early stage of paralysis, and may be present when the aneurysm is beginning to develop, before any clinical symptoms have made their appearance. As this form of paralysis produces no functional disturbances, it escapes the notice of the physician, unless it is accidentally discovered in the course of a laryngoscopic examination. It is owing to these two facts-the gradual, and at first painless, development of the aneurysm and the absence of symptoms in paralysis of the posticus-that the disease does not, as a rule, come under observation until it has made considerable progress, and the change from the median to the cadaveric position, which is the outward sign of paralysis of the recurrent, has taken place. Among other motor disturbances in the larynx in aneurysms of the aorta may be mentioned laryngospastic attacks and periodic palsies of the vocal cords. Löri and Grossmann have described certain laryngeal disturbances which are rarely observed as symptoms of incipient aneurysm of the aorta. Löri1 says that the pressure of the aneurysm on the recurrent nerve in some cases provokes transient motor phenomena in the muscles of one-half of the larynx, which manifest themselves in difficult articulation; in hoarseness, occurring at frequent intervals and without discoverable. cause; in sudden changes of the voice or of a single note; and occasionally in spasm of the vocal cords. These phenomena, however, which are due to the irritation of very slight pressure, according to Löri, are replaced after a few days or weeks by paralysis of the entire half of the larynx from the increased pressure on the recurrent nerve. In agreement with Löri, Grossmann explains similar phenomena observed by him as the effect of irritation by the gradually increasing pressure of the aneurysm on the nerves. His case 2 is remarkable from the fact that he was able to observe it more than a year. The patient came to be treated for frequent attacks of dyspnea of short duration, before there was any suspicion of aneurysm. After one of these attacks Grossmann observed a "paralysis of the left vocal cord," which disappeared on the following day. A few days later there was another attack of dyspnea, also accompanied by "total left-sided paralysis. 1"Die durch Allgemeinerkrankung bewirkten anderweitigen Veränderungen," etc., p. 61. 2 Arch. f. Laryng.," vol. II, p. 254. of the vocal cord." It is not quite clear from the description whether we have here a paralysis of the posticus or of the recurrent. One year later unmistakable clinical symptoms of aneurysm had developed, and, with the appearance of a total left-sided paralysis of the recurrent, the laryngospastic attacks ceased. We have so far confined ourselves to the effects of pressure on the left inferior laryngeal nerve by an aneurysm of the aorta. The explanation of those cases, first described by Gerhardt and Bäumler, 2 in which left-sided paralysis of the recurrent is combined with a similar paralysis on the right side, or in which there is right unilateral paralysis of the vocal cords, presents greater difficulties, as the course of the right recurrent nerve does not make the occurrence of such a condition appear probable. Among similar cases. may be quoted Onodi's, in which the right vocal cord was fixed in the cadaveric, and the left in the median position, and Cartaz's case, in which there was marked dyspnea and both vocal cords were seen in the median line, two or three millimeters apart, immovable, with concave edges. It is remarkable how often Löri 4 found the right nerve involved; he reports three cases of paralysis of the right half of the larynx and two cases of bilateral paralysis. Bäumler gives as an explanation of his case that the aneurysm produced overfilling, or even an aneurysmal dilatation, in the right subclavian artery, or that it pressed on the nerve from below at its origin from the pneumogastric. Another explanation appears to me to be suggested by the fact that unilateral paralysis of the pneumogastric is capable of producing bilateral disturbances of mobility. Semon, 5 and before him Löri,6 gives the following explanation: A peripheral stimulus of the pneumogastric is transmitted through the afferent fibers of that nerve to the center in the medulla; from there it passes into the two motor nuclei of the vagus (Semon calls them the accessory nuclei), and thus gives rise to a bilateral disturbance of motility (Johnson's theory 7). Aneurysms of the aorta ultimately produce changes in 1 Virch. Arch.," XXVII, p. 75. 2" Arch. f. klin. Med.," II, p. 550. 4 "Semon's Centralbl.," VIII, pp. 358 and 493. 6 Heymann's "Handb. der Laryng.," I, p. 615. 7 Semon quotes" Med. Chir. Trans.," vol. LVIII, 1875. 5 Loc. cit., p. 62. the trachea; pulsating movements, which may extend to the larynx; tracheal stenoses by compressing the walls; and, finally, pressure ulcers and perforations. The arch of the aorta curves over the left bronchus from before backward, and lies close to the left anterior aspect of the trachea, just above the bifurcation, so that it occupies the obtuse angle formed by the trachea and left bronchus. Even under normal conditions a movement can be observed in the spur of the trachea in the laryngoscopic image, caused by the transmitted pulsation of the aorta. When the arch and descending limb of the aorta are dilated by an aneurysm and brought into closer contact with the trachea, the pulsation is communicated to the entire trachea, and can be observed even in the larynx. Oliver suggests bending the patient's head back, so as to draw the larynx upward, for the purpose of bringing out tracheal pulsation, while Cardarelli observes the pulsation by the movements of Adam's apple with the patient's head bent back, and even pretends to be able