Chapter V: Part 5

The question of tracheotomy in spasm of the larynx should be considered. It is sometimes stated that there is never in simple spasm a justification for this operation, and that the other means at our control are always adequate to meet the indication. Krishaber, Thaon, and others are of this opinion. Gougenheim and Schnitzler think it is sometimes required. While in a very large majority of cases of uncomplicated spasm of the larynx the spasm will yield to the measures recommended, it is nevertheless true that there are cases in which this result is not realized. The slowness of the action of some of the drugs, the difficulty in securing their introduction into the system, their absence at the time of the attack, and the delay in their administration,--all these facts may render it absolutely necessary to resort to an operation for the purpose of saving the life of the patient. It is, however, rare that this necessity will occur. In one case recently in my own practice I think a life was lost for want of the operation. The trouble was, as I thought, of hysterical origin, and at the time of the consultation did not threaten life. There was free movement of the vocal cords, and the vestibule of the larynx was not obstructed. Spasm of the constrictors occurred at night, and did not continue for a great length of time. There was certainly not paralysis of the abductors of the glottis. I directed an antispasmodic, and advised that if the spasm returned the next night a physician in the neighborhood should be sent for. The spasm did recur, and the physician was called, but before he reached the house the patient was dead. No post-mortem was held, and {76} the question of the morbid anatomy could not be determined with any degree of certainty. From the fact that there had not been spasm till the night previous to the consultation, that she was an adult female previously in good health, with no organic disease, no tumor, no ulceration, no paralysis, and with a perfectly healthy condition of all the parts of the organ as revealed by the mirror, I am led to believe that the cause of death was simple spasm of the larynx. It is possible that this was one of those cases described by Krishaber and Charcot under the name of ictus laryngé or laryngeal vertigo, and that the death was due to some central disease; but the description given by the attendants was that of true spasm of the muscles of the larynx, and it is more probable that, as in Cohen's case, there was impaction of the epiglottis in the vestibule. The question of the operation should be considered in severe spasm which does not readily yield to the ordinary means. It is certain, I think, that life may sometimes be saved by a timely opening of the trachea.

E. F. Ingals suggests tubage of the larynx in cases of spasm threatening death. If the physician is present at the time of the dangerous symptoms, this may be attempted. A large-sized catheter or one of Schrötter's dilators may be used with no danger to the patient, and possibly with the result of saving life.

Chorea of the Larynx.

There is a kind of disturbance of the motor function of the larynx which has been described as chorea. The derangements of phonation and of respiration are such as we should naturally expect from want of co-ordination of the muscles concerned in speaking and breathing. There may be a true chorea of the laryngeal muscles when there is no other indication of the disease. Lefferts, in the first volume of the _Transactions of the American Laryngological Association_, reports three cases which he designates chorea of the larynx. They were all characterized by spasm of the muscles concerned in phonation. It is to be observed, however, that all three were women in early life, and that there were no other choreic troubles mentioned. There were, so far as the histories indicate, no hysterical phenomena present, if we assume that the laryngeal trouble was not of that character. In the recital of these cases the author seems to think that the evidence that the patients were not simulating is a sufficient proof that the troubles were not hysterical. This will not, I think, be accepted as adequate proof of the absence of hysteria. It is certainly possible that the patients were all three really choreic, but there is at least in the fact of the sex, the absence of other manifestations of this disease, and, so far as the author informs us, no antecedent history of rheumatism or other morbid conditions so frequently preceding chorea, a doubt as to the nature of the affection. Chorea affecting the muscles of the throat and of respiration is, I think, not unfrequently met with, but there is in these cases, so far as I know, such well-marked symptoms of the origin and nature of the trouble as to leave no reasonable room for doubt.

Cases of unmistakable chorea limited to the laryngeal muscles have been seen by Knight, Roe, and others. Chorea or spasm of the expiratory muscles alone may occur. I have the records of one such case, an adult male. I was unable to say certainly that the larynx was the only part involved. After a full inspiration there followed a series of short, jerky, expiratory acts till the movable air in the thorax was all expelled. For a few breaths the respiration was regular and full, when the same phenomena were repeated. There was no organic disease. There was forcible closing of the glottis during the {77} spasmodic expiratory efforts. The patient recovered under treatment by arsenic.[8]

[Footnote 8: It may not be easy in all cases to distinguish between the true choreic cases and the hysterical affections. Knight of Boston has given special study to choreic troubles of the larynx. He recognizes three varieties: The first includes those cases in which the adductor and expiratory muscles each side of the larynx are involved; second, in which the laryngeal muscles alone are involved; third, in which the expiratory muscles alone are involved.]

TREATMENT.--This should be the same as for other forms of chorea.

Nervous Cough.

