NEUROSES OF THE LARYNX.
BY HOSMER A. JOHNSON, M.D., LL.D.
DEFINITION.—Disorders of sensation or motion, or of both sensation and motion, due to disease, first, of the centres from which the nerves of the organ are derived; second, to disease along the track of the nerves; third, to disease in the terminal distribution of the nerves; fourth, to reflected irritation from neighboring or distant parts; and fifth, to myopathic change. This last condition is not necessarily a neurosis; it is nevertheless a cause of modification of the function of the parts to which the nerves are distributed, often a result of paresis or paralysis, and therefore inseparably associated with the neuroses of the organ. Disorders of innervation, depending upon structural disease of the larynx, such as ulceration or tumor, are not included in this definition.
ANATOMICO-PHYSIOLOGICAL CONSIDERATIONS.—The framework of the larynx consists of cartilages securely but rather loosely articulated with each other. The movements of these cartilages produce changes in the position and tension of the soft parts. The thyro-cricoid articulation allows ginglymoid and sliding motion; the aryteno-cricoid, rotatory and sliding motion; the hyo-thyroid, ginglymoid motion. The physiology of the muscles of the larynx is quite complex, since nearly all have fibres taking a number of different directions, and the changes in the form and positions of the parts depend upon the combined action of different muscles and parts of muscles which may be individually brought into action to produce the required results. The muscles may, however, be roughly divided into groups: 1. Constrictors of the superior strait; 2. Dilators of the superior strait; 3. Adductors of the vocal cords; 4. Tensors of the vocal cords, external, internal; 5. Relaxers of the vocal cords; 6. Abductors of the vocal cords.
The superior strait of the larynx is closed by the action of the oblique portions of the arytenoideus, acting in conjunction with the ary-epiglottici, into which some of its fibres are continued, thus drawing the cartilages of Santorini downward and inward and approximating the ary-epiglottic folds and depressing the epiglottis; while the thyro-epiglottici complete the closure by further depressing the epiglottis. Fibres of the latter muscle, acting alone, may dilate the superior strait by drawing apart the ary-epiglottic folds.
The transverse portion of the arytenoideus and the superior fibres of the crico-arytenoidei postici approximate the arytenoid cartilages. The crico-arytenoidei laterales, and also in a slight degree the external fibres of the thyro-arytenoidei, rotate these cartilages, turning their vocal processes inward: the action of the latter two muscles as adductors is imperfect unless the arytenoids are drawn backward and fixed by the arytenoidei postici.
The tensor group comprises a number both of the extrinsic and intrinsic muscles of the larynx. The crico-arytenoidei postici draw the arytenoids back, external rotation, and consequent abduction, being prevented by other muscles. The anterior fibres of the crico-thyroid and those fibres of the sterno-thyroid inserted anterior to the crico-thyroid articulation approximate the cricoid and thyroid cartilages, and thus tighten the vocal bands. The posterior fibres of the crico-thyroid slide the thyroid upon the cricoid, lengthening the antero-posterior diameter of the larynx. This muscle, acting as a whole, also compresses the alæ of the thyroid with the same effect. The constrictors of the pharynx have a similar function. The hyo-thyroidei, acting in conjunction with the elevators of the hyoid bone, draw the thyroid forward and tilt it downward upon the cricoid. The form and internal tension of the vocal bands are greatly influenced by the thyro-arytenoidei, especially their inner fibres, while the ascending fibres of the muscle draw the inferior portions of the vocal bands upward and prevent the sagging of their edges. This muscle, acting alone, has been thought to cause extreme relaxation of the vocal bands. Modern research renders this statement of relaxation doubtful. The contraction of those fibres of the sterno-thyroidei inserted posteriorly to the crico-thyroid articulation tilts the thyroid upward, and thus relaxes the tension of the bands.
The crico-arytenoidei postici rotate the arytenoid cartilages outward, separating the vocal processes, and, acting in conjunction with the posterior fibres of the crico-arytenoidei laterales, draw the cartilages outward and downward.
In the cadaveric condition, which is one of relaxation of all the laryngeal muscles, the glottis is neither closed nor widely open; the epiglottis is erect against the dorsum of the tongue; the arytenoid cartilages are slightly separated, so that the glottic opening is a triangle with the base posteriorly, as in the act of inspiration, but the separation is much less than in the act of breathing. This condition is met with in paralysis affecting all the muscles of the organ.
