besides tuberculous laryngitis, and deserve rethe
as
well
as
the
fauces
and
other
mucous
membranes,
larynx,
are, of course, pale ; in other cases the colour is quite normal, cognition ; and in a few cases where the first complaint is of
and very frequently the tuberculous larynx is in a state of the throat a correct estimate of their significance may direc
hypersemia as the result of coughing and irritation ; in fact, the attention to the pulmonary disease.
it may be stated that tuberculous larynges are reddened
Wimpole-street, W.
quite as frequently as unduly pale. lt is true that the
swollen infiltrated arytenoids are often pallid, and that the
NOTE ON A CASE OF JACKSONIAN EPILEPSY
margins of tuberculous ulcers are characteristically anasmio,
TREATED BY TREPHINING.
and this may have given rise to some misconception ; but
BY
BERNARD
W.
SECRETAN, M.B. LOND., F.R.C.S. ENG.
very often tuberculous infiltration is decidedly red and
congested, especially on the cords, ventricular bands, and
THE following are notes of a somewhat unusual case of
epiglottis.
Simple chronic pharyngitis and laryngitis are extremely Jacksonian epilepsy, in which cessation of the fits was
common among consumptive patients and not infrequently
brought about by operation.
The patient was an anaemic woman, aged 24 years. Her
give rise to mistakes in diagnosis, for there is naturally a
tendency to diagnose tuberculous laryngitis in a phthisical occupation was that of a clerk. About 16 years ago she fell
patient who complains of hoarseness and discomfort down a flight of steps on to her head. She was not stunned
The frequency of simple inflamma- at the time and was apparently able to get up by herself and
in the throat.
tion of the larynx may be explained by the strain of
1 Atlas de
constant coughing and by the contact with irritating
Laryngologie et de Rhinologie, p. 16.
S 3

and two holders, and while I am using one holder, the other,
with tubing attached, is being sterilised.
I use a fresh needle for each case, and the needle will
slip into the vein with ease if lubricated with a little sterile
vaseline, and for this purpose I use a five cubic centimetre
serum flask, filled to the shoulder with vaseline, which is
autoclaved at 120, and after the vaseline has solidified a few
drops of izal are introduced into the neck of the flask, which
is then covered with a sterilised rubber teat. The needle,
immediately after removal from the steriliser, is dipped into
the vaseline before use. After use the holder and tubing
should be washed through with a small glass urethral syringe
to remove the blood before placing in steriliser.
If the patient objects to venipuncture, which is seldom
the case, I use the glass tube depicted in Fig. 2 with which
I can easily collect one cubic centimetre from the finger. The
tube is made from No. 4 glass-tubing with one end drawn
out into a capillary tube and the other end sealed and a bulb
blown near the drawn-out end with a small hole blown in its
side (see Fig. 2). The tube is held with the hole in the
bulb uppermost and the blood will flow into the bulb by
capillary attraction and then collect in the sealed end, the
displaced air escaping through the hole in the bulb. After
filling, the drawn-out end is sealed in the flame and the hole
in the bulb is sealed with wax.

Clinical Notes:

SURGICAL, OBSTETRICAL,

comfort.

1250
go home.

Eight days after, however, she developed a very

headache, which was followed the same night by
three convulsions affecting the left arm and leg. Each convulsion lasted only a short time. The next day the left arm
and leg were found to be paralysed. The arm recovered after
ROYAL SOCIETY OF MEDICINE.
about five months ; the leg remained more or less useless for
a year, and weak for much longer, necessitating the wearing
of supporting irons. The growth of the leg was also imMEDICAL SECTION.
paired, so that it is now considerably shorter than the right.
Arterial Blood-pressure Readings.
Since the paresis passed away the patient up to the date of
A MEETING of this section was held on April 27th,
the present illness had always enjoyed good health with the
T. H. GREEN being in the chair.
exception of"a nervous breakdown"in the spring of last Dr.Dr.
0. K. WILLIAMSON said that observations by the
a
week.
have
lasted
seems
to
year. This, however, only
of circular compression were made on the leg and
method
The present illness followed a spell of extra work at bookin 21
of
arterial blood
severe

Medical Societies.

