DYSPNŒA LARYNGEA. ROARING. HEMIPLEGIA LARYNGEA.
Generic name for common symptom. Low and high notes. Grunter, roarer, whistler, piper, highblower. Pace or effort develops. Causes: of temporary roaring, inflammations, abscess, phlebitis, choking, dropsy, petechial fever, phlegmons along vagus. Causes of inveterate roaring, paresis of left recurrent laryngeal nerve, fatty degeneration of left arytenoid muscles, fracture of facial bones, polypi in air passages, chronic thickening of mucosa, foreign bodies in passages, tumors of lymph glands, abscess of guttural pouches, pseudo membrane, laryngeal ulceration, ossification, distortion, fracture of cartilages, action of forcible inspiration, leading on left side, deep origin of recurrent nerve, effect of chest diseases and violent heart action, examples of morbid conditions impairing innervation. Lesions in muscles, and nerves. Facial palsy, poison (chick vetch, winter vetch, lead, fungi, moulds). Intermittent roaring. Hereditary roaring. Symptoms, grunting when coughed or threatened, heavy draft, gallop, noise, laryngeal tremor, cold as a complication, roaring with expiration, lesions. Treatment, its use. Prevention, avoid breeding roarers, bearing reins, chick vetch, lead. Tonic medication, caustic to mucosa, firing, setons, iodine, pad nostrils, tracheotomy, arytenectomy, electricity.
This is the name of a symptom rather than a disease. It implies a sound made in breathing in connection with some contraction of the air passages. The term is however usually reserved for those conditions in which the sound results, from chronic disease or malformation, the noise attendant on laryngitis and other acute diseases being rarely spoken of as roaring. In neither case does the noise indicate more than that there is some impediment to the ingress and egress of air through larynx or trachea.
The pitch of the note varies exceedingly with the causes that produce it and with the hurried nature of the breathing. There have thus arisen the epithets of grunter, roarer, whistler, highblower, piper, trumpeter, wheezer, etc. The most common distinctions are those of roaring and whistling. The roarer produces a loud deep basso sound in inspiration, the larynx or windpipe being only slightly narrowed while the whistler or piper produces a shrill blowing or sibilant noise because of the greater constriction of the passage. The term grunter is derived from the facts that a roarer usually makes a grunting noise when struck or threatened with a cane, and that when the upper cartilages of the windpipe are pinched between the finger and the thumb the resulting cough is prolonged and somewhat like a grunt. A wheezer is usually suffering from spasmodic contraction of the bronchial tubes, from broken wind or from chronic bronchitis. A highblower should never be spoken of in the same connection, as the noise is made from a playful flapping of the false nostrils or soft palate and disappears when the animal is put to the top of his speed. It is from confounding high-blowing with roaring that Eclipse and other brilliant performers on the English turf have been erroneously pronounced roarers.
The noise produced by the roarer is not heard while he stands quiet, nor many cases even during a short trot or gallop. Such horses are in consequence often sold at the hammer and the purchaser is grievously disappointed to find that what he thought a sound horse is absolutely useless for the purpose for which he designed it.
Causes. Before noticing the symptoms of roaring a consideration of the causes will be useful to enable the reader the better to understand the signs by which the different forms are manifested.
Causes of temporary roaring. Whatever impedes the current of air causes roaring. Hence inflammatory diseases of the nose, throat, windpipe or bronchial tubes; abscess of one or the other of these parts; inflammation of a jugular vein and pressure on the trachea or vagus nerve by the resulting swelling; choking; the swelling in the neck consequent on the cutting open of the gullet for the relief of choking; thickening of the nostrils from dropsy, loss of a jugular vein, purpura hemorrhagica etc.; and swellings pressing on the vagus nerve, and which may be situated at the base of the brain, in the neck or in the anterior part of the chest. Also temporary infiltration of the laryngeal mucosa.
