1883.' 
Minor, The Field of Vision. 
83 
pora'l side of the V. F. to the nasal side of the retina, and so on for other 
parts.) 
In cataract the functional activity of the retina, as tested by a candle, 
or better, by the reflected light from a mirror, throughout the V. F., is a 
question which may decide for or against an operation. 
In a certain form of retinitis (pigmentosa) the concentric limitation of 
the V. F. is peculiar and characteristic. Cases of this disease are often 
seen with good and sometimes perfect central vision, while the V. F. is 
reduced to an area not exceeding 10° or 15° in extent. 
In glaucoma the V. F. is contracted, and most frequently on the nasal 
side. Often it is this symptom that decides the diagnosis in a doubtful 
case. 
In hemianopsia (blindness in one-half of the V. F.) we often gain im- 
portant information as to the locality of the intra-cranial lesion upon which 
it depends, by a study of the V. F. The most frequent form is homony- 
mous hemianopsia, or blindness of corresponding halves of each V. F. (the 
nasal of one and the temporal of the other), and in these cases the lesion 
will be on the opposite side of the brain, involving either the optic tract 
or the cerebral substance further back. Crossed hemianopsia presents two 
yarieties—first, absence of the temporal half, and, second, absence of the 
nasal half, of eacli eye. In the first variety the lesion involves the chiasm, 
and in the second, which is very rare, the lesion is a double one, involving 
each side of the chiasm or the outer side of each nerve. 
In megrim, or sick headache, there are often transient attacks of blind- 
ness, or interruptions in the V. F., sometimes of a zigzag form, which is 
likened to a line of fortification. The cause of these phenomema is prob- 
ably ischaemia of the retina. They are sometimes seen witluout headache 
or other symptoms. 
In optic neuritis interruptions in the V. F. are common. They may 
be peripheric or central. The latter are called scotomata, and they are 
usually indicative of less gravity than peripheral as 
a rule followed by atrophy of the nerve. I 
In optic nerve atrophy defects in the V. F. are frfequkntly seen, ahqJ 
most often they begin with peripheral limitation on tli&.t£!i*qjoral side. 
Irregularity, such as sinuosity of outline, or scotomata, of 
an unfavourable prognosis. /S'V?- 
Amblyopic affections usually present irregularities in the V. F. tluThsffdi 
us in forming a prognosis. It may be said in general terms, that cases with 
peripheral contraction are progressive, and that those with perfectly out- 
lined fields, either remain stationary or improve. 
A more careful examination as to the amount of vision in the various 
parts of the V. F., will probably enable us to diagnose our cases with 
more accuracy, and to speak with greater positiveness about the prog- 
nosis in cases which are embraced under the last three headings. 84 
Cohen, Laryngoscopy as a Means of Diagnosis. 
[July 
All that can at present be claimed for colour defects in the V. F., of 
pathological origin, is that they are of material assistance as an aid to 
diagnosis, and that they help us in rendering a prognosis, when taken in 
connection with the other conditions, that go toward making up the case 
in question. Peripheral limitation of the colour-field, or inability to dis- 
tinguish certain or all colours, in a circumscribed area (colour scotoma) 
or throughout the entire Y. F., is of frequent occurrence in optic neuritis, 
in optic nerve atrophy, and in amblyopia. And the same rules that 
govern defects in the ordinary Y. F., apply to abnormal colour perception. 
Red is the colour that usually suffers first, and green usually coincidently 
or next, and finally blue. 
A central scotoma for red, complete or partial, accompanied with more 
or less marked intra-ocular appearances, is considered by many as being 
almost pathognomonic of tobacco amblyopia. In most of these cases 
alcohol will also have been used, and a low grade of optic neuritis can 
usually be detected. 
Quinia, when given in large doses, sometimes causes narrowing of the 
V. F. and limitation of the colour-field or colour-blindness, and may cause 
total amaurosis. 
The same effects are ascribed to salicin. The functions slowly return 
under the influence of time and proper treatment. 
New York, December, 1882. 
Article V. 
Some Points in relation to the Diagnostic Significance of Immo 
BILITY OF ONE VOCAL BAND ; WITH ESPECIAL REFERENCE TO ANCHYLOSIS 
OF THE CrICO-ArYTENOID ARTICULATION ANI) ANEURISM OF THE AliCII 
of the Aorta: with Six Illustrative Cases.1 By Solomon Solis 
V Cohen, A.M., M.D., Demonstrator of Pathology and Microscopy in the 
Philadelphia Polyclinic and College for Graduates in Medicine. 