Besides this ataxic condition we have hysterical disturbances of the motor functions, which are of various kinds according to the muscles involved. A constant effort to clear the throat, as it is called, is sometimes met with--a scraping of the throat, by which there is produced a rough, harsh sound similar to that which is heard in some of the inflammations of the organ. At other times the form is that of cough--a cough which is almost constant, and which is not associated with disease of the mucous surfaces of the thoracic viscera. This cough is sometimes almost continuous for days, and months even. It occurs at intervals of a minute or more, with the same character of hoarseness and roughness, without any interruption, except during sleep, when the breathing is free and easy. I saw a few years ago a little patient who had a cough of this nature which lasted several weeks, when it was replaced by the peculiar rasping, scraping effort mentioned above. The patient was a girl of fourteen years and had not developed. The moral effect of a severe case of typhoid fever in a younger sister, followed by the confinement of the mother, effected a cure. It is not at all uncommon to find that certain patients suffering from uterine troubles are also affected with laryngeal derangement of this character. A lady was seen by the writer a few months ago who had a rough, harsh cough, with attacks of asthma. There was no evidence of thoracic disease, and I learned that she had had this cough from the time of her last confinement. I advised her to consult a gynæcologist, who found that she had a laceration of the cervix uteri. For this she was operated upon, and from the time that she recovered from the immediate effects of the operation she had no more asthma or cough. It had been purely hysterical.

Cohen reports in his work _On Disease of the Throat_ (p. 627) an epidemic of hysterical cough in a school for girls near Philadelphia. The cough was peculiar in character. The neighbors called them the barking girls. Cough of this character may be dependent upon other conditions than hysteria. Irritations reflected from other parts, as the ear and naso-pharynx, have been noticed.[9]

[Footnote 9: Cohen, p. 636.]

E. F. Ingals reports a case of an adult female whose voice had been abnormal for several years. It had been preceded by measles. Upon laryngoscopic examination the ventricular bands were seen to be approximated during the effort of phonation, while the true or vocal bands were, when last seen, moderately separated. The voice was not extinct, but hoarse, low in pitch. The true cords could not be seen during phonation on account of the closure of the false cords. This could hardly be considered as chorea, but there must have been an irregularity of muscular action, something between chorea and hysterical ataxia. There were no other abnormal movements of the larynx.

TREATMENT.--For these hysterical forms of trouble the treatment should be such as to correct, if possible, the morbid conditions upon which they {78} depend. Under the subjects of Anæsthesia, Hyperæsthesia, and Paralysis this has been sufficiently discussed.

PARALYSIS AND PARESIS OF THE MUSCLES OF THE LARYNX.

The function of the muscular apparatus concerned in respiration and phonation depends mainly upon the action of the recurrent nerves, as stated in the paragraph devoted to the Anatomico-physiological Facts. Disease of the centres in or near the floor of the fourth ventricle, where, in close proximity, the pneumogastric fibres of the accessory and the glosso-pharyngeal nerves take their origin, may be the sole cause of a paralysis of these muscles. Disease along the course of the nerves anywhere between this centre and the termination of the nerves may give rise to the same result. Change in the structure or function of the nerves at the point of their contact with the muscles in some instances may possibly be the sole cause of the paralysis. Alteration of the muscles themselves, such as atrophy or degeneration, produces a like effect. In certain cases both the nerves and muscles are involved in the morbid processes, but in some instances, even where there are undoubted changes in the muscles, these changes are secondary, the result of the long inactivity of the muscles. It is possible to group these morbid conditions with reference to the nerves involved; but it frequently happens that several different conditions are present at the same time, and groups of muscles supplied by different nerves are simultaneously involved. It is therefore difficult to classify these troubles with reference to the nerves by which the parts are supplied. The further fact that of individual muscles or parts of muscles supplied by the same nerve-trunk some are affected, while others are intact, renders this effort to make a physiological classification still more unsatisfactory. As a rule, however, we may state in general terms that diseases of the superior laryngeal nerves produce paralysis or paresis of the external tensors of the vocal cords, the crico-thyroids, and, to a certain extent, of the constrictors of the larynx. Diseases of the recurrent nerves produce paralysis or paresis of the other muscles of the organ. If the disease of the nerve is of one side only, we have, as a rule admitting of only a very few exceptions, a unilateral impairment of the motor functions of the parts. In the case of the loss of power of individual muscles or parts of muscles it is by no means easy to find a satisfactory explanation. It seems probable that in some instances the reason is to be sought in the centres, but in a great majority of cases the muscles are degenerated or the nervous filaments of the particular parts are in a morbid condition.

Notwithstanding this difficulty of classification, the troubles of respiration and phonation due to the complete or partial paralysis of the muscular apparatus are, for the convenience of study, divided into groups. These groups are based either upon the seat of the primary lesion or upon the kind of disturbance or the symptoms of the case. Neither method of grouping is satisfactory. We must content ourselves with a provisional arrangement. With the single exception of the arytenoideus, the muscles are double and symmetrical; paralysis may therefore be general or partial, unilateral or bilateral.

The causes, symptoms, or terminations vary with this general or partial, double or single, character of the affection. We propose, therefore, to consider these motor derangements under the following heads, which in the main follow the classification of Mackenzie and most other writers upon the subject:

1. Paralysis of the whole larynx--of one-half of the larynx; {79}

2. Paralysis of the constrictors of the larynx;

3. Paralysis of the adductors of the vocal cords: _(a)_ unilateral, _(b)_ bilateral, _(c)_ central;

4. Paralysis of the tensors of the vocal cords: _(a)_ internal, _(b)_ external, _(c)_ unilateral, _(d)_ bilateral;

5. Paralysis of the abductors of the vocal cords, openers of the glottis: _(a)_ unilateral, _(b)_ bilateral.

Paralysis of the Whole Larynx.