Causes of inveterate roaring. The one great cause of roaring and that which sustains the disease in nineteen cases out of every twenty is paralysis of the left recurrent nerve of the larynx and wasting of several of the arytenoid muscles on that side. It may be well, however, first to notice the less frequent causes and wind up with this more common one. 1st, Fracture with distortion of the nasal bones and narrowing of the nasal passages (Gamgee). 2nd, Polypi and other tumors of the nose, pharynx, larynx, windpipe or bronchi. 3rd, Chronic thickening of the nasal mucous membrane, the result of inflammation. 4th, The presence of foreign bodies in the nose, as for example balls coughed up from the pharynx. 5th, Hering records a case resulting from the closure of the posterior opening of one nasal chamber by a membrane. 6th, Cancerous or melanotic deposits in the lymphatic glands above and to each side of the pharynx and larynx. 7th, Distension of the guttural pouches by inspissated pus. 8th, Chronic thickening of the mucous membrane of the larynx consequent on inflammation. 9th, The formation of a projecting fold of the mucous membrane or of a new production (false membrane) in the windpipe as the result of inflammation. Such false membranes have been known to become detached at their median part and remain attached at their two extremities thus constituting a band stretching from one side of the windpipe to the other. 10th, Ulceration of the membrane of the larynx particularly on the projecting folds circumscribing the glottis, 11th, Ossification of the laryngeal cartilages and loss of their elasticity. 12th, Distortion of the cartilages of the larynx, most commonly from unduly tight reining and pulling the nose in toward the chest. In such cases the cartilages of the larynx and those of the windpipe adjoining being compressed slide within each other, and the enclosed edge projecting within the air tube materially diminishes its calibre. 13th, Fracture of one or more rings of the trachea. This usually results from blows, as in running the neck against the back of a cart or wagon. The cartilaginous rings are usually broken at their median part in front and being retained together by the investing elastic tissue which enables the pieces to move on each other as by a hinge, and being approximated by the contraction of the trachealis muscle above, the ring is flattened from side to side and the channel for the passage of air correspondingly decreased. This flattening can be easily felt by the hand in the living horse. 14th, A peculiar congenital distortion of the trachea caused by the curling in of one end of each cartilage of the windpipe and the straightening out of the other. This occasionally proceeds so far that the gullet is lodged in the interspace overlapped and hidden by the free ends of the cartilages, the diameter of the windpipe being proportionately diminished. Distortions and fractures are usually overlooked by veterinarians but from the frequency with which the author has met with them in his dissection he is convinced that they deserve greater attention than has been awarded them. 15th, Percivall records a case of inveterate roaring in which, even tracheotomy having failed to cure, the patient was destroyed and the lungs found to be extensively consolidated, many of the air tubes having been so compressed as to be almost impervious. I have known a case of roaring from the presence of a pedunculated tumor in the lower end of the windpipe where it divides to enter the lungs, and the same result may ensue from the partial obstruction of the bronchial tubes by masses of tenacious mucus in chronic bronchitis.
16th. The immediate cause of roaring in the immense majority of cases is the paralysis and fatty degeneration of certain muscles on the left side of the larynx. The muscles supplied with motive power by the left recurrent laryngeal nerve (Crico-arytenoideus posticus, Crico-arytenoideus lateralis, thyro-arytenoideus, and the left half of the arytenoideus) are those constantly and exclusively affected, while those supplied by the superior laryngeal nerve (Crico-thyroideus, hyo-thyroideus and hyo-epiglottideus) remain unchanged. The left recurrent nerve is also wasted and considerably attenuated as compared with that on the opposite side. The modus operandi of this paralysis and wasting in the production of roaring is beautifully seen when the upper part of the windpipe is laid open so as to expose the interior of the larynx in laryngectomy. The triangular opening of the glottis is seen fairly dilated while the muscles are relaxed in the act of expiration. As soon, however, as inspiration commences the left arytenoid cartilage slides completely into the passage, its lower border projecting so much to the right that it forms a prominent crest extending beyond the median line and in some cases closely approaching the right wall of the larynx, the superior elastic and free border of the same cartilage meanwhile gets drawn inward by the suction power of the air so as to block up the passage still more. The closure of the glottis being thus seen to be largely controlled by the current of inspired air, it becomes evident that any increase in the force of the current will aggravate it and a decrease will lessen the extent of the closing and alleviate the distress of breathing. This fact furnishes a means of palliating the symptoms. (See treatment.) It explains moreover why roaring should not be heard in quiet breathing and why it should increase in force and in pitch as the respiration becomes more and more hurried. It further accounts for the noise being heard only during the act of inspiration, the outward rush of the air in the expiratory act being of itself sufficient to carry this valvular cartilage out of the passage and secure a free and unimpeded current.
The paralysis and wasting of the left recurrent nerve and muscles are in their turn due to very varied morbid states.