to diagnose the seat of the aneurysm by the oblique direction of the pulsating movements. Compression of the windpipe by an aneurysm in most cases produces a so-called scabbard-like stenosis of the trachea on the left side, with stenosis of the left bronchus. When the aneurysm is in the ascending limb, or in the arch, the pressure may in rare cases be exerted on the right side of the trachea and on the right bronchus. It is important to recognize these tracheal stenoses, as the respiratory embarrassment might otherwise be attributed to paralysis of the vocal cords which is usually present at the same time. Tracheotomy under such circumstances is, of course, useless; even the introduction of a cannula to the bifurcation, beyond the seat of the stenosis, gives only a temporary relief, because the pressure of the cannula very soon produces decubital ulcers in the trachea, through which rupture of the aneurysm takes place. The rupture of an aneurysm into the trachea or bronchus is not a rare occurrence, but the mechanism has been variously explained by different anatomists. Eppinger 2 believes that the tracheal rings are forced apart by the wall of the aneurysm, and that rupture takes place through secondary aneurysms which form between the separated. 1 "Centralbl. f. inn. Med.," 1894, No. 42, p. 988. 2 Klebs, 66 Handb. der pathol. Anatomie," VII, p. 270 et seq. rings. He saw no proliferation of the cartilage or ulceration of the mucous membrane: "The edges around the seat of rupture were turned toward the interior of the trachea, and regularly sharp or delicately serrated and scaly, just as in true traumatic ruptures." Other authorities have described "conversion of the cartilage into detritus in consequence of compressing aneurysms, and atrophy of the cartilage by a process of fatty degeneration." i Accord ing to Selter, who examined five cases, ulcers form in the mucous membrane as a result of the pressure, and subsequently lead to rupture of the aneurysms into the trachea or bronchus, so that the rupture is prepared from without. In rare cases, paralysis of the vocal cords follows disease of other arterial trunks. Selter 2 saw an aneurysm of the innominate artery with paralysis of the right recurrent; E. Meyer describes the same lesion in aneurysm of the right subclavian artery; in another case, marked pulsation in the pharynx was referred to aneurysmal dilatation of the carotid. current. 3 A pericardial exudate sometimes gives rise to paralysis of the left recurrent. Bäumler first pointed out that the same condition can also produce paralysis of the right re"If the exudate is very abundant, and distends the pericardium as far as the jugular notch, the engorgement of the veins which meet at that point may exert direct or indirect pressure on the right recurrent." The case he quotes, which seems to me entirely convincing, has been called in question by Landgraf, because the autopsy showed some slight syphilitic alterations in the larynx. The paralysis attains its greatest intensity at the height of the exudative process, and subsides with the pericarditis. In this respect Landgraf's case is instructive: a pericardial effusion developed after articular rheumatism, and produced at first a paralysis of the posticus in the median position, which developed into paralysis of the recurrent in the course of the next two weeks, but the paralysis disappeared when the primary disease was removed. Palpitation of the heart is one of the reflex neuroses, due 1 Klebs, "Handb. der pathol. Anatomie," VII, p. 270 et seq. 2 Virch. Arch.," 133; also comp. D. Gerhardt, Virch. Arch.," 123, to irritation in the nose. It occurs in chronic rhinitis with hypertrophy and polypus formation, and sometimes takes the paroxysmal form, analogous to sthenocardiac attacks and cardialgia. An interesting phenomenon, which has not as yet been satisfactorily explained, is sudden death from heart failure, which sometimes takes place a few days after extirpation of the larynx. Stork 1 attributes the phenom1 enon to injury of a depressomotor branch of the superior laryngeus, which is not constantly present; Grossmann 2 thinks it is caused by a central irritation of the superior laryngeal or of the vagus during the operation, while Toti3 reports, without explaining, a case in which acceleration of the pulse rate to from 160 to 180 occurred thirty hours after an operation for the total extirpation of the larynx; and after twenty-four hours more of uninterrupted tachycardia the patient died of cardiac paralysis. 2. DISEASES OF THE HEART AND BLOODVESSELS IN THEIR RELATION TO THE EAR. Tinnitus aurium is a frequent symptom of disease of the heart and blood-vessels and of anemia or hyperemia of the vascular systems within the ear. Our knowledge of these conditions is unfortunately very scanty, and we are hardly more advanced than was v. Tröltsch twenty years ago, when he wrote: "There is no doubt that tinnitus aurium is much oftener due to vascular murmurs than the profession has been inclined to believe up to the present time, as we are in the habit of attributing them chiefly to the influence of the nervous apparatus. It is often impossible to decide which of the two varieties is present, and simultaneous processes in both the circulatory and the nervous apparatus are probably of still more frequent occurrence." Before proceeding to the discussion of pathologic changes, let us direct our attention for a moment to the normal conditions in which we do not observe any vascular murmurs. Since Weil could hear the heart-sounds communicated to 1" Wien. med. Wochen.," 1888; and Alpiger, "Langenb. Arch.," xl. 2 Wien. med. Presse," 1892, Nos. 44-46. 366 Deutsche med. Wochen.," 1893, p. 87. 4 Die Auscultation der Arterien u. Venen," 1875. |