The object of this paper is twofold: 1st, to show that laryngoscopy 
may sometimes be the sole, or most efficient means of diagnosis in affec- 
tions located exterior to the larynx ; and 2d, to point out that a liability 
to error might often be incurred, were we to place too exclusive a reliance 
upon the objective symptoms, as presented by the image seen in the laryn- 
goscopic mirror. 
These points, however, will not be treated of in extenso, or with any 
attempt at completeness; but a single phase of the subject will be illus- 
1 Presented as an Inaugural Thesis to the Faculty of Jefferson Medical College. 
Session 1882-1883. 1883. 
Coiien, Laryngoscopy as a Means of Diagnosis 
trated by a group ot' cases not heretofore reported in this connection. 
These cases, while differing in aspects to be mentioned later, agreed very 
closely in the character of the picture seen upon laryngoscopic inspection; 
the principal and only well-marked feature of which was immobility of 
one vocal band. 
As is well known, immobility of a vocal band is the result of one of two 
conditions : 1st, mechanical impediment to the movement of the arytenoid 
cartilage ; 2d, want of power in the muscles acting upon that cartilage. 
Excluding such obvious causes as the presence of a tumour or of a 
foreign body, excessive thickening of the inter-arytenoid fold, etc. ; me- 
chanical difficulty may arise from anchylosis (either true or false) of the 
crico-arytenoid joint; from destruction, more or less complete, of the 
articulation, or of the arytenoid cartilage; or from luxation of the aryte- 
noid cartilage ; of all of which conditions, instances have been reported. 
Loss of muscular power may be either myopathic or neuropathic in 
origin. If defective innervation be the cause of the impairment, this con- 
dition may be due to disease or injury affecting the nervous system, or 
may be merely a secondary effect, resulting mechanically from pressure 
exerted upon a nerve trunk by a consolidated lung, an aneurism, a tumour, 
or an enlarged gland, etc. The seat of the lesion or pressure, may be 
central, or at some portion of the course of the fibres transmitting motor 
impressions ; whether these fibres be known in that particular situation 
under the name of spinal accessory, pneumogastric, or recurrent laryngeal. 
Poisoning by lead, and perhaps other toxic agents, may also be the 
cause of vocal paralyses, and without being able to indicate the exact 
modus operandi in such instances, we may, in passing, mention them as 
among the possibilities to be considered. 
Some of the conditions here indicated will not be again alluded to, as 
they would give rise to manifestations beyond the larynx sufficiently 
prominent to attract attention, and sufficiently characteristic to render the 
diagnosis comparatively easy. Nor is it purposed to enter upon the 
characteristics by which different forms of muscular and nervous paralyses 
are differentiated; these being, for the most part, sufficiently obvious upon, 
consideration of the anatomy and physiology of the parts. In order to> 
restrict this paper within reasonable limits, attention will be directed only 
to the means by which, in certain cases, a conclusion may be reached as 
to what may be termed the gross character of the lesion ; the finer details 
being considered merely in so far as they may have a direct bearing on 
this subject. 
With this object in view, it seems appropriate to introduce at this junc- 
ture, the histories of the cases from which our deductions will be drawn. 
Case I. Anchylosis of the Left Crico-Aryt noid Articulation ; proba- 
bly due to LJxteusion of the Inflammatory Process in a case of Chronic La- 
ryngitis—C. S. G., a*t. 23, clerk, applied to Dr. J- tSolis Cohen May 27,. 86 
Cohen, Laryngoscopy as a Means of Diagnosis. 
[July 
1881, giving the following history : He bad enjoyed fairly good health 
until about sixteen years old. At that time, he contracted from expo- 
sure, what was probably a naso-pliaryngeal catarrh, the inflammation in- 
volving, also, the Eustachian tubes ; for he states that he experienced in 
addition to nasal symptoms, a disagreeable sense of fulness in both ears, 
and that the physician under whose care he then placed himself, treated 
him exclusively for ear-trouble, but without affording relief. 
As frequently happens in such cases, the larynx became slowly in- 
volved ; and in the spring of 1879, he first noticed a huskiness in his 
voice. This huskiness gradually increased, becoming attended with dys- 
phonia, until considerable and painful effort was necessary in order to 
carry on conversation ; and in the fall of 1880, he became completely 
aphonic. His general health having greatly deteriorated, he made a trip 
to Texas, from which he derived considerable benefit; his voice sharing 
in the general improvement. 
