AntiL 1,
OX
1866.]
DYSPHAGIA,
BY W. J. PALMER.
ORIGINAL COMMUNICATIONS.
but slight pain is experienced whenever pressure is made on the thickened dorsum of the tongue. Pulse beats 80 in a minute, and is very soft, weak, and compressible. History.
CLINICAL
OBSERVATIONS ON A BARE FORM OF DYSPHAGIA LATELY TREATED IN THE GENERAL
HOSPITAL, CALCUTTA. BY W. J. PALMER. First Assistant Surgeon, Presidency General Hospital. Dysphagia is a symptom which is always viewed with some amount of anxiety, and often with alarm, for the same cause which produces it generally threatens the life of your patient, at the same time, by closing either the entrance to the lungs, or the stomach, or both. The following case affords a good illustration of one of the least known forms of difficult deglutition; its rarity, however, is not that which most commends itself to the practical physician ;
greatest interest in it will be found in its curability, for when
is generally amenable to careful and proper medical treatment, while it becomes rapidly fatal if maltreated, either positively or negatively. I will now copy from the case book the notes which were taken when the patient applied for admission:? Patrick Cassidy, recently discharged from the army in
early recognized, it
Ceylon, aged 28 years, was admitted in the evening of the 17th January, 1866, with a peculiar expression of countenance, complaining of sore throat, which prevented him from speaking, except by almost inarticulate monosyllabic sounds; 'the pain is referred to either side of the upper part of the larynx or hvoid bone, whence it extends to the ears; there is no marked tenderness on pressure over the painful parts; the sub-maxillary glands appear slightly swollen and are tender, but firm pressure may be made on the front part on the larynx and hyoid bone, without giving any pain; when any attempt is made to swallow, he is obliged to stand or sit up, he then appears to be pre-
paring himself for some extraordinary exertion ; a little fluid is first taken in the mouth, without any difficulty ; then, with a convulsive effort, throwing the head upwards and forwards, and at the same time the two arms violently in a
.
thrusting
similar
direction, a little fluid appears to go down; for after three such violent efforts, made at intervals of half a minute, he being exhausted, is obliged to reject the unswallowed remainder from his mouth ; about half the original quantity is so rejected. During these efforts the fluid in his mouth has undergone a considerable alteration, for when that originally taken is only water, the rejected matter is almost as viscid as the white of an egg; it is, however, still quite transparent. He appears very restless, and in great agony; being in constant motion, either making efforts to swallow or to steam his throat, or else walking and with the caused
about, moving
groaning
such efforts. He can open his mouth to a very small extent with difficulty, when so open, the tongue is seen covered with a thick, white, parchment-like skin (he had used some tannin lotion), and the whole organ is'slightly swollen ; when he is placed in a
pain
sun-light, be
ly
bright tongue slightly depressed, the fauces duskey-red colour, covered with a layer
and the swollen of
a rather mucus, but not at all swollen in any part; on the contrary, the gorge appears unusually large and open, there being a broad flattened interval between the anterior and posterior faucial pillars, and a large open space between the back of the can
of
seen
transparent
tongue and the pharynx;
feather does not produce any motion freely rubbed about all parts of the fauces. The finger can be pushed into the mouth and all about the fauces and pharynx, without producing any reflex actions, although the patient in all other respects appears to be so irritable and excitable ; no swelling is detected in the epiglottis or any other part of the pharynx, when the finger is thus pushed about, or
a
inconvenience when it is
81
little time ago, on board a sailing ship, quite well; he suffered on board from fever and ague; first felt any soreness in the throat on the 14th instant; this became rapidly lie left
Ceylon,'
a
worse, until yesterday, the 16th, when it was as bad as at present; he came to the hospital as soon as the ship reached Calcutta ; he has taken nothing but rice-water since the throat became bad. Before proceeding with an account of the progress and treatment of his case, it will be well to pause awhile and consider the cause of the dysphagia, the nature of the disease, and our means of recognising it. There are, however, one or two deficiencies in the above notes, which I should like to remedy before
proceeding further. The patient is described as presenting a "peculiar expression of countenance." There was something in this peculiarity difficult to describe, but which brought vividly before my mind all the history of a similar case that I had watched in 1852; there were, however, other characters which should be described, viz., an amount of redness in the cheeks and lips, which showed there had been no chronic blanching disease of any kind; at the same time, there was a general duskiness of the face, as well as of the throat, which indicated disorder of the blood ; there was a bright, open, staring state of the eyes, which, together with his irritability, rapid movements, and determined action when called upon to swallow,