The nerves of the larynx are derived from the pneumogastrics. The superior laryngeal is mainly a nerve of sensation for the parts above the edges of the vocal bands. There are some notable exceptions to this statement: a branch, external, descends to the crico-thyroid muscles and is motor in its function. Filaments from the superior laryngeal endowed with motor functions are also distributed to the folds extending from the arytenoids to the epiglottis; these are the ary-epiglottidean bands, and are concerned in the movements of the epiglottis. It is probable that the arytenoids are also in part supplied by the superior laryngeal; in other words, that both the superior and inferior laryngeal nerves are mixed, branches from the spinal accessory, as well as from the pneumogastric proper, entering to each of these nerves. Beclard1 states that the one, the spinal accessory, is a nerve of phonation; the other, the pneumogastric, is a nerve of respiration. The sensations of the mucous surfaces below the glottis depend upon filaments from the pneumogastrics returned along with the motor fibres from the spinal accessory. The two orders of fibres go to make up the recurrents. The relations of the recurrents themselves to the large vessels, as well as to the bronchial glands, are of importance. At the point of their origin they are in close relation with the aorta and right subclavian; they are also in close relation with the top of the lungs. Disease of these organs and structures, especially of the large blood-vessels, such as aneurism of the aorta or subclavian, disease of the glands, tumors, abscess, traumatism, etc., may modify or completely destroy the functions of the laryngeal nerves. In short, anything or any condition by which pressure may be made upon the pneumogastrics or recurrents may become a cause of nervous disturbance in the larynx. In addition to this general source of innervation, Elsberg2 describes a special centre of sensation for the throat in the medulla oblongata. He also describes three kinds of sensibility in the larynx—tactile, dolorous, and reflex. Rossbach3 details experiments from which he concludes that there are nerve-cells in the mucous membrane of the larynx which preside over the function of secretion. The larynx is endowed with at least two kinds of sensibility: the one tactile—when exalted it becomes painful; the other, reflex sensibility, is double. First, there is as a result of excitement a contraction of the subjacent muscle, and there follows closure of the glottis. This is seen in the application of irritants to the parts, such as solutions of nitrate of silver or other escharotics. There is no cough, but great difficulty of inspiration. Expiration is free and easy. There may follow some degree of pain for several hours. It will be seen that the phenomena are the same as those observed in the irritation of other mucous surfaces. The irritation is immediately translated into motion; this motion is probably reflex, but not necessarily through the centres, such as the brain or cord. The motion is of the subjacent muscles. Second, the mechanical irritation produced by the presence of a drop of water or a morsel of food in the larynx results in violent and explosive cough. The cough persists until the offending drop or body has been removed. This kind of sensibility calls into action distant muscles. There is no spasm of the adductors of the glottis, as in the case of the application of caustics. It is probable that the filaments of the nerves, the irritation of which gives rise to spasm, are distributed more generally than those which preside over reflex action at a distance and produce cough. The one set of functions are designed probably to protect the organ from the intrusion of foreign bodies; the other for their expulsion, as well as for the removal of the secretions of the parts or of matter brought up from below. The hypothesis of a third form of sensibility, as described by Elsberg—namely, the dolorous—seems hardly to be demanded for the larynx more than for all other mucous surfaces subject to pain. The nerve-cells of Rossbach in the mucous membrane may be peculiar to the larynx and trachea, as he claims, but further observations are required for the demonstration of this as a special histological fact distinguishing laryngeal from other mucous surfaces.
1 Dic. Eng. des Sci. med.
2 Int. Med. Cong., 1881.
3 Ibid.
PERVERSION OF SENSATION OF THE LARYNX.
There is some difficulty in grouping the derangements of the sensibility of the larynx, for the reason that in many cases the perversion of this function is only a symptom of some other disease of the organ. Probably in all cases the trouble is, in fact, an expression either of disturbance in the structures of the larynx, involving more than the sensory nerves, or it is the result of change in structure or function of neighboring or distant parts. Various attempts have been made to classify these disorders according to the kind of perversion and also according to the cause of the trouble. Elsberg, in a paper presented to the International Congress, London, 1881, p. 224. vol. iii., makes an attempt at a scientific classification based upon anatomico-physiological facts. That there is yet much to learn in regard to these facts, especially the physiological facts, will be admitted by every one at all familiar with the literature of the subject. Elsberg, under the term of dysæsthesia, makes two principal divisions—namely, first, disorders having reference to the quantity or intensity of the sensation; this embraces simple hyperæsthesia and simple anæsthesia. The second grand division relates to the quality of the sensation, and includes only paræsthesia or sensory delusions. These grand divisions are still further subdivided.
In fact, we have to do with exaltation of sensibility simply, with sometimes pain; second, with delusion of sensation; and, third, with lost or diminished sensation. For all practical purposes, therefore, we may adopt this arrangement, but should consider it as only provisional, as has been well observed by Schnitzler. These conditions are described under the terms hyperæsthesia, with or without pain; paræsthesia; anæsthesia.