Paralysis of all of the muscles of the larynx gives rise to a position of the parts which has, as before stated, been called the cadaveric condition. The vocal cords are neither abducted nor adducted. The opening of the glottis is sufficiently wide to admit of easy respiration, but the cords are so far apart as to make phonation impossible. The effort to articulate is not attended with any change in the position of the vocal bands. In respiration there is no additional widening of the glottic chink. The superior portion of the larynx is also in a peculiar condition. The epiglottis is erect, standing against the dorsum of the tongue; the vestibule of the larynx is widely open; deglutition is difficult.

ETIOLOGY.--So far as we know, the causes are to be found either in central disease or hysteria. When the cause is in the centres, there is almost of necessity functional lesion of other parts of the muscular apparatus, especially of the parts supplied by the glosso-pharyngeal nerve. There will, therefore, be dysphagia. It is possible that the central lesion may be very circumscribed; in such cases we may have paralysis of individual laryngeal muscles or parts of muscles. These cases are probably very rare, and the indication of more general paralysis is, in fact, the point upon which the diagnosis of central disease depends. Tumor or other disease along the track of the spinal accessory before it unites with the pneumogastric may produce the same effect. When the affection is upon one side only the paralysis is also unilateral. There are, as before noted, exceptions to this statement. In these instances it is probable that the innervation of the affected part or side is supplied by branches from the opposite trunk. Such cases have been reported by George Johnson, Lefferts, and others. It has also been found that injury or paralysis of one recurrent nerve is sometimes followed by bilateral paralysis. Schnitzler reports a case in the _Wiener Med. Report_ for 1882. The left recurrent was compressed by aneurism of the arch of the aorta; the right was normal. There was, however, bilateral paralysis. Experiment by Tourgues[10] demonstrated the fact that powerful excitation and consequent exhaustion of one of the pneumogastrics may result in paralysis of the other. This result is in accordance with facts seen occasionally in traumatism of one of the pneumogastrics.

[Footnote 10: Reported in the _Gazette de Montpellier_, Nos. 35 and 36, 1882.]

A pure, uncomplicated paralysis, in which all of the muscles of the larynx are implicated, and in which no other muscles are concerned, will almost always be found to depend upon some lesion of the pneumogastrics or the spinal accessories after they leave their point of origin. Whether the paralysis is dependent upon the lesion at one point or another, the symptoms are the same so far as the larynx is concerned. The vocal cords are in a state of absolute rest between abduction and adduction; the effort at phonation gives rise to no contraction of the tensors; the arytenoids leave the cartilages slightly separated; and the state of the organ is that of muscular death.

When the lesion upon which a paralysis of the muscles of the larynx depends is below the point at which the superior laryngeal nerves leave the {80} pneumogastrics, the paralysis is limited to the phonators and respirators. The muscular bands and fibres by which the glottis is constricted are, in part at least, still capable of being thrown into contraction. This condition of recurrent paralysis may be due to a disease of the nerve-trunks, tumor pressing upon the nerves, cicatricial tissue by which the nerves are compressed, aneurism of the arch of the aorta or right subclavian artery, disease of the apex of the lung, especially of the right side, pleuritic adhesions, or, in fact, any injury or lesion along the trunks of the recurrents or pneumogastrics. The paralysis may of course be partial or complete.

The SYMPTOMS vary according to the extent of the muscular disability. In case of complete paralysis of one side there may be aphonia, but not dyspnoea. The glottis admits a sufficiency of air, but does not close so as to allow of the vibration of the cords. Where there is complete paralysis on one side only, the voice is not necessarily entirely suppressed, but it is changed in its quality; it becomes rough, weak, and in its use gives rise to great fatigue. In long-continued cases there is in part a compensation for the want of motion of one of the vocal bands. The muscles of the sound side act with increased vigor, so as to carry the sound cord at its posterior extremity beyond the median line. The result is, that the two cords are brought so near each other that phonation is possible. The arytenoid of the non-paralyzed side is drawn forward beyond its fellow. The cord upon the affected side is less tense than that on the healthy side. The vibrations are therefore not equal; the pitch is different; the voice is therefore unnatural, rattling, uncertain.

As we proceed to discuss the lesions in individual muscles or sets of muscles we shall have occasion to refer to these etiological considerations, as well as to some of the symptoms noted with partial or complete loss of power of the whole group of muscles of the organ.

Paralysis of the Constrictors.

Complete paralysis of the muscles, by which the vestibule of the larynx is closed, is rare. The partial paralysis of these muscles is, however, by no means uncommon. As we have already endeavored to show, it is probable that the motor functions of the muscular fibres in the ary-epiglottic folds--the superior constrictors--are mixed. Probably both the superior and inferior laryngeal nerves are concerned in their movements. It is not, therefore, easy to group these disorders according to the nerves involved, as has been done by Von Ziemssen, Mackenzie, and others.

Partial paralysis of the constrictors may be due to deficient power of one or both of the laryngeal nerves, superior or inferior. The parts involved are the arytenoids, transverse and oblique, and the muscular fibres in the folds going from the arytenoid and from the thyroid cartilages to the epiglottis.