His condition on applying to Dr. Cohen, was as follows : His voice 
was hoarse and rough, but distinct and easily heard. It was deficient in 
tone and power, and any extended use of it w'ould cause the throat to 
feel tired and sore, while respiration would become slightly embarrassed. 
When, however, the nasal passages seemed to be clogged with mucus, so 
that respiration was less free than usual, the voice sounded clearer and 
stronger, and the throat did not tire so quickly. Owing to his nasal ca- 
tarrh, the sense of smell was slightly impaired, and nasal respiration 
always somewhat obstructed. Fulness in the ears, unattended with pain, 
was a not infrequent symptom. There was no cough, and deglutition 
w7as not painful. Appetite was good, and nutrition seemed to be wrell 
carried on. The muscles of the right side of the neck and face appeared 
to have undergone hypertrophic development; probably from the in- 
creased action necessary to bring the vocal bands into approximation. 
On laryngoscopic examination, the mucous membrane of the larynx 
presented evidences of chronic inflammation, and there was seen to be 
moderate tumefaction of the ary-epiglottic folds, ventricular bands and 
arytenoid eminences. The right ary-epiglottic fold was extremely tense. 
The left ventricular band exhibited a peculiar fold or knuckle, posteriorly, 
which became more marked on phonation ; when it was also seen that 
the left vocal band remained immobile in abduction, the right band 
crossing the median line, its upper surface being 
on a plane almost inappreciably lower than that 
of the left band ; while the right arytenoid 
cartilage was sw'ung to the inside and in front 
of the left arytenoid cartilage. This appear- 
ance, almost as difficult to depict as to ex- 
plain, is showm in the accompanying drawing, 
Pfig. 1 ; for which, the writer is indebted to 
the artistic skill of an undergraduate of the 
College, Mr. Max. .T. Stern. 
No sign of cardiac or pulmonary lesion, of 
aneurism or intra-thoracic tumour, could be 
discovered, nor were any enlarged glands found 
in the neck. The urine was examined with 
negative results. Attempts to move the left 
arytenoid cartilage by direct pressure were unsuccessful; and while the 
catarrhal condition yielded to appropriate remedies, prolonged treatment 
Fig. 1. 1883.1 
Cohen, Laryngoscopy as a Means of Diagnos 
87 
by means of both galvanic and faradic currents, as Avell as the internal 
administration of strychnine, failed to restore in the slightest degree the 
mobility of the affected vocal band. 
Case II. Anchylosis of the Right Crico-Arytenoid Articulation, due to pro- 
longed enforced inaction, consequent upon Fibroma of the Fight Vocal Band. 
Reported by Dr. J. Solis Cohen.—W. B., set. 26, shoemaker, applied to Dr. 
Cohen May 1, 1867, to be treated for loss of voice of more than two years’ du- 
ration. Laryngoscopic inspection having revealed the existence of a neoplasm 
occupying the entire length of the right vocal band, thyrotomy was performed, 
and the growth was removed. The patient’s voice, though improved by the 
operation, was still aphonic. On laryngoscopic examination, the band from 
which the tumour had been removed was seen to be immobile in abduction, and 
slightly above the level of that of the opposite side. A peculiar angular fold 
which had been noticed at the posterior portion of the free border of the right 
ventricular band, and had been attributed to its being pushed out of shape by the 
tumour, was seen to be persistent. Xo effect being produced by treatment, Dr. 
Cohen concluded that during the development of the neoplasm, the crico-aryte- 
noid articulation had become anchylosed. This opinion was verified byr Dr. R. 
J. Levis, who had assisted at the operation, and who now, at Dr. Cohen’s re- 
quest, placed his forefinger, “ which is a long one,” upon the arytenoid cartil- 
ages, and succeeded in moving that of the left side, while that of the right side 
remained fixed.—Med. Record, July 1, 1869. 
Case III. Aneurism of the Arch of the Aorta compressing the Left 
Pneumoyastric and Recurrent Laryngeal Nerves; Left Vocal Band 
immobile in Abduction. Death from Rupture of the Sac—A. J., aet. 60, 
sailor, applied to the Throat Clinic of the Jefferson Medical College 
Hospital, July 1, 1881, for the relief of hoarseness and dyspnoea which 
had persisted since the previous October, in association with violent 
attacks of coughing, lie attributed the origin of his trouble to exposure, 
resulting in a severe cold. There was a history of a venereal sore con- 
tracted forty years previously, but there had never been any secondary 
symptoms in evidence of syphilitic infection. lie had several times suf- 
fered with rheumatism, a severe attack in 1864 lasting for two months. 