It may commence in the larynx from distortion of its cartilages and inflammation of the mucosa, in which case the wasting of the nerve is probably a result of its prolonged inactivity. This mode of origin is strongly insisted on by Percivall, and no doubt occasionally arises. Under this explanation, however, it is difficult satisfactorily to account for its almost invariable occurrence on the left side. The mere fact that the horse is habitually approached on this side and more commonly turned toward it is a most insufficient reason.
Even if admitted it utterly fails to explain the immunity of the muscles supplied by the superior laryngeal nerve.
The fact that a horse has usually a hard and soft side of the mouth and carries the head slightly to the latter is no better explanation, as the tender side is not always the left.
More commonly the disease arises at some other point near the origin or in the course of the nerve, and the changes in the larynx follow as the consequence of deficiency or entire absence of motor innervation. Many cases can be cited in which such an origin was unquestionable, and on the hypothesis that this is the true and constant history of the development of the malady, its regular occurrence in the left side, and the absence of all signs of wasting in the muscles supplied by the superior laryngeal nerve are alike perfectly explainable.
Let it be noted that the vagus nerves (right and left) of which the recurrent laryngeal are branches, originate from the base of the brain, pass down the neck beneath the jugular vein in company with the carotid artery; that on entering the chest the right vagus nerve gives off its recurrent branch which proceeds at once up the neck along the course of its parent trunk till it reaches the larynx, to the muscles on the right side of which it is distributed; that the left vagus nerve on the other hand proceeds backward in company with the left innominate artery as far as the base of the heart, where on about the level of the space between the sixth and seventh ribs it gives off the left recurrent nerve; that this left recurrent nerve closely applied at its point of origin to the great parent arteries turns round the posterior aorta enclosing it in a loop, and gaining the lower end of the windpipe follows its course to the larynx. It will thus be understood how many chest diseases may implicate the left recurrent nerve, and from which the right, which extends no deeper than between the two first ribs, may be completely exempt. The frequent supervention of roaring as a sequel of chest diseases receives in this an ample explanation. Its connection with pleurisy becomes especially probable, as the nerve lies in contact with the surface of the pleura alike in its descending and ascending course within the chest.
Finally the loop encircling the posterior aorta exposes the nerve to constant stretching and shocks from the heart’s action during violent exertions and in excited states of the circulation generally. Vaerst and Sussdorf show that the nerve is habitually flattened between the posterior aorta and trachea, the effect being worst when the heart’s action is excited.
It remains to notice a few instances in which dissection established the connection of interference with the nerve at some part of its course and the existence of roaring.
(a.) Godine found in a roarer a tumor about the size of a chicken’s egg, pressing on the commencement of the pulmonary artery. He attributed the roaring to the impaired circulation of blood in the lungs by the pressure on the artery. Considering that the tumor must have been precisely in the situation of the left recurrent nerve at its point of origin, it becomes much more probable that the symptom resulted from pressure on this nerve.
(b.) The elder Bouley found in one case a considerable engorgement of the group of lymphatic glands in the anterior part of the chest and through the centre of which the left recurrent nerve passed.
(c.) Fergusson of Dublin dissected a roarer in which he found besides some tumors of the lymphatic glands in the pelvic and sublumbar regions, an indurated and enlarged gland about four inches behind the anterior opening of the thorax. The recurrent nerve between this and the larnyx was wasted so that its fibres could scarcely be recognized, the laryngeal muscles on that side were atrophied, and degenerated, and the glottis distorted and partly closed. Fergusson has in his description made the mistake of writing the right for the left; it is evident that the right recurrent nerve could not possibly pass through a tumor in the situation described.
(d.) Gamgee furnishes a drawing of an immense tumor filling up the anterior part of the chest, pressing on the vagi and recurrent nerves and causing roaring.
(e.) The Clinique of the Alfort Veterinary School furnishes the following among other cases of roaring consequent on inflammation of the jugular vein. A well-bred and very fast English thoroughbred had been used for two years by his owner who was a hard rider. In June, 1857, he was bled as a preventive (saignée de precaution), suppurative phlebitis was induced and was only cured at the end of six weeks. When again put to work he proved a roarer and was still affected when seen six months later.
In connection with this it may be noted that the swelling in connection with the inflammation of the vein extends easily to the subjacent vagus and recurrent nerves, leading to their inflammation, functional inactivity and atrophy. Bleeding is usually done on the left side of the neck so that the paralysis and wasting would still be on the same side. Happily with a more humane system of treatment, accidents of this kind are less frequent than formerly. Glöckner furnishes a case which followed thrombosis of the carotid.