The ETIOLOGY of this form of paralysis associates itself with that of anæsthesia of the parts--namely, the arrest of motor impression in the centre, obstruction along the course of the nerve, disease in the nerve itself, in its trunk or termination, or, lastly, myopathic changes rendering the muscle incapable of responding to the nervous influences. Disease in the centres may possibly affect only these muscles; the disorders of motion may be well defined and local in extent, but usually, in case of central disease, there is a complication of external manifestations and we have a wider range of disturbances. The most common cause of this loss of power is diphtheria.

SYMPTOMS.--The symptoms of paralysis of the constrictors of the larynx are for the most part mechanical. The failure to close the vestibule of the organ in the act of swallowing allows food or drink to pass into the larynx, {81} and, as there is usually anæsthesia of the parts also, the invasion of the larynx is not perceived; no reflex irritation is produced, no cough for the extrusion of the offending matter, which may descend into the trachea, and, reaching the bronchi, may become the agent in the development of a bronchitis or a broncho-pneumonia. The secretions of the mouth overflow the borders of the laryngeal opening and fall into the tube below. Fluids are swallowed with greater difficulty than solids. The voice is not altered except in cases where the crico-thyroids, one or both, are involved, as in complete paralysis of the superior laryngeal nerve. The effort to close the glottis, as in the preliminary act of coughing, is accomplished with difficulty. The sound of the cough is somewhat altered. This is for want of the reinforcement to the adductors furnished by the closure of the vestibule of the larynx. Upon laryngoscopic examination the epiglottis is seen to stand erect against the dorsum of the tongue. The ary-epiglottic folds are lax or wide apart. With this is loss or diminished sensibility of the surfaces. There is little or no change in the color of the membranes. The secretions are normal in quality, and only slightly in excess in quantity.

The course of the disease is in cases of diphtheritic origin like that of anæsthesia from the same cause. The termination, except in rare instances, is recovery. In cases of central origin the local symptoms in the larynx are almost necessarily associated with disorders of other parts. The progress and termination will depend upon the nature and extent of the central lesion.

The PATHOLOGY of this form of paralysis is probably multiple. When of diphtheritic origin it has been believed to consist in a change of the nerves along the trunk or in their distribution, or an alternation of nutrition due to the local changes in the larynx or pharynx during the progress of diphtheria, or to both of them. It is also probable that it is in many cases as much a myopathic as a neuropathic trouble. In other words, during the progress of the diphtheria the muscles, as well as the nerves, have undergone a change in their nutrition; and this local change in the peripheral portions of the nerves, along with this degeneration of the muscles, goes to make up the pathological anatomy and constitutes the essential local morbid condition.

There is, however, abundant reason to think that in some cases at least the influence of the diphtheria in the production of paralysis reaches far beyond the parts which are the seat of the local manifestations of the trouble, or even the centres from which these nerves are derived. It is well known that the extremities may be affected, and that other muscles become involved which can have no direct and immediate relation to the tissues which have been attacked with the diphtheria. It seems therefore evident that there must, at least in certain cases, be a general derangement of the centres, or that there must be some other explanation for the impairment of the muscular power than that which ascribes its loss solely to the local and poisonous action of the morbid deposit or to the defective nutrition of the parts. It is probable that there is in these cases a widespread influence, a constitutional trouble, which, like the disease itself, is general and not local except as to its manifestations.

Paralysis of the Adductors.

A pure, uncomplicated paralysis of the adductors of the vocal cords is extremely rare. When present it is marked by symptoms and signs which are easily recognized. A partial paralysis of an hysterical nature is, however, not unfrequently encountered. The etiology of paralysis of the lateral crico-arytenoid muscles is in most instances the same as that of the other muscles of the larynx. There may be a morbid condition of the centres in the fourth {82} ventricle, from which the spinal accessory takes its origin. It is certainly possible in theory that certain fibres ultimately distributed to these muscles may alone become diseased in their course along the trunk of the nerve. There may be change in the final distributions by which the function of the nerve is arrested. There may be myopathic change in the muscle itself, rendering it non-responsive even to normal nerve-impressions. All of these causes are theoretically possible. In fact, however, we know but little of the real causes which operate in any given case. Mackenzie, Von Ziemssen, and others ascribe it in some instances to catarrh from exposure to cold. There is developed a hyperæmia of the mucous surfaces of the supraglottic space. The structures beneath are involved in the tumefaction as a result. The voice is impaired or lost; the aphonia, which was at first due to the mechanical difficulties in the way, persists after the local inflammation has subsided. The vocal cords remain permanently apart, even though there is no swelling to prevent the arytenoids from approaching each other. Gerhardt attributes this form of paralysis in certain cases to a rheumatic inflammation affecting either the articulations or the muscles themselves. Trichina have been found in one or both muscles, producing a paresis. Syphilis, central or laryngeal, may account for a number of cases. When the loss of power is due to local syphilitic trouble, there is, however, usually a recognizable change in structure, something more than a simple paralysis.