cases
high
the absence of one of her fellow clerks. arm of the same patient
home one week end complaining of intense pressure. In all of the cases in which the arteries of the
headache ; this continued and on the following Monday she leg and foot could be felt these were found to be
He abnormally resistant and more so than those of the upper
was seen by her own medical man, Dr. C. G. S. Leeds.
found her in a dazed, dreamy condition, every now and then extremity; and in nearly all the cases there was also
thickening in the arteries of the upper extremity.
crying out with the pain, which was not localised to any one marked
Ten
cases of normal or low blood pressure, in which the
her
whole
head.
She
was
but
affected
given bromide,
spot
phenazone, and later aspirin, and appeared to improve some- arteries presented no clinical evidences of disease, were
what, so that on the following Thursday the pain was investigated in the same manner, so as to afford a basis of
decidedly better. On the Friday night, however, she had 11 comparison. The observations were made on the calf and
convulsive attacks. The convulsions were limited to the left arm, the patient observed being recumbent, and the part of
the limb on which the observation was made was at the level
arm and leg, affecting the former more than the latter. They
lasted from two to five minutes and apparently there was no of the heart. Olivers compressed air hæmomanometer was
complete loss of consciousness. On the Saturday morning used with his 12 centimetre armlet. These observations showed
there was a temporary cessation of fits, but they recommenced that the resistance due to the arterial wall might markedly
in the afternoon so that by the following day (Sunday) the influence the readings, for the following reasons : 1. In the
patient had had another 20. By this time the convulsive high blood-pressure cases the leg systolic readings were
movements were more violent and in some of the worst in nearly all cases markedly higher than the corresponding
attacks there was complete loss of consciousness.
Clonic arm readings (average difference 32 millimetres), and the
movements of the muscles of the face and of the eyeballs cases of highest blood pressure yielded distinctly greater
also occurred. The patient was able to tell when a fit was differences than the cases of somewhat lower blood pressure.
about to occur and would cry out to this effect about a minute On the other hand, the leg diastolic readings in these cases
were, on the average, practically identical with the arm
before the actual onset.
I saw her with Dr. Leeds, and as she was obviously going diastolic readings (average difference less than 2 mm.
downhill and becoming more and more exhausted we de- Hg). 2. In the case of normal or low blood pressure the
cided to trephine the next morning. By that time (Monday) systolic arm and leg readings were found, on the average, to
she had had another 29 attacks, and so frequent were they be identical (average difference less than 2 mm. Hg).
the blood pressure in the leg could
becoming that no less than four occurred whilst we were in 3. Inasmuch as than
that in the arm (either limb
the house making our preparations. I turned down the usual not be higher
scalp flap and removed an inch and a quarter disc of bone being at the level of the heart), and seeing that
the influence of the tissues superficial to the artery might
over the right fissure of Rolando, having its centre about one
and a half inches from the upper end of the fissure. (when a sufficiently wide armlet was used) be neglected, it
I could find no depression or thickening of the bone, necessarily followed that the difference between the arm and
The brain leg readings could only be due to resistance of the arterial
nor was
the dura adherent to the skull.
a
into
the
dura was wall. 4. The conclusion that the abnormal condition of the
deal
The
bulged
good
opening.
incised for about three-quarters of an inch, without, arterial wall was a direct result of the increased blood
however, throwing any further light on the case, and pressure would seem to be inevitable, for the only obvious
finally the scalp was sutured in position over the hole in difference between the conditions to which the arteries of
the skull. The night following the operation the patient the legs and those to which the arteries of the arms are
had altogether six fits, but these were not nearly so severe exposed in daily life was that, owing to the action of gravity,
The next day she had none. That night the former were subjected to greater hydrostatic pressure
as her former ones.
she
had
three
very slight attacks. Since then up to from a higher column of blood than were the latter.
again
Dr. GREEN said that it was very important to deterthe present time (six months) she has had none.
The
headache ceased the day following operation. The woman mine how far the pressure readings were influenced by the
to-day is fit and fell. She has only been allowed to do easy condition of the vessel wall, and on that point there seemed
work, but is very anxious to do more. She says that her head to be no definite agreement amongst various workers on the
is much clearer than formerly and that she is much quicker subject. A great deal had been done in the matter during
at figures and less easily fatigued by them than before her the last few years, but much remained to be done. While
attack.
waiting for that further information physicians had to be
The case is remarkable on account of the long period of largely guided by their own unaided senses. When the
time which elapsed between the initial injury and previous blood pressure was largely increased and when the arteries
attack and the present one. Also on account of the benefit were markedly thickened those facts were evident to the
resulting from trephining, although nothing abnormal wastrained finger. There seemed to be danger at the present
found at the time of operation. I am not, of course, at thetime of relying too much on instrumental aids. Even with
end of only six months so bold as to call the patientthe best instruments if there was not clinical skill physicians
cured. Time alone will show that. I see no reason thoughmight fall far short of what they ought to achieve.
Dr. W. P. HERRINGHAM said that he had been making exwhy the fits should recur provided the woman can be induced
to lead a placid, quiet life. Anyhow, the operation un- periments on arteries that had been removed from the body
24 hours, and on arteries that had been three days out of the
doubtedly saved her life at the time.
room, being kept during those three days in a
post-mortem
Reading.
1 per cent. solution of sodium chloride. He found that those
arteries still gave in some cases high resistance readings just
IRISH MEDICAL SCHOOLS AND GRADUATES Asso- as other arteries did. The figures he obtained were 8, 13,
CIATION.—A special meeting of this association will be held 5, 4, 6, 12, 15, and 22 millimetres, showing that there was
at Harrogate on Saturday, May 22nd. Arrangements have something in the artery itself quite apart from contractility.
been made with the Majestic Hotel to allow of members He had also been experimenting on simultaneous readings
remaining until Monday to visit places of interest in the from the arm and leg, testing two places at the same moment,
neighbourhood. Full particulars may be obtained from the and his results confirmed those of Dr. Williamson.
Dr. T. D. SA. VILL asked whether the author of the paper
!
honorary secretary, 30, Myddelton-square, London, E.C.

keeping, owing to
She

came