Case of Paralysis of both Spinal Accessory Nerves. 211

ART. X . - -A Case of Paralysis of both Spinal Accessory Nerves, followed by Recovery. ~ B y ARTHUR WYZeNE FOOT, M.D. , Univ . Dubl . ; F . K . Q . C . P . ; Sen ior Phys i c i an to the M e a t h Hosp i ta l .

THe. fo l lowing case, which I e x t r a c t f rom m y note-book of " O b s e r - va t iones Rar iores ," m a y possibly be w o r t h y of record, as a f fo rd ing a cl inical demons t ra t ion of fac t s expe r imen ta l ly es tab l i shed b y Bischoff, b Longe r , ~ B e r n a r d , a and o thers : - -

CASE.--At noon, on the 20th Oct., 1880, a little boy, eight years old, fell headforemost down a flight of stone steps leading to the playground of the school to which he went. He got up without assistance, was not stunned, cut, or bruised, and remained in school till it was over, at 3 p.m. He said nothing about the fall at the time, I suppose from fear of punish- ment. :Next morning his mother brought him to hospital, perceiving something was wrong with him. As his symptoms were obscure, and the history of the fall was suppressed at the time, he was prescribed for as an out-patient, and no particular attention was paid to him. He was brought again to hospital the following morning, and admitted to my wards by the clinical clerk, who, at the time, had not formed any very definite opinion as to his ailment. When I saw him forty-eight hours had elapsed since the fall, and there was then incomplete motor paralysis of both legs and both arms ; at every attempt to swallow, even his saliva, choking fits ensued, from the fluids entering the larynx; his respiration was wholly diaphragmatic; and his head was peculiarly loose on his neck, falling backwards, forwards, or to either side, when he was held up, just as the head of a corpse does when rigor morris has vanished. He was quite unable to attempt to stand, nor could he raise himself in bed, or change his posture in any degree. Sensation was unaltered in his body and limbs ; there was no paralysis of either bladder or rectum, nor any increase of reflex action. He complained bit terly of pain in his back and in his neck.

His mother's account.of him was that he had always been a very delicate and irritable child; i t was only within the last twelve months he had been anything llke thriving ; he had always been subject to head- ache, and had had a bad chest since he had the whooping-cough, when two months old.

I t was plain that it would be most dangerous to persist in giving him

a Read before the Medic~l Society of the King and Queen's College of Physicians in Ireland, Wednesday, February 2, 1881. [For the discussion on thiB paper, see p. 243.]

Nervi Accessoril Willlsii. Anatomia et Physiologia~ Darmstadii, 1832. * Anatomic et Physiologic du Systbme l~erveux. Paris, 1842. e Lef~ns Bur la Physiologic et la Pathologic du Systbme Nerveux. Paris, 1858,

312 ca** o/Paraz sl, of bee, Sp naZ A,ce**o, Verve,.

food by the mouth--even the nurse objected to giving him any liquid by the mouth~ it was so apparent she might choke him. He said he could not swallow even his spittle, because it choked him. I watched him being given a few teaspoonfuls of milk in the most cautious manner. I t appeared to go straight into the larynx, producing painful efforts to cough, during which he got black in the face, and asphyxia seemed imminent. .h_fter the rectum had been well cleared out by an enema of soap and water, an injection of beef-tea was given~ and he was fed in this way for six days ; he had three or four beef-tea enemata daily, and during the night a little wine was sometimes added to them.

1~'o sooner had his sustenance been provided for by the rectal alimen- tation, than difficulties sprung up on the side of the respiratory organs. The only respiratory muscles which were in action were the diaphragm and those of the aim nasi. The "nosework," as the Germans call this respiratory action of the portio dura nerve, was very conspicuous, a The bronchial tubes were loaded with mucus, and the single, short, and ineffectual puffy expirations, when he attempted to cough, only served to give audible evidence of the large accumulation of mucus in the air- passages, while they failed completely to expel any of it. The sterno- inastoid muscles were of no assistance to him, as both were quite paralysed. His face was puffed, and of a violet tint, from congestion of the capillaries~ with insufficiently aerated blood ; the pupils were rather contracted, and the respirations shallow and frequent; his average respiration-rate during the first seven days (16 observations) was 41 per minute.