It would seem strange to find a rheumatism so localized as this hypothesis implies. Mackenzie has met with a case in which the paralysis was unilateral and toxic, due to lead-poisoning. He thinks there may be other cases of similar origin, and suggests arsenic also as a possible cause. In his case he compares this paralysis of the lateral crico-arytenoids to the loss of power in the extensors of the forearm in well-marked cases of lead-poisoning. The affection was limited to the adductor muscles. Seifert and Lublinsk in _Berlin. klin. Woch._ also report cases. The adductors only were affected. The very few cases in which this form of paralysis has been carefully noted do not supply us with the material for a more exact opinion as to the causes of the trouble.

SYMPTOMS.--The symptoms of this form of paralysis are for the most part such as depend upon the mechanical relation of the parts. There is no pain; there is no dyspnoea, except in cases in which there is a catarrh of the larynx; there is no cough. There is however, complete aphonia. There may be an exception to this statement when the paralysis is unilateral. It is possible that where one cord comes to the median line, and the other is affected only with paresis, in the course of time the cord on the sound side may pass beyond the median line and render phonation possible. In such cases, however, the voice is not normal in quality.

Upon inspection with the laryngoscope the glottis is seen to be widely open. The cords approximate the lateral walls of the supraglottic space. Upon an effort to phonate the cords remain immobile. If the constrictors are unaffected, the act of laughing is still possible, from the fact that a partial occlusion of the lumen of the tube is accomplished by the action of the borders of the laryngeal opening and by the approximation of the false cords. In case of unilateral paralysis of course there is motion of the cord upon the sound side, leaving one-half of the glottis open. It has been stated by Von Ziemssen that there is sometimes an anæmic condition of the mucous surfaces. When present, this is probably only a contingent phenomenon, the evidence of a slight alteration of the circulation in the tissues. It is true that the permanent immobility of the parts ought to diminish the activity of the circulation in the muscles, and perhaps also in the neighboring structures. On the other hand, the surfaces have been found hyperæmic. Probably no importance should be attached to the surface condition as a means of diagnosis.

{83} The course, duration, and termination of this form of paralysis must depend largely upon the cause. When the disorder depends upon a catarrh, we may expect that the trouble will disappear, or at least be mitigated, as the local affection is relieved. If of syphilitic or rheumatic origin, it should disappear pari passu with the primary disease. So far as we know, there is no danger to life, the loss of voice being the only important result.

The DIAGNOSIS is easy. The laryngoscope will enable the observer to differentiate it from all other affections by which the voice is destroyed. It is possible that disease affecting the articulation of the arytenoids, and thus preventing their movement, might give rise to a doubt. A careful examination in such cases will, however, generally reveal the fact of tumefaction or other evidence of structural change.

Closely allied to the paralyses which we have just been considering are the affections of the glottis of hysterical origin.

If the cases of true paralysis of the lateral crico-arytenoid muscles are rare, it is equally true that a partial arrest of the action of these muscles, and temporary for the most part in duration, is not unfrequently met with. The etiology of these cases seems to be much more within our knowledge than that of those of which we have just been speaking; at least the conditions under which they occur are much better known. For the most part they occur in females. They are met with in patients of nervous temperament, generally adults, though I have seen one case in which the subject was still undeveloped. There are very generally the evidences of hysteria in some of its various manifestations. We may therefore assume that the disease is functional in its nature and that it is reflex in origin. It has been said that, as it is not dependent upon any disease of the muscles or nerves of the larynx, so far as we know, it should not be classed among the paralyses. For the same reason it should not be considered as a neurosis of the organ, but of the system in general. But it is a neurosis of the larynx, and therefore ought to be placed here. In addition to this, it is in its symptoms identical with or very similar to the true paralyses dependent upon alteration of the nerves or of the muscles of the part.

The etiology of the affection has already been suggested in the definition. A disturbance of the functions of the uterus, or possibly of other portions of the nervous system, may be so reflected as to materially interfere with the action of the muscles of the larynx. It is possible that the affection may occur in males, as other troubles called hysterical sometimes do. That the uterus is not always the source of the reflex disturbance is certain. I have very recently seen a case in which there was unquestionably an intermittent partial paralysis of the adductors of the muscles in an adult man. It seemed to be dependent upon the condition of the stomach. Whenever there was flatulence or an accumulation of gases in the stomach, the voice became husky, requiring great effort and expenditure of air in phonation, and then extinct. Examination with the laryngoscope showed the cords in the condition of adduction. In the effort to speak there was a very slight approximation of the vocal bands, but not enough to admit of their vibration. With the recovery from the disorder of the stomach this condition disappeared. I have seen one other case similar in character. I think we may therefore assume that the trouble can be produced by any affection which creates a disturbance of the pneumogastrics, and which by reflex action interferes with the proper functions of the spinal accessory.

The disease is always bilateral. Its advent is generally sudden. The symptoms are first and almost solely loss of voice. The aphonia may from the beginning be persistent, or there may be intervals when the patient speaks with ease. In some cases the patient is able to whisper; in others this power is also lost: in the effort to phonate there is absolutely no sound. There is {84} no pain, but there is often cough: this cough is hoarse, like that which has been described under a previous heading. The general health is in some cases apparently perfect, but in a majority of instances there will be found some disturbance of the viscera of the abdomen. Perhaps in all cases this is true, but so slight that we are obliged to look carefully in order to find it. Upon inspection with the laryngoscope the cords are seen to be separated, but not so widely as in complete paralysis of the adductors from other causes. There is no marked morbid condition of the mucous surfaces. The secretions are not affected. It is possible that there may be at the same time a partial paralysis of the pharyngeal muscles, so that there is also dysphagia. In a few instances there is a paræsthesia of the parts above. The dysphonia or aphonia is then associated with a feeling as though there was a foreign body in the throat. In efforts at phonation the cords usually move slightly toward the median line, but not enough to enter into vibration. When this condition of things is observed, and there is no other cause for the explanation of the loss of voice, we may with safety assume that we have to do with an hysterical paralysis of the adductors.