(f) Reynal reports several cases in which roaring had occurred as a sequel of inflammations and abscess about the throat, and in which infiltrations or gray or yellow indurations had taken place in the areolar tissue around the vagus nerve. As nothing is more common than to find roaring resulting from severe sore throat, parotitis, etc., this may explain its occurrence.
Mandl first carefully examined the paralyzed muscles which present to the naked eye a flattened and wasted appearance in marked contrast to the full well-rounded forms or those on the opposite side. They differ no less in color. In place of the deep red of the healthy muscles those on the diseased side are of a yellowish white hue with here and there a pink streak indicating the position of some unchanged muscular fibre. When placed under the microscope the healthy elements of the muscular fibres (sarcous elements) are seen to be replaced by granules of fat. The nerve (recurrent) is not only visibly wasted but its internal white substance (white substance of Schwann) can no longer be recognized and it approximates closely in character to a filament of ordinary white fibrous tissue.
17th. Muscular paralysis due to other causes and even located in different parts has been known to give rise to roaring.
Goubaux and others have noted the occurrence of roaring from paralysis of one nostril, alike when the loss of power was special to the nasal muscles or common to all on one side of the face.
Roaring apparently from paralysis of the laryngeal muscles has been seen frequently in animals fed on the seeds of leguminous plants and specially of the Lathyrus Cicera (Lathyrus Sativus Stendel). The whole family of the Leguminosæ is open to suspicion as occasionally containing a poisonous principle capable of inducing paralysis in animals fed on them. The Lathyrus Sativus induces paralysis in man and the domestic animals in some parts of India (Sleeman, Irving). The common cultivated tare (Vicia Sativa) is well known to induce general paralysis, commencing with the hind extremities, when fed to horses at the period of ripening in Great Britain. In France the chick vetch (Lathyrus Cicera or Sativa) has been repeatedly noticed to lead to the development of roaring apparently from paralysis of the laryngeal muscles. Horses fed on 17 lbs, daily (straw and seeds) were attacked with roaring in five days. They gained in flesh and vigor, had a smooth shining coat and supple skin, and standing at rest presented nothing amiss, but after ten minutes trot they were seized with roaring and if not stopped they soon fell to the ground, with symptoms of impending suffocation, (Delafond). Horses fed heavily on the winter vetch with cut hay and molasses were attacked with roaring if gently exercised for one or two minutes. It came on suddenly and threatened instant suffocation. One horse fell and lay half an hour in a frightful state of dyspnœa. More commonly they recovered after a few minutes rest. In the intervals no disturbance of breathing nor any change of appetite attested the slightest deviation from health. Reynal, Cruzel, Caffin, Motte and Ayrault mention similar occurrences.
The paralysis of chronic lead poisoning will also cause roaring.
Occasional or intermittent roaring. Puzzling cases are met with in which a horse will roar at one time and not at another. In such cases the veterinary profession has incurred an amount of odium which was by no means deserved. Two veterinarians, equally respectable and talented, appearing in a Court of Justice to swear to the same animal which they had examined on different days, respectively pronounce it a roarer or a sound horse, as it happened to be at the time of the respective examinations. Such cases have been differently accounted for.
Slight colds or sore throats may cause roaring so long as they persist. Tight reining with the nose drawn in toward the chest induces a stridor in certain animals by distorting the larynx and trachea. Some horses with thick necks, badly set on heads, and in a state of obesity, roar, yet the symptom subsides when the superfluous fat is got rid of and they are brought into hard working condition. Stallions are very liable to make a noise from this cause. In a case of roaring which disappeared when the horse had been exercised for some time Leblanc diagnosed an œdema of the glottis which was absorbed under the increased movement of the parts. He did not test his opinion by dissection.
Roaring sometimes hereditary. That roaring runs in families there can be no doubt, but the direct cause appears to be mostly the transmission of a faulty conformation. A head with faulty shape and badly set on; a thick, short neck, deficient in mobility, or a small, narrow chest, predisposed to acute diseases, descends from parents to offspring, entailing a predisposition to roaring. The large Normandy horse is notoriously subject to roaring, but then he is equally characterized by a big, coarse head, narrow forehead and nostrils, big jowl, and narrow intermaxillary space. In all breeds this form is very subject to roaring, because of the stiffness of the neck and tendency to compression of the larynx. With the head badly set on, as it is almost of necessity in these animals, everything is done to produce roaring. Not only is the head cruelly reined in at work, but the horse is kept a great part of his time in the stable in the same or even in a worse condition, the larynx meanwhile unnaturally compressed between his narrow jaws and the nerve compressed or the larynx distorted.