Different means were employed to assist in the unloading of the bron- chial tubes. Emetic doses of ipecacuanha wine were given, but without effect~ owing to the paralysis of the abdominal expiratory muscles. Four two-drachm doses of good vinum ipecacuanh~e were given, at intervals of fifteen minutes, but no attempt to vomit was induced. Though the doses were cautiously administered by an experienced nurse, still a good deal may have been lost, owing to the difficulty of deglutition, yet enough was probably received into the stomach to have made a child vomit under ordinary circumstances. The only effect apparent from the ounce of ipecacuanha wine was a copious diaphoresis, and one discharge from the bowels, l~'aradisation of the intercostal muscles was used, and inhalation of sulphuric ether. This latter seemed of more use than anythin~ else.

For the first fortnight after his admission he required a special nurse to attend to him alone; his helpless restlessness was unceasing, his complaints being a constant round o f - - " Put in my hands" (when they fell out over the sides of his cot), " T u r n me round," "Set t le me up,"

a It w~ the aynchronism between the acts of dilatation of the nostrils and the m o v e m e n t s of inspiration which first led Sir Charles Bell to regard the facial M a reepi~atory n e r v e ,

By Dm Foo~. 213

" P u t my feet in a cool place," "Uncross my legs," " P u t me straight." When he was being sat up the nurse held a small pillow at the back of his head ; if she removed her hand from it his head fell back till the skin on the front of his neck was tightly stretched~ and if a hand was not kept against his forehead the head fell forwards till the chin met the chest. For the first two or three days he frequently had raving--fancled he saw people about him, and that he was falling out of bed. The delirium did not seem to arise from over-heated blood, for his mean average temperature for the first seven days (14 observations) was 99"6 ~ F., and the highest point reached in that time was 102"8 ~ F. He was always quite intelligent when spoken to. The delirium was more probably connected with the venosity of his blood from impeded oxida- tion, or with venous congestion of the membranes of the brain, because one leech behind the ear relieved him of violent headache, attended with fits of screaming. While we were leaving no stone unturned to save his life, his mother was with great difficulty dissuaded from her intention of taking him away " to die at home," as she said there was "noth ing being done for him, because he was getting no medicine." As soon, therefore, as he was able to swallow ever so little, he was, for the sake of appear- ances, and to avoid the imputation of neglect, given minute doses of aqua camphorm.

The first improvement appeared in the power of swallowing, and this was soon followed by return of tone to the sterne-mastoids and the trapezii muscles. His cough then got stronger; he began to be able to make a second expiratory effort instead of the single jerky puff he used; the leaden colour and the puffiness left his face, so that his complexion and appearance underwent a marked change; his face seemed to have got quite thin, though bright. He was able to put one hand to his mouth on the 30th October (ten days after the fall). On the 4th November he was able to raise his head off his pillow; on the 6th could drink as well as any other child, and stand with his hands holding on to a table or person, but not without some such support. On November 10th he was ordered a tonic of tinct, nuc. veto. and tinct, fer. perchl. ; and he left hospital on November 15th, twenty-slx days after the accident, able to breathe naturally and use his limbs, but still unsteady in rapid movements of the legs, and having some trouble in rising up off a low seat without assistance.

There was no great difficulty in making out that the spinal cord had sustained an injury, and it was also easy to localise the spot; and a diagnosis to that effect was written on his card the day he came under my observation. I t was plainly between the third and the fifth, or perhaps sixth, cervical vertebrm. I t should be below the third, as the phrenie nerve was uninjured; and it should be above the sixth, as the spinal accessory nerve was paralysed, which rises from the lateral tract