He had followed the sea for forty years without other sickness. 
Ilis breathing was stridulous, especially during sleep; dyspnoea was 
marked, increasing in the recumbent position, so that he was compelled 
to sleep propped up with pillows. There was severe pain on the left side 
of the chest, front, and back, increasing at night. At times he com- 
plained of pain in the left hip and in the lower third of the left thigh, 
lie had lost flesh, being reduced from 182 pounds to 150 pounds. His 
appetite was poor, but he had been a dyspeptic for years. Any attempt 
at laryngoscopic examination provoked an attack of coughing and dysp- 
n<ea, so severe as to completely prostrate him ; thus leading to suspicion 
of paralysis of the posterior crico-arytenoid muscles. After some days, 
however, he became more tolerant, and with delicate manipulation it was 
possible to conduct a rapid examination. It was thus gradually ascer- 
tained that the left vocal band was immobile in abduction, while the 
right vocal band performed its movements in a somewhat jerky and spas- 
modic manner. On inspection of the chest, a prominence was noticed in 
the sternal region, extending from the clavicle to the level of the fourth 
sterno-chondral articulation, most marked at the level of the third sterno- 
chondral articulation. Xo satisfactory information could be obtained, 
however, as to the length of time for which this condition had existed, or 
as to whether or not it had been congenital. Percussion elicited slight 88 
Cohen, Ljiryngoscopy as a Means of Diagnosis. 
[July 
dulness anteriorly on both sides as far down as the fourth rib. On aus- 
cultation tubular breathing was heard in the right infra-clavicular region. 
The expiratory sounds were very feeble on both sides. 
The heart sounds were normal, but the second sound was distinctly 
heard two and one-half inches to the right of the sternum. No difference 
w'as discernible between the radial pulses or between the pupils. Exami- 
nation of the urine gave negative results. 
This case was presented to the Philadelphia Laryngological Association, 
and held by competent observers to be one of crico-arytenoid anchylosis. 
The extreme irritability of the larynx prevented a successful attempt to 
verify or disprove this diagnosis by the application of direct pressure. 
Although it was endeavoured to keep this patient under constant obser- 
vation, his unwillingness to enter the hospital on the one hand, and the 
irregularity of his attendance upon the clinic—caused by the relief afforded 
by palliative treatment—on the other hand, rendered it impossible to do 
so. After an unusually prolonged absence, an attempt to trace his where- 
abouts revealed the fact that his death had occurred during a profuse 
hemorrhage, about ten days previously (August, 1882). The physician 
who was called in the emergency, reports that there was spitting of blood 
for two days, after which came the fatal hemorrhage, by him suspected 
to be of pulmonary origin. Post-mortem examination was not permitted. 
Case IV. Aneurism of the Arch of the Aorta compressive/ the Left 
Recurrent Laryngeal Nerve; Left Vocal Band Immobile in Abduction. 
—W. M. K., aet. 57, farmer, presented himself September 13, 1882, at 
the Throat Clinic of the Jefferson Medical College Hospital; and on the 
following day was made the subject of a clinical lecture to the class, by 
Dr. J. Solis Cohen. 
In May, 1881, this patient became hoarse while at work, after profuse 
perspiration. In the last four weeks dyspnoea had developed. There 
was no cough, and no difficulty in deglutition. The patient’s general 
health and family record were good. Syphilis was at first denied, but 
upon cross-questioning a history of constitutional symptoms was obtained. 
He had also suffered a number of years ago with rheumatism. 
Laryngoscopic examination revealed the left vocal band immobile in 
abduction. This led to the suspicion of aneurism of the arch of the aorta, 
and upon physical exploration of the chest the suspicion became a cer- 
tainty; thrill and bruit being unmistakably present. The pulse was also 
characteristic of aneurism. The patient was placed in one of the wards 
of the hospital under the care of I)r. Cohen, and as the result of appro- 
priate treatment rapidly improved. Dr. Charles Meigs Wilson, the resi- 
dent physician, reports that w'hen he was discharged at his own request, 
after six weeks’ confinement to bed, the dyspnoea had disappeared, the 
voice was stronger, the equality of the pulses restored, and the signs in 
the chest scarcely perceptible. 