present
indicated mental anxiety and alarm. There was disinclination to move the lower jaw; there was also a total absence of the ordinary rapid ascent and descent of the larynx and hyoid bone
which accompanies the natural act of deglutition, and the saliva, constantly flowed from his mouth, was extremely viscid and very transparent. In tbe natural act of swallowing, as soon as the food reaches the isthmus faucium, it is held also on to the dorsum of the tongue, while the whole bag of the pharynx is suddenly drawn upwards and forwards, leaving the food immediately over the which
oesophagus; here the middle and inferior constrictors of the pharynx close in upon the posterior aspcct of the larynx, forcing the morsel into the oesophagus, where its contact excites the ordinary vermicular action of that tube; this action can only result in forcing the food downwards, its upward passage being preveuted by .the contraction of the pharyngeal constrictors upon In our patient the food is conveyed to the base of the larynx. the tongue as usual, and there it remains, until by the violent spasmodic movement of the head upward and forward, above described, the patient tries to imitate or substitute something for the. ordinary movements of the pharynx at this stage in the process of deglutition. He doubtless succeeds in doing this ; the fluid falls into the open bag by the force of gravitation ; as soon, however, as the first portion of this reaches the oesophagus, the ordinary vermicular contraction takes place, by which a small portion is carried onward towards the stomach ; the larger portion is, however, pushed back into the mouth, to be again subjected to a similar process ; after three such efforts the patient is exhausted, and allows the remaining fluid to run out of his mouth. When the quantity originally taken is about an ounce, rather more than four drachms would be rejected. The above facts, together with the non excitability of the faucial muscles by irritation, ard the absence of any mechanical impediment, afford proof that the proximate cause of the dysphagia is paralysis of toe faucial and pharyngeal muscles, or rather in the nerves supplying them, viz., the glossopharyngeal and the pharyngeal branches of the vagus. Wnat is the cause of the nerve paralysis ? Is this cause peripheral, central, or merely reflex or inhibitory. Inhibitory or reflex paralysis of these muscles, giving rise to considerable difficulty of swallowing, sometimes arises from thoracic aneurisms, involving portions of
82
THE INDIAN MEDICAL GAZETTE.
the vagus ; in these cases, as the aneurism
however, the difficulty comes on very increases, while in our patient its in two days it was more complete than it
gradually
progress was rapid, and could possibly exist in cases of aneurism without the co-existence of other signs, as the presence of the tumour or affection of other nerves. Similar dysphagia sometimes also results from disease of the brain
or medulla oblongata ; in these cases, however, many nerves besides those branches which supply the fauces will be involved, while in our patient careful observation of the act of deglutition shows that both the oesophagus and
the
intact. In some severe cases of influenza, the throat hes been so much involved that a peripheral paralysis, similar in kind to that in our patient, has been produced ; the
tongue
are
absence of other symptoms of influenza decide against this as the cause. Diphtheria, again, sometimes produces a similar form of dysphagia ; the absence of either the exudation membrane the symptoms of extreme depression seen in these cases, obliged us to seek further for a satisfactory explanation of the case under review. That our patient was suffering from some form of in-
or
flammation was evident from the enlarged sub-maxillary gland and generally thickened condition of all the parts between them and the root of the tongue ; the dusky colour of the fauces, the abundant secretion of viscid, transparent mucus, and from the
pain produced by his voluntary efforts to swallow. The only clear published account I have seen of these
cases
is that in Dr. Todd's "Clinical Lectures on Acute Diseases calls it an erysipelatous inflammation of the fauces. In case
he the
under review there
spread, though
which the
absence of that tendency to was an generally characterises erysipelatous affections, local dusky colour and the general depression
of the system seemed in favor of this view of the essential nature of the disease ; whether, however, this be the correct explanation or not, my recollection of two cases quoted in the above lectures, viz., George lving and John Covay, assured me that Cassidy was suffering from the same disease, and that his
danger. The following treatment was adopted immediately I saw him, viz., at 7 a. m., the 18th January. Solution of nitrate of silver, 40 grains to the ounce, to be freely applied to the fauces and pharynx twice a day. A large poultice covered with flannel to be kept constantly applied to the throat. The following draught to be taken every two hours :? Ijb Acidi nitro-hydrochlor : dil: jss mx Spiritus setheris chloric: Infusi kraxnerise giss M The following lotion to be used alternately with steam and life was in imminent "
vinegar inhalations, viscid mucus
p.