The duration of this form of motor disturbance is uncertain. It may terminate suddenly after a short duration or it may continue indefinitely. It is a cause neither of dyspnoea nor asphyxia. It always ends finally in recovery. This statement is possibly subject to an exception in cases in which there are other diseases present and when these diseases are of themselves dangerous to life.

The pathology and morbid anatomy are dependent upon the length of time during which the muscles have been in a state of inaction. It is possible that the muscles may degenerate or lose their power to act with the normal vigor, or there may be a simple atrophy of the muscles, as in a case reported by Mackenzie. So far as I know, this alteration of the muscles is very seldom found in hysterical paralysis. When degeneration or atrophy does exist, it is probably a result, and not a cause, of the paralysis. So far as we know, there is no antecedent change in the larynx. This must of necessity be the case, since the disease is reflex, and not primarily in the organ of speech. Why the morbid influences are manifested in this organ to the exclusion of others we do not know. In fact, we do not know that this is the case. So far as we can judge from the records of similar cases found in the literature of the subject, we may safely believe that there is in nearly all of the patients some other disorders of motility, but the derangements of speech are so striking that these have masked all minor troubles.

The intimate relation between the organs of expression, of which speech is one of the most important, finds in these cases a striking illustration. The quality of the voice is modified by emotion. The evident relation of the generative functions to this psychical state is well known. This fact explains the association of these troubles so frequently encountered in the study of the morbid conditions of the larynx. It is true that the disturbance is not always limited to the phonators, but it is nevertheless more frequently met with in these muscles than in the muscles of respiration. Emotion and the expression of emotion go together. Their morbid conditions are therefore associated.

Paralysis of the Arytenoideus--Central Adductor.

The function of this muscle is to approximate the arytenoid cartilages. Its paralysis leaves the posterior borders of the cartilages separated, even though the vocal processes are by the action of the lateral crico-arytenoids made to approach the median line. There is left a triangular opening at the base of the cartilages, through which the air escapes in the act of speaking. This, the {85} cartilaginous portion of the glottis, remains patent even though the anterior three-fourths of the space be closed. The result is generally, but not always, a loss of speech. The air whistles through this opening, but phonation is difficult or absent. The causes are to be sought in the derangements resulting in the loss of power of the other muscles. Upon examination with the laryngoscope the triangular opening is readily seen. The ligamentous portion of the glottis is seen to close in the effort to speak, while the cartilaginous portion is widely open. There is no other morbid condition necessarily present. The trouble is frequently associated with paralysis of the adductors of the two sides--that is, the lateral crico-arytenoids. In these cases there is complete separation of the cords throughout the whole length.

The DIAGNOSIS is easy except in instances where there is ankylosis of the articulation of the cartilages. Even in these cases a careful study of the parts, as revealed by the mirror, will enable the observer in most instances to recognize evidence of structural disease on the walls of the larynx. There will also be a history of some antecedent affection, such as syphilis or tuberculosis, or possibly arthritis. The course and termination of this form of paralysis depend largely upon the etiology in any given case.

Paralysis of the Tensors of the Vocal Cords.

It will be remembered that these are in two groups, the internal and external.

The internal are the thyro-arytenoids. While their function is in part still a matter of discussion, it is very generally conceded that they have to do with the form and tension of the cords. Their paralysis produces a very marked derangement of the functions of the larynx as the organ of speech. They act ordinarily along with the crico-thyroids, but from the fact of their separate innervation it would seem very probable that they should be the seat of special functional derangements. In fact, it is true that their paralysis in a limited number of cases is found to be quite independent of any disturbances of the external tensors.

ETIOLOGY.--In addition to the general causes of laryngeal paralysis, the use of the voice in an unnatural or too high a key or the too long-continued use of the organ may result in a temporary or even permanent impairment of the power of these muscles. Their exposure to the causes of inflammation, lying as they do so near the surface of the mucous membranes, subjects them to the morbid influences of the catarrhal troubles to which the glottis is liable. They are probably more frequently affected than the literature of the subject would lead us to suppose, as in many cases the disease is temporary.

SYMPTOMS.--These consist mainly in the alteration of the voice. It is hoarse, the register is lower, the quality is uneven. Occasionally a note is, if not lost, uttered with difficulty; some letters, such as the aspirates, requiring the careful adjustment of the glottis, are articulated with great uncertainty. There is what has been called a rattling of the voice. It is quite impossible to sing or to speak long in a high key; even prolonged ordinary conversation gives rise to fatigue, for the reason that there is so great a waste of air in the effort. The pressure upon the under surface of the cords in their relaxed condition forces its way upward and through the glottis without throwing them into normal vibration.