Case V. Aneurism oj the Arch of the Aorta, compressing the Left Pneumo- 
gastric and Recurrent Laryngeal Aerres ; Cadaveric position of the Left Vocal 
Band; Sudden Death from Asphyxia; Autopsy. Reported by Dr. C. E. Bean.— 
R. C., set. 42, engineer, presented himself Sept. 29, 1880, at the Throat Clinic 
of the Jefferson Medical College Hospital, under the charge of Dr. J. Solis 
Cohen. In December, 1878, the boiler of which he had care exploded, and 
after working for several hours in the heat and steam, he became chilled upon 
exposure to the night air. Two days later his voice became hoarse, getting 
gradually worse, until at the end of a week there was complete aphonia; but 
at no time was there any pain or soreness in the throat. Dysphagia soon became 1883.] 
Cohen, Laryngoscopy as a Means of Diagnosis. 
89 
a prominent symptom. About a week after the explosion he began to cough, 
expectorating thick frothy mucus. Three months later he first experienced a 
sense of fulness in the upper part of the chest, just behind the sternum. .Respiration 
was not materially interfered with. The cough, though occasionally wheezing, 
had assumed a ringing metallic character. Laryngoscopic examination showed 
fixation of the left vocal band in the cadaveric position. 
Thrills were detected below the clavicles, synchronous with the pulse, but 
these signs disappeared the day after the patient was put to bed. There was no 
perceptible difference between the radial pulses. The heart sounds were normal. 
The left pupil was markedly contracted, but this had been the case as far back 
as the patient’s recollection extended. A diagnosis of aneurism of the arch of 
the aorta was made, but its correctness was disputed by several experienced and 
qualified observers who made careful examination of the case. 
The patient died suddenly Nov. 13, “gasping for breath, unconscious, face 
and neck very much congested,” despite the performance of tracheotomy by the 
resident physician of the hospital, who reports the case, and who had been hastily 
summoned in the emergency. 
The following is the report of the conditions found on post-mortem exami- 
nation : — 
“ The apex of the heart corresponded to the left sixth intercostal space, one inch 
beyond the line of the nipple. The upper part of the anterior mediastinal space 
was broadened and filled with a fluctuating mass, commencing at the upper 
border of the pericardium and extending to the sternal notch. The heart and 
lungs with the descending aorta were removed en masse. It was found that the 
aorta was dilated into a large sac, commencing just above the valves and involv- 
ing the arch to a point beyond the left subclavian artery. The sac of the aneu- 
rism was tightly adherent on the left side of the second and third dorsal vertebrae. 
On removing the mass, the wall of the sac was found to have disappeared at 
this point. The aneurism had deflected the lower portion of the trachea strongly 
to the right, and pressed mostly on the root of the right lung. On looking into 
the trachea it was seen that its calibre was nearly closed by pressure. Examin- 
ing the interior of the aneurismal sac, the lower tracheal rings partly calcified 
had been laid bare and eroded by the pulsation. They protruded with the 
aneurismal cavity. The left pneumogastric nerve was found running over the 
aneurism, and had been evidently much pressed upon. The right nerve was less 
involved. A large ante-mortem clot was discovered in the sac.”—Louisville 
Med. News, Jan. 22, 1881. 
Case VI. Aneurism of the Arch of the Aorta compressing the Recurrent 
Largngeal Nerve; Left Vocal Band immobile in Abduction. Reported by Dr. 
C. E. Bean.—J. S., ajt 70, weaver, applied to Dr. J. Solis Cohen May 17, 
1882, for the relief of hoarseness. Sept. 1 7, 1879, after lifting heavy rolls of 
carpet, he felt “a peculiar heavy stroke of the heart, and a sense of extreme 
weakness, so that he ‘came near fainting.’” This soon passed away. One 
week later, two similar attacks occurred. Soon after this hoarseness set in, be- 
coming gradually worse. At the time of examination there was slight dysphonia, 
and the voice was a falsetto. For several months, even during warm weather, 
the patient’s feet had been cold, but, with this exception, his general condition 
was good. 
Laryngoscopic examination showed the left vocal band immobile in abduction. 
Inspection of the chest revealed nothing abnormal. On auscultation, a blow- 
ing sound was heard in the second intercostal space, £ inch to f inch to the left 
of the sternum. This sound was synchronous with the ventricular systole. 
Inspiration was found to be shrill at the second sterno-cliondral articulation, and 
percussion elicited marked dimness over the same region. Palpation failed to 
discover thrills or pulsation. 