Acidi
:
to
clear
the
mouth
and
throat of the
?
nitro-hydrocl
Acidi Tannici
:
dil: ...
...
...
...
...
5iv 5j gxvi
M Aquce milk, beef-ea, arrowroot, and wine to be administered throughout the day and night. January 18/A, noon.?Looks more cheerful and speaks better. Ordered a solution of nitrate silver, 60 grains to the ounce, to be applied immediately and repeated thrice daily. Smearing this solution freely over the fauces with a brush did not produce the slightest movement. 4 p. mi.?Appears still better; keeps trying all day to swallow something, either beef-tea, or milk, or arrowroot and wine ; tongue changed from white to yellowish-brown colour, and it is cleaner at the edges. \9th, 7. a. m.?Says he feels more pain on either side of the larynx and in the ears this morning; has not slept at all; ...
...
...
A diet of
to swallow half an ounce Pulse very soft and compressible ; 80 beats in a minute ; hawks up large quantities of viscid mucus from about the fauces still.
still has to make three violent efforts of
fluid.
[April 1,
1866.
4 p. m.?Has consumed two pints of milk and one of beef-tea since morning, but from half to two-thirds of this is always rejected ; only a very small quantity is swallowed at
each effort, but continues the whole day trying to get it down. wink ; that he feels free from anydusky in colour, and covered with a layer of viscid transparent mucus. The tongue is still thickened at the base, and is painful when the spoon is pressed upon it. Pulse
20th, morning.?Says
weaker ; swelling, rather
much
the
he has not
throat
slept
a
continues
quite
weak and
compressible; 96 beats in a minute; fauces still finger is rubbed about. Ordered.?To have solid caustic applied to the throat ; to add two giains of quinine to each dose of the mixture, and to immoveable when the
have eggs beaten up with the cold milk. Evening.?Feels better ; swallows better. 21s/, morning.?Tongue still swelled;
it
has
again
the
white, opaque, leathery appearauce ; throat quite free from swelling, covered with transparent mucus ; ropes of the same transparent mucus are seen between the tongue and palate when he opens his mouth ; says he did not sleep again last night from the pain between the top of the larynx, angles of the jaw, and root of the tongue. Pulse 72 ; swallows much more
at each effort.
2\st, evening.?Has swallowed
nine-tenths of all the fluids says he is getting on finely. The tongue is still rather swollen and tender; the whole mouth is filled with a semi-fluid transparent mucus, hiding the throat from view until taken
to-day
;
it is cleared away by gargling. Fauces still appear immoveable when the finger is applied, i'ulse 84 ; voice almost na-
again. Does not contort himself so much when swallowing. 22nd.?Slept all last night. Feels much better. His expression of countenance has lost almost all its restraint and peculiarity. Tongue still covered with a drab leather-like layer, tural
which appears almost as if it could be peeled off. There is 110 laver of mucus between the roof of the mouth and the tongue to-day ; that the uvula and all the parts reached by the caustic
hue ; one side a bright red colour, instead of a dull leaden of the uvula is excoriated by the caustic, covered with opaque puriform lymph, by which it adheres to the left side of the He could now move the posterior pillars of the fauces velum.
are
and the
pharynx,
when told to do so ;
the larynx also moved
whenever he swallowed ; the fauces, insensitive to the application of the finger.
upward
Ordered.?Solution of nitrate of silver
to
however, be
were
applied
still
instead
of the solid caustic. To have a dose of opening medicine, as his bowels have not acted for a week, and he is feeling uncomfortable about it.
Evening.?Still improving. 23rcl.?Slept quite well. Can drink off a pint at a draught; the finger can still be pushed in every direction about the pharynx, without producing any reflex action. Tongue still slightly swollen and tender. No mucus about the mouth ; sublingual and maxillary glands still swollen." over two or three more pages, but rd little of importance, but that he was put on tincture of steel and solid food from to-day, and that he was discharged cured on the 3rd February.