214 Case of Paralysiz of both Spinal Accessory Nerves.

of the spinal cord as low down as the fifth or sixth cervical vertebra. The view I formed myself of the nature of the accident was, that as the boy pitched on his head, a sudden flexion of the neck occurred, with consequent compression of the spinal cord at the seat of flexion. I Iad he been older his neck would in all probabili ty have been broken ; but owing to the great elasticity of the spine in early life, fracture of the vertebrae is not an accident of boyhood. The temporary compression of the cord injured it sufficiently to interfere with its functions for a short time, and was fortunately repaired without myelitis or any other conse- quence which might have ensued setting in. In reference to the total absence of paralysis of sensation it appears a general rule that motor power is more subject to be damaged by itself than sensation. The explanation of this probably resides in the more superficial implantation of tile motor roots of the spinal nerves in their appropriate column, whereas the posterior sensitive roots plunge suddenly into the interior of the cord. A t all events, it may be deduced from these anatomical con- siderations that the column of motion which sends off tile anterior roots is injured by violence inflicted generally on the cord more readily than the column of sensation which gives off the posterior roots.

The difficulty of swallowing, which was so prominent a symptom, and which necessitated the child being fed by the rectum, has l ight thrown on it by a consideration of the influence of the internal branch of the spinal accessory nerve upon deglutition. The internal or anastomotic branch is the branch which passes to the pneumogastric~ and is com- posed principally, if not entirely, of the filaments of the spinal accessory which take their origin from the medulla oblongata. Bernard's elaborate researches upon the spinal accessory have shown that there are two ways in which deglutition is affected through this n c r v e : - - l s t . When the larynx is paralysed as a consequence of the extirpation of both nerves, the glottis cannot be completely closed to prevent the entrance of foreign bodies into the air passages. In rabbits particularly it was noted that particles of food penetrated the trachea and found their way into the lungs. 2rid. The spinal accessory furnishes numerous filaments to the pharyngeal branch of the pneumogastric, and, through this nerve, directly affects the muscles of deglutition ; but the muscles animated in this way by the spinal accessory have a tendency to draw the lips of the glottis together, while they assist in passing tile alimentary bolus into the oesophagus. When these important acts are wanting there is difficulty in the process of deglutition itself, as well as danger of the passage of al imentary particles into the larynx, a

I t would have been desirable to have inspected the larynx with the laryngoscope~ but the child's condition at the time was such that I did not think a useful examination could be satisfactorily made.

i :Flint's Physiology. Vol. IV., p. 175.

By D~. FOOT. 215

When he left hospital thei r power had quite returned to the sterno- mastoids and trapezii, and he had full command over those muscles.

Independent of any clinical interest this case may present, it seems to me to have some physiological value as corroborative of Bernard's ingenious experiments on the influence of the spinal accessory nerves upon dcglutition. Both accessory nerves were here paralysed as completely as if they had been paralysed by the difficult operation of section immediately below the foramen magnum by incisions through the occipito-altoid~ligaments--an operation which is generally speedily fatal except in the most experienced hands ; and this paralysis was here followed by effects similar to those observed in Bernard's experiments on animals, except tha t the voice was not lost, possibly because the injury was not sufficiently severe. Although I am unwilling to draw positive conclusions from lesions in the most delicate and complicated organ of the body by means so absurdly rough when compared with section in able hands, that, as Ludwig has forcibly put it, they may be compared to injuries of a watch by means of a pistol shot, yet I cannot avoid thinking that there was here a demonstration by accidental injury of a particular region of the spinal cord of a function of the spinal accessory nerves which has only recently been recognised--namely, their intimate concern with the move- ments of the larynx, and thereby with deglutitiom

EUCALYPTUS OIL AS AN ANTISEPTIC DRESSING.

S IEGEN, in the Deutsche reed. Wochenschrifl, reports his method of using the oil of eucalyptus as an antiseptic dressing. He greatly prefers gauze steeped in this oil, because it is less liable to produce irritations of an eczematous character. His mode of preparing gauze is as follows : - Three grammes of eucalyptus oil are dissolved in fifteen grammes of alcohol. To this solution he adds one hundred and fifty grammes of water. One metre of thoroughly-washed gauze is steeped in this solution until impregnated. The gauze as a dressing should be applied while still wet and covered with gutta-percha leaves. The dressing should remain three to five days. Even a five per cent. solution will not irritate the skin. This dressing was used successfully in a case of eczema, due to the irritant action of the oil of thymol.--Mediccd IIera!d.

S . W .