The pulse was 70 and feeble, that of the left side being scarcely perceptible, 
and lagging one-fourth of a beat behind that of the right side. There was no 
difference between the pupils. A considerable quantity of sugar was found in 
the urine. 
Marked improvement took place under treatment directed against the condi- 
tion of aneurism, but the patient became impatient of confinement to bed, and, 90 
Cohen, Laryngoscopy as a Means of Diagnosis. 
[July 
contrary to advice, resumed liis usual occupations. At last accounts lie was still 
living, and, except for slight hoarseness, perfectly satisfied with his condition.— 
Med. and Surg. Reporter, June 10, 1882. 
In reviewing the cases presented in the foregoing pages, there are a 
few points of special interest to be noticed in each, which it may be well 
to consider in logical rather than numerical order. 
Case II. demonstrates the possibility of anchylosis taking place in the 
crico-arytenoid joint simply from prolonged inaction. The history, the 
absence of any other local or systemic disturbance, the failure to respond 
to treatment, and, finally, the expertmentum crucis of the application of 
direct pressure, all place the diagnosis beyond doubt. 
Case I. The history of pre-existing, long-continued chronic laryngitis 
rendered two view's within the bounds of possibility: 1st. Myopathic 
paresis of the crico-arytenoideus lateralis, resulting from extension of the 
inflammatory process ; 2d. Anchylosis of the crico-arytenoid articulation 
from a similar cause. Apart from the greater improbability of the former 
opinion, the failure to respond to treatment would be against it; while, as 
in Case II., the diagnosis seems to be fully established by the experimentum 
crucis. 
In both these cases, there are certain points connected with the laryngo- 
scopic image deserving of attention. The vocal band of the affected side 
occupied a higher level than that of the other side. Can this be explained 
upon the supposition of inflammatory deposit within the joint, and is it to 
be considered pathognomonic ? This would seem w ell worthy of observa- 
tion in future studies of this rare affection. Furthermore, the peculiar 
fold or knuckle in the ventricular band of the affected side, occurring in 
cases so far removed in time, and owing to such different causes, would 
appear to be more than a mere coincidence. 
Still another symptom, not mentioned in the resume, of Case II. because 
not bearing on the subject then in hand, yet shared by both of the cases 
now under discussion, is of interest in connection with the general topic 
of mechanical impediment to the movement of the vocal bands. 
Previous to the removal of the tumour from his right vocal band, the 
patient w'as compelled to draw his head and neck well down toward his 
right shoulder in order to produce his aphonic wdiisper to the best advan- 
tage ; though subsequent to the operation this was no longer necessary. 
In Case I. the left vocal band was immobile, and the patient spoke with 
his head slightly inclined downward and to the left; the muscles of the 
right side of the face and neck, as previously stated, being noticeably 
hypertrophied. This point also appears worthy of remembrance in future 
observations. 
Case V. possesses a high degree of interest, inasmuch as the existence 
of an aneurism of the arch of the aorta was suggested to a laryngoscopist 
in a diagnosis by exclusion, of the condition leading to what is usually 1883. 
Cohen, Laryngoscopy as a Means of Diagnosis 
91 
termed unilateral vocal paralysis. While the rational symptoms were 
confirmatory of this opinion, the entire absence of the usual physical signs 
of aneurism caused experts in physical diagnosis, unfamiliar with laryn- 
goscopy, to doubt its correctness. This case alone fully exemplifies the 
two texts of this paper; for by relying solely upon the laryngoscopic image 
the diagnosis would have been neurotic paralysis, while failure to examine 
the larynx, or to give due weight to its testimony, would have rendered it 
unlikely for aneurism to have been surmised in the absence of the phe- 
nomena usually associated with that affection; there being neither tumour, 
bruit, nor thrill. 
In Case VI. again we have apparent laryngeal disease leading to the 
discovery of an aneurism which might otherwise not have been detected. 
The probable small size of the'sac, or its favourable situation, prevented 
compression of the trachea or oesophagus. The pneumogastric trunk not 
being subject to pressure, another possible cause of cough and dyspnoea 
was eliminated; hence, the only symptoms attracting the patient’s atten- 
tion were the persistent hoarseness, and the deficient peripheral circulation 
—the latter condition, however, being easily attributable to old age. The 
presence of sugar in the urine, probably from reflex irritation of the pneu- 
mogastric nucleus in the floor of the fourth ventricle, was confirmatory of 
the diagnosis ; but, as shown by other cases, this sign is not invariably 
present. The only one of the ordinary physical signs of aneurism exhib- 
ited by this case, was the blowing sound in the left second intercostal 
space. 