DIAGNOSIS.--The laryngeal mirror reveals the glottis only partly closed. There is an oblong opening extending from the thyroids to the base of the arytenoid cartilages. The vocal processes even are not brought to the median line, but are so far apart as to leave a noticeable slit between them. It seems from this fact that these muscles are therefore the aids of the lateral {86} crico-arytenoids in the rotation of the cartilages on their bases. In the effort at phonation the cords are seen to move with difficulty. The disease may be unilateral or bilateral.

This form of paralysis in course and termination does not in any essential respect differ from other paralyses of the larynx. The duration is therefore very uncertain, and will depend largely upon the cause of the affection.

Paralysis of the External Tensors of the Cords.

This is a rare disease, but is present in complete paralysis of the superior laryngeal nerve. It is then associated with anæsthesia of the superior portion of the glottis, as well as paresis of the depressors of the epiglottis, and generally of the constrictors of the vestibule of the larynx.

ETIOLOGY.--It may be the result of injury to the external branch of the superior laryngeal in its distribution to the muscles. It may be caused by diphtheria. It is possible that the motor fibres of the superior laryngeal nerve may be alone involved, while the sensitive portion is still normal. Cases of partial paralysis are recorded by Von Ziemssen, Gerhardt, and others.

The SYMPTOMS are such as we should expect in diminished tension of the vocal bands: lowering of the pitch of the voice, with inability to reach the higher notes. There ought to be, therefore, hoarseness. Acute paralysis of this muscle has been known to produce aphonia (Ramon).

DIAGNOSIS.--It is said that this form of paralysis gives rise to a well-recognized condition which may be seen in the laryngeal mirror. The cords are described as wavy, irregular in their relation to each other, like the position of two pieces of ribbon, which, having an attachment at their extremities near to each other, are allowed to fall into folds. This condition, if ever present, is, I am convinced, very rare. It is probable that the descriptions have been given to correspond with what ought to be seen, rather than what is actually seen, in the mirror. There is said to be a slight depression of the vocal processes in the act of inspiration, and a corresponding elevation of them in the act of expiration and phonation. The diminished tension should produce this change in position. The disease may also be recognized by placing the finger upon the edge of the crico-thyroid muscle during the effort to speak. The muscle acts so strongly in the healthy condition that it may be easily felt; in paralysis this contraction is wanting.

The course and duration of the disease must depend upon the cause and complications. When the muscles suffer in common with the sensory apparatus supplied by the superior laryngeal nerve, as in the case of diphtheria, there is reason to expect that it will disappear with the other morbid phenomena.

Paralysis of the Posterior Crico-Arytenoids.

The functions of these muscles render any loss of their power as glottis-openers a matter of importance. It will be remembered that they are so situated that they not only rotate the arytenoids, turning the vocal processes away from each other, but they also serve to fix the cartilages, giving them a firm support as points of attachment for the vocal cords. The outer fibres tend also to draw the body of the arytenoids away from each other, as well as to fix them in a postero-lateral position. They are, more than any other of the muscles of the larynx, organs of respiration. They are also in constant action: with each inspiration they contract, and during expiration they {87} fall into rest. In this respect they resemble the other muscles of respiration and the central organ of the circulation. In some respects they also resemble the muscles of the heart in the degenerative changes to which they are subject. Their antagonists are the lateral crico-arytenoids. When both sets of muscles are paralyzed, the glottis is in what is known as the cadaveric condition; that is, the vocal cords are neither widely separated nor parallel to each other. There is an opening of a triangular shape as in the act of easy inspiration, not sufficiently approximated to admit of speech, but sufficiently open to admit of free inspiration. With this understanding of the physiology of the parts, we can readily appreciate the results of the loss of power of these muscles. As stated by Bosworth, the especial danger is in the integrity of the adductors, tending for the want of antagonism to keep the glottis closed. Of all the muscles of the larynx, these are therefore the most important so far as life is concerned.

The disease is progressive (Lefferts, Semon, Bosworth).

The first symptom which attracts attention is generally inspiratory dyspnoea while taking active exercise. The difficulty continues to increase till there is constant difficulty in the act of inspiration, usually with spasm. The dyspnoea is more marked during sleep than when awake. Death may occur at this period of the disease before the gravity of the trouble has been recognized. As a rule, tracheotomy will be required to prolong life, after which the dangers to the patient are passed.