It must be added, however, that like some other acquired distortions or alterations roaring may repeat itself in the progeny. Goodwin mentions an instance of it on the female side through three successive generations of thoroughbreds. Of transmission on the side of the male the following instance is noteworthy: M. Liphaert, an extensive proprietor in Livonia, bought a first-class English thoroughbred stallion. His progeny were healthy until he became a roarer at ten years old. All his foals, got after this date, followed the sire in becoming roarers, and, it is important to observe, almost all at the age of ten years.
Symptoms. These, of course, are manifest enough while the animal is sufficiently excited to give rise to the noise. Certain indications may be obtained even while the animal stands in the stable. If cough is excited by pinching the upper rings of the windpipe it is prolonged into a groan. If suddenly threatened with a cane the abrupt inspiration which results is attended by a grunt. The absence of these symptoms is not, however, sufficient to establish the nonexistence of roaring. The horse must be galloped or put to heavy draught to fully test the breathing organs. Galloping up a steep hill is perhaps the best test. A gallop over a recently ploughed field is about equally good. Soft pasture land or an unpaved road is preferable to Macadam or pavement. Galloping in a riding school on the soft tan is an excellent measure as the sound is confined and the animal is always within earshot of the examiner. The person examining should either ride the horse himself or have a disinterested party, in no way connected with either buyer or seller, to mount him. If the rider is in the interest of the seller he may contrive to slacken the pace before he reaches the examiner, or by irritating the horse may make it difficult to approach him immediately on his being pulled up. If in the interest of the buyer he may succeed, by the use of a powerful bit, in drawing the horse’s nose in to the chest, or by compressing the larynx with a tight throat latch he may produce noise in breathing when the animal is suddenly brought to a stand. Unless the course is up a steep hill or over a ploughed field the horse should be galloped for from five to ten minutes; he should be then made to pass close to the examiner at full speed, and finally brought up suddenly by his side and without any previous slacking of his pace. The ear should be at once placed close to the nostrils, when the slightest abnormal sound accompanying the inspiratory act will be at once recognized.
Draught horses are sufficiently tested by driving them in a heavy vehicle or one with the wheels dragged. By walking alongside or keeping the ear near to the nostrils any harsh sound additional to the normal blowing noise of hurried breathing is easily noted.
The finger placed on the larynx detects the strong vibratory tremor, and Friedberger notes that the left arytenoid is much more easily displaced than the right, increasing the stridor.
If the horse is, at the time of examination, the subject of a cold, sore throat, or other acute disease of the air passages no importance is to be attached to any noise made in breathing, but he cannot be pronounced a sound horse until, this malady having passed off, it is found on careful examination that no such sequel has been left.
Among the most puzzling cases are those in which the roaring occurs with periods of intermission. If the horse has been fed for a short time on vetches this may account for its temporary access, and unless the same feeding is again allowed a recurrence is not to be looked for. If due to the occasional displacement of a pedunculated tumor of the nose or pharynx and its interference with the action of the larynx its existence may be recognized by careful examination, diminished current of air through one nostril, etc. But there remain some rare cases in which there are no such appreciable causes, and yet the horse would be pronounced sound or unsound as examined at certain intervals. On this subject more information is desirable.
The following varieties of roaring will be distinguished from that of paralysis by the occurrence of the sound in both acts of breathing (expiration and inspiration):—distortions, tumors or foreign bodies in the nose:—tumors about the throat, in the windpipe or bronchi:—distortion of the windpipe, from tight reining, fracture or congenital deformity:—and the presence of a false membrane stretching across the windpipe.
Examination by manipulation, auscultation and percussion along the whole length of the air passages alike during rest and after exercise, may enable one in unusual cases to recognize the structural changes that give rise to roaring.
Treatment. This has long been considered as hopeless, yet preservative and palliative measures are usually accessible, whilst even cures can be effected in certain conditions.