Case III. is so obscure that in the absence of an autopsy it is .impossible 
to definitely decide its true nature ; nor can any one hypothesis explain it 
fully. Disregarding for the purposes of this paper any possible complica- 
tion not directly bearing upon the lesion manifested by the laryngeal 
symptoms, the manner of death would point to aortic aneurism; and upon 
this supposition the dyspnoea can be explained as the result of com- 
pression of the trachea, while the tubular breathing in the right infra- 
clavicular region may be accounted for by pressure exerted upon the air- 
vesicles in that situation. To the sternal bulging no weight can be 
attached. The history of rheumatism, while it favoured somewhat the 
view of aneurism, might likewise, especially in connection with the 
chronic laryngitis following subacute laryngitis due to direct exposure, 
have strengthened the view of anchylosis; while evidences of nervous 
disturbance might have justified the reference of cough and dyspnoea to 
disease of the pneumogastric trunk. The intensity of these symptoms at 
first, and their amelioration under medication, point at least to partial 
nervous origin ; probably a secondary effect of the pressure of the aneurism 
upon the nerves, exactly similar to the immobility of the vocal band. The 
fact that the position in which the band was fixed was not cadaveric, but 
that of abduction, is of interest, illustrating (as do Cases IV. and VI.) 92 
Coiien, Laryngoscopy as a Means of Diagnosis. 
[July 
the greater liability to impairment of the adductor, over the abductor, 
filaments of the recurrent laryngeal nerve; a clinical point to which atten- 
tion has been prominently directed of late years. An intra-thoracic neo- 
plasm might have produced the same mechanical effects as an aneurism ; 
but it is difficult to imagine a morbid growth of sufficient size occupying 
just this situation, and giving rise to no definite manifestations elsewhere 
in the economy. 
In Case IV., also, we have aneurism detected by means of the laryngo- 
scope; the patient complaining merely of hoarseness and slight dyspnoea. 
But the evidences of aneurism were so distinct, that the diagnosis pre- 
sented no difficulty, and might have been made without laryngoscopic 
assistance. 
In three of these cases of aneurism, it is interesting to note that expo- 
sure very likely to lead to ordinary subacute laryngitis preceded the laryn- 
geal symptoms, thus causing the patients to imagine that they had simply 
“ caught a bad cold and well calculated to mislead the physician ; espe- 
cially had the larynx not been examined. 
The question arises, in this connection, whether the exposure and 
resulting inflammation precipitated the laryngeal complications of the 
aneurism, or whether the condition of paralysis had not been pre-existent, 
thus rendering recovery from the inflammatory hoarseness protracted, if 
not impossible. 
In two cases we have history of preceding rheumatism ; in one, of 
syphilis as well. 
Finally, to generalize from all the cases herewith presented, generaliza- 
tions which are warranted by the recorded observations of several authors, 
we may conclude :— 
I. That whenever the left vocal band is immobile in abduction, or in 
the cadaveric position (positions in which the patency of the glottis is not 
interfered with), and there is cough or dyspnoea (or both), without car- 
diac or pulmonary lesion to account for these symptoms, we are justified 
in suspecting aneurism of the aortic arch ; and difficult deglutition will 
be almost certainly confirmatory of the diagnosis, notwithstanding the 
absence of tumour, pulsation, thrill, and bruit. The only, and exceedingly 
improbable source of error, would be intra-thoracic neoplasm. 
II. That anchylosis of the crico-arytenoid articulation may fairly be 
suspected in cases of immobility of one vocal band, no-t referable to 
mechanical interference with the transmission of nervous force; unaccom- 
panied with evidence of central or local nervous disease; and in which 
failure to respond to appropriate treatment will warrant us in excluding 
muscular atrophy. But the diagnosis can be finally established only by 
the application of direct pressure to the affected arytenoid cartilage. 
III. That whenever one vocal band is immobile in the cadaveric 
position or in abduction, and there are no other signs or symptoms to 1883. 
Burr, Primary Monomania. 
93 
assist the diagnosis, anchylosis being eliminated, we should not be satis- 
fied with a diagnosis of neuropathic paralysis; but should keep the patient 
under observation, with a view to detecting the earliest manifestation of 
aneurism, consolidated lung, or other mechanical cause for the impaired 
innervation. 
Note Since the above was written, a case has presented itself (Jan. 