24th.?The notes extend
they
recr
OX
1866.]
DYSPHAGIA,
BY W. J. PALMER.
ORIGINAL COMMUNICATIONS.
but slight pain is experienced whenever pressure is made on the thickened dorsum of the tongue. Pulse beats 80 in a minute, and is very soft, weak, and compressible. History.
CLINICAL
OBSERVATIONS ON A BARE FORM OF DYSPHAGIA LATELY TREATED IN THE GENERAL
HOSPITAL, CALCUTTA. BY W. J. PALMER. First Assistant Surgeon, Presidency General Hospital. Dysphagia is a symptom which is always viewed with some amount of anxiety, and often with alarm, for the same cause which produces it generally threatens the life of your patient, at the same time, by closing either the entrance to the lungs, or the stomach, or both. The following case affords a good illustration of one of the least known forms of difficult deglutition; its rarity, however, is not that which most commends itself to the practical physician ;
greatest interest in it will be found in its curability, for when
is generally amenable to careful and proper medical treatment, while it becomes rapidly fatal if maltreated, either positively or negatively. I will now copy from the case book the notes which were taken when the patient applied for admission:? Patrick Cassidy, recently discharged from the army in
early recognized, it
Ceylon, aged 28 years, was admitted in the evening of the 17th January, 1866, with a peculiar expression of countenance, complaining of sore throat, which prevented him from speaking, except by almost inarticulate monosyllabic sounds; 'the pain is referred to either side of the upper part of the larynx or hvoid bone, whence it extends to the ears; there is no marked tenderness on pressure over the painful parts; the sub-maxillary glands appear slightly swollen and are tender, but firm pressure may be made on the front part on the larynx and hyoid bone, without giving any pain; when any attempt is made to swallow, he is obliged to stand or sit up, he then appears to be pre-
paring himself for some extraordinary exertion ; a little fluid is first taken in the mouth, without any difficulty ; then, with a convulsive effort, throwing the head upwards and forwards, and at the same time the two arms violently in a
.
thrusting
similar
direction, a little fluid appears to go down; for after three such violent efforts, made at intervals of half a minute, he being exhausted, is obliged to reject the unswallowed remainder from his mouth ; about half the original quantity is so rejected. During these efforts the fluid in his mouth has undergone a considerable alteration, for when that originally taken is only water, the rejected matter is almost as viscid as the white of an egg; it is, however, still quite transparent. He appears very restless, and in great agony; being in constant motion, either making efforts to swallow or to steam his throat, or else walking and with the caused
about, moving
groaning
such efforts. He can open his mouth to a very small extent with difficulty, when so open, the tongue is seen covered with a thick, white, parchment-like skin (he had used some tannin lotion), and the whole organ is'slightly swollen ; when he is placed in a
pain
sun-light, be
ly
bright tongue slightly depressed, the fauces duskey-red colour, covered with a layer
and the swollen of
a rather mucus, but not at all swollen in any part; on the contrary, the gorge appears unusually large and open, there being a broad flattened interval between the anterior and posterior faucial pillars, and a large open space between the back of the can
of
seen
transparent
tongue and the pharynx;
feather does not produce any motion freely rubbed about all parts of the fauces. The finger can be pushed into the mouth and all about the fauces and pharynx, without producing any reflex actions, although the patient in all other respects appears to be so irritable and excitable ; no swelling is detected in the epiglottis or any other part of the pharynx, when the finger is thus pushed about, or
a
inconvenience when it is
81
little time ago, on board a sailing ship, quite well; he suffered on board from fever and ague; first felt any soreness in the throat on the 14th instant; this became rapidly lie left
Ceylon,'
a
worse, until yesterday, the 16th, when it was as bad as at present; he came to the hospital as soon as the ship reached Calcutta ; he has taken nothing but rice-water since the throat became bad. Before proceeding with an account of the progress and treatment of his case, it will be well to pause awhile and consider the cause of the dysphagia, the nature of the disease, and our means of recognising it. There are, however, one or two deficiencies in the above notes, which I should like to remedy before
proceeding further. The patient is described as presenting a "peculiar expression of countenance." There was something in this peculiarity difficult to describe, but which brought vividly before my mind all the history of a similar case that I had watched in 1852; there were, however, other characters which should be described, viz., an amount of redness in the cheeks and lips, which showed there had been no chronic blanching disease of any kind; at the same time, there was a general duskiness of the face, as well as of the throat, which indicated disorder of the blood ; there was a bright, open, staring state of the eyes, which, together with his irritability, rapid movements, and determined action when called upon to swallow,