The ETIOLOGY of this form of paralysis presents some peculiar problems. In all paralyses of the individual muscles we are obliged to invoke nerve-changes in special nerve-cells in the centres from which the individual nerves have their origin--changes along the course of the nerves; or, on the other hand, some myopathic change in the muscles themselves. In the muscles now under consideration we have a special function--namely, respiration--involved. The disorder is usually limited to these muscles alone. If it becomes general, it commences here. The phonators not being involved, it is probable that in a part of the cases reported the essential cause of the paralysis must be ascribed to disease in a centre in the brain, or at least along the course of the nerve near its origin. Other cases are evidently due to pressure on the pneumogastrics or recurrents. This view has been proposed by Bosworth. Von Ziemssen and others have thought that syphilis enters very largely into the pathology of this group of cases. There has been noted, as confirmatory of this proposition, that other symptoms of central disease have been in a few instances observed. Diseases affecting the recurrents have been known to affect these muscles alone: Ingals reports cases. On the other hand, it is quite certain that in a large majority of the cases recorded there has been no satisfactory cause assigned. In nearly all of the post-mortems there has been found a degeneration of the muscles. This is as we should expect to find it where the structures have been for a considerable time in a state of inaction. The histological change may possibly be in any case only the result of the paralysis, and not the cause of it. In a few instances there has been discovered a degeneration of the nerve-trunks by which the parts are supplied. As to the causes by which the muscles may become affected, we can imagine that the exposed position suggested by Mackenzie renders them peculiarly liable to mechanical injuries from hard substances forced down the oesophagus. They are subjected to changes of temperature produced by hot and cold drinks and food. Their relation to the seat of local inflammation of a specific as well as of a non-specific character renders them liable to become involved in morbid processes. The fact that the disease occasionally occurs after diphtheria, as I have in two instances demonstrated, gives additional weight to this hypothesis. The fact probably is that there are several varieties of the affection. The want of more accurate information as to the {88} previous history, as well as to the immediate antecedents of the attack, renders it impossible as yet to differentiate the cases due to one or other of these causes. For the present, then, we may conclude that paralysis of these muscles may depend upon either disease of the centres, disease along the track of the nerves, pneumogastric or recurrent, or to disease of the peripheral branches or fibrils, or to disease of the muscles themselves.

SYMPTOMS.--These are at first so slight that the trouble is usually not recognized till it has reached such a stage that the act of inspiration is either attended with fatigue or there is stridor which annoys the patient or alarms his friends. Soon afterward there begins to be a dyspnoea, a difficulty in breathing, especially during any active exertion and during sleep. The voice in the mean time remains normal. Expiration is free. The general health is usually undisturbed. There may be a catarrhal affection of the mucous surfaces, but if so it is quite accidental. Spasm supervenes. There is at times great difficulty of breathing, and, finally, the effort becomes so great that the patient becomes alarmed. Upon examination with the laryngoscope the vocal cords are seen in close proximity to each other even during the inspiratory effort. In fact, they are, by the pressure of the air upon their upper surfaces, brought closer together during inspiration than during expiration. They seem to act as valves which are closed by the weight of the atmosphere upon their wide, flat upper surfaces, pressing them against each other. Hence the inspiratory stridor and dyspnoea. The act of expiration is a passive one in health, and in this condition the air is easily forced out by pressing the cords away. The order of the movements of the cords is therefore changed--in the normal condition wide in inspiration, narrow in expiration; in this disease narrow in inspiration, and while not wide, at least wider, in expiration than in inspiration. In other respects the parts are normal. There is nothing to suggest the trouble except the closure of the glottis during inspiration.

The course and duration of the disease are in a large majority of cases chronic. Once established, it tends to persist. The cases of diphtheritic origin should be excepted from this statement. In those forms in which the trouble is entirely in the muscles of the part life may, so far as we know, be continued indefinitely. Where the trouble is central it is probable that the cause has a tendency to involve other parts of the brain, and in this way to lead to other, and possibly dangerous, complications. Of this, however, we know but little. The paralysis is not directly the cause of death, except as it closes the glottis. The dangers are therefore mechanical. When the patient has once been placed in a condition of safety by the operation of tracheotomy the local paralysis no longer endangers life.

Mackenzie, Von Ziemssen, Cohen, and in fact almost all writers upon the diseases of the larynx cite and publish cases by the way of illustration of the symptoms, course, and termination of this class of troubles. They are now so numerous that it would seem to be hardly necessary to do more than to give the conclusions which the recorded instances suggest. Fortunately, this form of laryngeal disease is rare, and when present it is easily recognized. The treatment is clearly indicated. In all cases in which the inspiratory difficulty is marked tracheotomy should be performed, even though suffocation does not seem to be imminent. The treatment for the radical cure of the disease must be in the main the same as that required in other forms of laryngeal paralysis.

TREATMENT OF PARALYSIS OF THE LARYNX.--The grouping of these disorders for the purpose of description has, for the reasons already given, been based largely upon symptoms. For the purpose of treatment we may properly divide them with reference to their causes. With these in view, we have, first, those cases in which the cause of the affection is within the {89} cranium--central disease; second, those in which the loss of power is the result of disease or pressure along the course of the nerves outside the cranium and before reaching the larynx; third, those in which there is disease of the structure of the larynx itself, nerves or muscles; fourth, those in which the cause is to be found in some distant part--reflex paralysis; fifth, those of toxic origin. This last includes paralysis after typhoid fever, diphtheria, etc., as well as those produced by lead, arsenic, mercury, and possibly copper and other toxic agents.

Diseases of the base of the brain or medulla are for the most part not amenable to treatment. They are generally organic and progressive. The exception to this statement, or at least the most notable exception, is syphilis. The influence of this disorder in the production of paralysis of central origin must be admitted, but it seems to have been by many authorities overstated. The coincidence of paralysis with an earlier infection does not by any means justify the inference that the one disease has been produced by the other. When, however, there is reason to think that this relation may exist, antisyphilitics should be administered. In a few cases this treatment has been followed by marked improvement of the laryngeal disease.