29, 1883) at the Throat Clinic of the College Hospital, in which an aneu- 
rism of the innominate artery, involving as well the first portion of the right 
subclavian artery, around which latter winds the right recurrent laryngeal 
nerve, has, by compressing that nerve, produced cadaveric paralysis of the 
right vocal band. The voice of this patient has a peculiar shrill tone, 
and in the act of phonation he carries his head downward and well over 
to the left. There is a pulsatile tumour just behind the sterno-clavicular 
articulation, extending laterally about two inches from the median line, 
rising about one and a quarter inches above the clavicle, and projecting 
about one-quarter of an inch. 
A Case of Primary Monomania (Primare Verriicktheit). By C. B. Burr, 
M.D., Asst. Physician to the Eastern Michigan Asylum, Pontiac. 
Article VI. 
The circumstances connected with the trial of Guiteau brought promi- 
nently to notice a peculiar form of insanity, the so-called primary mono- 
mania. In view of the professional interest attaching to this variety of 
mental disease, the following case is reported:— 
K., age 40, was born in New York. His father was of Irish birth, a 
drunkard, and abusive in his family. Ilis mother was of English descent, 
but a native of New Jersey; one of a family that is said by the patient to 
have inherited upward of seventy millions of dollars (?) which cannot be 
recovered. The early life of the boy wras one of hardship, privation, and 
suffering, and his surroundings were such as to leave enduring unpleasant 
impressions in his mind. Through the neglect and cruelty of the father 
the family was separated early. He at the age of eight years was bound 
out to a mechanic with whom he remained until he was fifteen. After 
this period he worked at different trades, but showed no capacity for in- 
struction, could not apply himself, and failed to succeed. He hired out to 
one employer and another, but his “ mind was roaming all over the world 
he was restless, unsettled, and governed by impulses. In this mental 
state he made his way to New York, and shipping on a sailing vessel 
made a six weeks’ voyage. He ascended the Mississippi from New Orleans, I)urr, Primary Monomania. 
[July 
came across the intervening States to Michigan, and took up his residence 
with an uncle in Grand Haven. There he remained for one year; for the 
next four he resided in different Connecticut and New York. Dur- 
ing this latter period he received his only schooling, studying the ordinary 
branches of reading, spelling, and arithmetic. 
At the age of twenty-one he was living in Jackson, Mich. Here, as 
near as can be ascertained from his own account, mental alienation became 
pronounced. A fixed light appeared to him “ coming from the morning 
and evening stars, descending in the shape of a heart.” He was at first 
dazed and bewildered, and at a loss to account for this strange manifesta- 
tion ; then he set about diligently to discover an explanation. He scru- 
tinized his own condition carefully, was critical and morbidly suspicious 
of others. A recurrence of the visual hallucination rendered him still 
more thoughtful. He experienced strange sensations and felt a conscious- 
ness of being no longer his former self. What could produce such a change? 
lie could account for it only on tlie supposition that a miracle was being 
wrought, and it dawned upon him at once that he was “ inspired.” 
The most trifling circumstances confirmed him in this view. The mere 
mention of his name by one in conversation had a peculiar significance ; 
a look, a glance, or a casual inquiry impressed him deeply, and he drew 
absurd conclusions from the most innocent remarks. Conceiving himself 
of necessity an object of great interest, he imagined his affairs were the 
topic of general conversation. The sight of persons talking together in 
the street aroused in his mind the belief that a conspiracy was forming 
against him, a look or gesture being sufficient to convey such important 
intelligence. He heard his name repeatedly mentioned by men of promi- 
nence, and concluded that if he were not the object of their active enmity 
at least there were special reasons why they should be talking and think- 
ing about him. 
Casting about for an explanation of imaginary slights, it was revealed 
to him that his secret liking for a young lady, the daughter of a wealthy 
farmer, had been divined, and that a “campaign” was being inaugurated 
to force him to leave the country. He was naturally bashful, retiring, 
reserved, and ill at ease in female society, but at this period there seem 
to have been several ladies whose destinies he imagined in some way in- 
volved with his own. There were none to whom he paid active court ; 
indeed with many he had not even a speaking acquaintance ; but a toss of 
the head, a glance, the jostling incident to a crowded place, gave him a 
peculiar thrill, and caused him to understand the deep regard in which he 
was held. 
In 1861 he enlisted in the army. Here, according to his own account 
contained in a pamphlet entitled “ The Hero of Seven Battles,” he was 
many times the object of special interposition of Providence, having been 
miraculously rescued for some great purpose. “ Persecution” followed