present
indicated mental anxiety and alarm. There was disinclination to move the lower jaw; there was also a total absence of the ordinary rapid ascent and descent of the larynx and hyoid bone
which accompanies the natural act of deglutition, and the saliva, constantly flowed from his mouth, was extremely viscid and very transparent. In tbe natural act of swallowing, as soon as the food reaches the isthmus faucium, it is held also on to the dorsum of the tongue, while the whole bag of the pharynx is suddenly drawn upwards and forwards, leaving the food immediately over the which
oesophagus; here the middle and inferior constrictors of the pharynx close in upon the posterior aspcct of the larynx, forcing the morsel into the oesophagus, where its contact excites the ordinary vermicular action of that tube; this action can only result in forcing the food downwards, its upward passage being preveuted by .the contraction of the pharyngeal constrictors upon In our patient the food is conveyed to the base of the larynx. the tongue as usual, and there it remains, until by the violent spasmodic movement of the head upward and forward, above described, the patient tries to imitate or substitute something for the. ordinary movements of the pharynx at this stage in the process of deglutition. He doubtless succeeds in doing this ; the fluid falls into the open bag by the force of gravitation ; as soon, however, as the first portion of this reaches the oesophagus, the ordinary vermicular contraction takes place, by which a small portion is carried onward towards the stomach ; the larger portion is, however, pushed back into the mouth, to be again subjected to a similar process ; after three such efforts the patient is exhausted, and allows the remaining fluid to run out of his mouth. When the quantity originally taken is about an ounce, rather more than four drachms would be rejected. The above facts, together with the non excitability of the faucial muscles by irritation, ard the absence of any mechanical impediment, afford proof that the proximate cause of the dysphagia is paralysis of toe faucial and pharyngeal muscles, or rather in the nerves supplying them, viz., the glossopharyngeal and the pharyngeal branches of the vagus. Wnat is the cause of the nerve paralysis ? Is this cause peripheral, central, or merely reflex or inhibitory. Inhibitory or reflex paralysis of these muscles, giving rise to considerable difficulty of swallowing, sometimes arises from thoracic aneurisms, involving portions of
82
THE INDIAN MEDICAL GAZETTE.
the vagus ; in these cases, as the aneurism
however, the difficulty comes on very increases, while in our patient its in two days it was more complete than it
gradually
progress was rapid, and could possibly exist in cases of aneurism without the co-existence of other signs, as the presence of the tumour or affection of other nerves. Similar dysphagia sometimes also results from disease of the brain
or medulla oblongata ; in these cases, however, many nerves besides those branches which supply the fauces will be involved, while in our patient careful observation of the act of deglutition shows that both the oesophagus and
the
intact. In some severe cases of influenza, the throat hes been so much involved that a peripheral paralysis, similar in kind to that in our patient, has been produced ; the
tongue
are
absence of other symptoms of influenza decide against this as the cause. Diphtheria, again, sometimes produces a similar form of dysphagia ; the absence of either the exudation membrane the symptoms of extreme depression seen in these cases, obliged us to seek further for a satisfactory explanation of the case under review. That our patient was suffering from some form of in-
or
flammation was evident from the enlarged sub-maxillary gland and generally thickened condition of all the parts between them and the root of the tongue ; the dusky colour of the fauces, the abundant secretion of viscid, transparent mucus, and from the
pain produced by his voluntary efforts to swallow. The only clear published account I have seen of these
cases
is that in Dr. Todd's "Clinical Lectures on Acute Diseases calls it an erysipelatous inflammation of the fauces. In case
he the
under review there
spread, though
which the
absence of that tendency to was an generally characterises erysipelatous affections, local dusky colour and the general depression
of the system seemed in favor of this view of the essential nature of the disease ; whether, however, this be the correct explanation or not, my recollection of two cases quoted in the above lectures, viz., George lving and John Covay, assured me that Cassidy was suffering from the same disease, and that his
danger. The following treatment was adopted immediately I saw him, viz., at 7 a. m., the 18th January. Solution of nitrate of silver, 40 grains to the ounce, to be freely applied to the fauces and pharynx twice a day. A large poultice covered with flannel to be kept constantly applied to the throat. The following draught to be taken every two hours :? Ijb Acidi nitro-hydrochlor : dil: jss mx Spiritus setheris chloric: Infusi kraxnerise giss M The following lotion to be used alternately with steam and life was in imminent "
vinegar inhalations, viscid mucus
p.