Preventive treatment. First may be noticed the rejection for breeding purposes of all animals possessing those conformations of head, neck and chest already referred to as conducing to disease of the air passages or distortion of the larynx or windpipe. Equally ought all roarers to be set aside unless the exciting cause is accidental such as fractures of the nasal bones, of the trachea, the existence of polypi, etc. Stallions that make a harsh noise in breathing from an accumulation of fat about the throat are not necessarily objectionable.
The employment of the bearing rein so as to compress and distort the larynx is to be avoided. If bearing reins are used in horses having short thick necks and badly set on heads and especially with intermaxillary narrowness they should be passed through rings in the cheek piece of the bridle or between the ears and over the forehead (overdraw check) so that while the head is elevated the nose may be projected forward after the Russian fashion of equitation. This measure has indeed appeared to cure several cases of roaring. I have met with fewer roarers in the same number of horses in America than in England, and this I attribute to the better mode of using the bearing rein on this side of the Atlantic.
The Chick Vetch (Lathyrus Cicera) should be excluded from the fodder of horses or used in small proportion only. In man it is found to be injurious when it forms a twelfth part of the bread used and gives rise to paralysis if it amounts to a third (Aitken).
Palliative and Curative treatment. Medicinal treatment will prove useless in the great majority of cases: as for example in paralysis and degeneration of the muscles, in ossifications, fractures, or distortions of the cartilages, etc., etc. Nevertheless where there is merely thickening of the membrane of the larynx alterative and tonic treatment may be successful especially if associated with iodine ointment or active blisters applied to the throat. A case is reported by Dupuy in which a course of arsenic cured. In these cases as well as in those due to ulceration of the membrane the application of caustic by means of a staff and sponge as advised in laryngitis may prove beneficial. In some cases of this kind the application of the firing iron to the region of the larynx has an excellent effect. Setons have proved useful in some cases.
In cases due to tumors or enlarged glands pressing on the air passages the internal use of iodine and other alteratives and diuretics, and the local applications of iodine, or mercurial ointments or of blisters have been successful. Failing in this the tumors may be removed with the knife when accessible.
If by auscultation the existence and position of a band of lymph can be made out, tracheotomy may be performed and the band excised. Percivall with reason doubts the possibility of the diagnosis.
In cases due to distortion of the larynx from tight reining the bearing reins should be dispensed with or rearranged so as to encourage protrusion of the nose, and the horse should be bitted to the side chains or straps in the stall several hours daily so that the head shall be elevated and the nose protruded.
When roaring depends on paralysis of the laryngeal muscles, a mode of palliation may be adopted as practised by the London omnibus and cab men. A strap is fixed round the nose supported by a strap passing down the middle of the face and the cheek piece of the bridle on each side and buckled beneath the chin. On the inner side of this strap where it passes over the false nostrils is attached on each side a semiovoid pad which presses on the flap of the nostril and regulates the entrance of air. The principle on which it acts will be understood when we consider that the paralyzed cartilage is drawn into the passage by the rush of air and that the closure of the channel is more complete and the roaring more marked in proportion to the force of the current. The pads by lessening and regulating the rush of air into the lungs thus leave the passage in reality more open and largely obviate the difficulty of breathing and the noise.
In extreme cases with the structural lesion in the head, throat, or upper two-thirds of the neck relief may be secured by tracheotomy.
A more radical operation is that introduced by Günther for the excision of the left arytenoid cartilage. As improved by Möller and others this consists in an incision through the cricoid cartilage and crico-thyroid membrane (or even the first rings of the trachea) and the complete extirpation of the left arytenoid cartilage and left vocal cord. The manipulations belong to surgery. The result is satisfactory in removing the violent dyspnœa in hurried breathing and in very favorable cases in obviating noise altogether. More commonly some stridor remains but not enough to interfere with pace or with heavy draft. From my personal experience in performing the operation, I would recommend it in all cases in which the obstruction is so great as to interfere with the use of the horse on the track, or road, or for heavy draught. But in slight cases, in which the disease causes little or no inconvenience beside the noise, I would advise some less radical measure.
Another obvious line of treatment is by the use of electricity locally and of strychnine internally. A weak current kept up for fifteen minutes may be sent from the positive pole in the left jugular furrow to the negative pole over the left side of the larnyx. Strychnia in the dose of two grains may be given daily in the food or in half that amount hypodermically over the left side of the larnyx. This would be useful only in the early stages with little or no fatty degeneration of the muscles.