Acidi
:
to
clear
the
mouth
and
throat of the
?
nitro-hydrocl
Acidi Tannici
:
dil: ...
...
...
...
...
5iv 5j gxvi
M Aquce milk, beef-ea, arrowroot, and wine to be administered throughout the day and night. January 18/A, noon.?Looks more cheerful and speaks better. Ordered a solution of nitrate silver, 60 grains to the ounce, to be applied immediately and repeated thrice daily. Smearing this solution freely over the fauces with a brush did not produce the slightest movement. 4 p. mi.?Appears still better; keeps trying all day to swallow something, either beef-tea, or milk, or arrowroot and wine ; tongue changed from white to yellowish-brown colour, and it is cleaner at the edges. \9th, 7. a. m.?Says he feels more pain on either side of the larynx and in the ears this morning; has not slept at all; ...
...
...
A diet of
to swallow half an ounce Pulse very soft and compressible ; 80 beats in a minute ; hawks up large quantities of viscid mucus from about the fauces still.
still has to make three violent efforts of
fluid.
[April 1,
1866.
4 p. m.?Has consumed two pints of milk and one of beef-tea since morning, but from half to two-thirds of this is always rejected ; only a very small quantity is swallowed at
each effort, but continues the whole day trying to get it down. wink ; that he feels free from anydusky in colour, and covered with a layer of viscid transparent mucus. The tongue is still thickened at the base, and is painful when the spoon is pressed upon it. Pulse
20th, morning.?Says
weaker ; swelling, rather
much
the
he has not
throat
slept
a
continues
quite
weak and
compressible; 96 beats in a minute; fauces still finger is rubbed about. Ordered.?To have solid caustic applied to the throat ; to add two giains of quinine to each dose of the mixture, and to immoveable when the
have eggs beaten up with the cold milk. Evening.?Feels better ; swallows better. 21s/, morning.?Tongue still swelled;
it
has
again
the
white, opaque, leathery appearauce ; throat quite free from swelling, covered with transparent mucus ; ropes of the same transparent mucus are seen between the tongue and palate when he opens his mouth ; says he did not sleep again last night from the pain between the top of the larynx, angles of the jaw, and root of the tongue. Pulse 72 ; swallows much more
at each effort.
2\st, evening.?Has swallowed
nine-tenths of all the fluids says he is getting on finely. The tongue is still rather swollen and tender; the whole mouth is filled with a semi-fluid transparent mucus, hiding the throat from view until taken
to-day
;
it is cleared away by gargling. Fauces still appear immoveable when the finger is applied, i'ulse 84 ; voice almost na-
again. Does not contort himself so much when swallowing. 22nd.?Slept all last night. Feels much better. His expression of countenance has lost almost all its restraint and peculiarity. Tongue still covered with a drab leather-like layer, tural
which appears almost as if it could be peeled off. There is 110 laver of mucus between the roof of the mouth and the tongue to-day ; that the uvula and all the parts reached by the caustic
hue ; one side a bright red colour, instead of a dull leaden of the uvula is excoriated by the caustic, covered with opaque puriform lymph, by which it adheres to the left side of the He could now move the posterior pillars of the fauces velum.
are
and the
pharynx,
when told to do so ;
the larynx also moved
whenever he swallowed ; the fauces, insensitive to the application of the finger.
upward
Ordered.?Solution of nitrate of silver
to
however, be
were
applied
still
instead
of the solid caustic. To have a dose of opening medicine, as his bowels have not acted for a week, and he is feeling uncomfortable about it.
Evening.?Still improving. 23rcl.?Slept quite well. Can drink off a pint at a draught; the finger can still be pushed in every direction about the pharynx, without producing any reflex action. Tongue still slightly swollen and tender. No mucus about the mouth ; sublingual and maxillary glands still swollen." over two or three more pages, but rd little of importance, but that he was put on tincture of steel and solid food from to-day, and that he was discharged cured on the 3rd February.
24th.?The notes extend
they
recr