Hyperæsthesia.
DEFINITION.—Exalted sensibility of the larynx, not necessarily associated with pain or other disorders of function. This condition is rare, but it is nevertheless met with. We sometimes find that the larynx is abnormally sensitive to touch or to an irritant, even though there is no marked inflammation. The symptoms and history justify the consideration of the condition apart.
ETIOLOGY.—Predisposing causes are probably to be found in the general condition of the nervous system. Persons of a highly susceptible nervous organization are, other things being equal, more prone to this affection. Certain habits of life, such as confinement to the house or want of exercise in the open air, excessive use of the voice in singing, especially in unnatural keys or after unnatural methods, have seemed to me to predispose to the exaltation of the sensibility of the organ. It must be confessed, however, that so little is accurately known of the history of the disease that we are left in much doubt as to the rôle of these conditions in the production of the abnormal state. The exciting causes of hyperæsthesia of the larynx are the long-continued action of the predisposing causes—acute and chronic inflammation, mechanical and chemical irritants, etc. So far as my own experience goes, the use of the voice in an unnatural key, or perhaps rather the strain upon the parts by efforts to force the organ to perform the function of phonation in an abnormal manner, has more frequently been assigned by the patient as the cause than any other one thing. I have seen quite a number of singers who have by an effort of the muscles, apparently, produced an intensified irritability of the mucous surfaces. It is possible that in rare instances there may be an exalted activity of the receptive centres, and that the local trouble in the larynx is only a manifestation, in the distribution of the nerves, of the central disease. In such cases, however, the disorder should reach all the parts supplied by the pneumogastrics. Inflammation of the pharynx, soft palate, posterior nares, and perhaps of the structures of the ear, have an influence over the sensibility of the parts below, probably through the relations of the glosso-pharyngeal and other nerves to the laryngeal branches of the pneumogastrics. E. F. Ingals of Chicago has seen a case of laryngeal hyperæsthesia produced apparently by a varicose condition of the vessels about the base of the tongue. Frankel, Tornwaldt, Bayer, Schnitzler, A. H. Smith, Glasgow, and others have reported cases in which there were symptoms of hyperæsthesia or of reflex motor disturbances due to trouble in the nose or pharynx. The general health has much to do with the development of the local trouble. Asthenia is associated so frequently with hyperæsthesia of other parts that we should expect to find this relation also in the larynx.
SYMPTOMS.—The symptoms of hyperæsthesia of the larynx are in part involved in the definition of the affection—exalted susceptibility to the touch, intolerance to the presence of mechanical irritants, a sensation of discomfort in the presence of chemical agents, such as gases or impure air, and, when the exaltation is excessive, positive pain. This pain may be only a soreness or tenderness or it may amount to neuralgia. This last form of exaltation is rare. When present it has been considered a special disease and treated as a separate affection. Von Ziemssen and Mackenzie regard it as a variety of hyperæsthesia. Schnitzler, Jones, Wagner, and Mackenzie report cases. The pain is said to be not confined to the larynx, but to extend up toward the ear and along the course of the superior laryngeal nerve. In two cases observed by the writer the pain not only extended along the course of this nerve, but into the pharynx and posterior nares as well. In these cases the patients were both singers, and both had adopted with great enthusiasm a new method by which the abdominal muscles were brought into action at the expense of the muscles of the thorax. The pain was always aggravated by any effort to sing, but more especially by any return to the method noted. The pain not unfrequently extended to the face as well as to the ear.
Neuralgia of hysterical origin, according to Thaon,4 is more frequently met with on the left side than on the right. Instead of being general, it is not unfrequently limited to points or circumscribed patches.
4 Proceedings Laryng. Cong., Milan.
COURSE AND TERMINATION.—The course of the affection is very uncertain. In the neuralgic variety the pain may be transient, passing away in a few days or hours even, but generally there are frequent recurrences extending through weeks or months. Simple exaltation of the common sensibility is much more persistent and more uniform in its character.
Hyperæsthesia of the larynx is so largely dependent upon the general health that not only is it very irregular in its course and duration, but its termination is equally uncertain. It can hardly be said to be a cause of death, as it does not involve structures necessary to life. It disappears occasionally without treatment. When complicated with other affections, such as acute or chronic inflammation, alterations of the function of the pneumogastrics, with disease of the thoracic viscera or with general derangements of the nervous system, its course and termination must depend largely upon the persistence of these complications.
PATHOLOGY.—So far as the pathology and morbid anatomy have been studied, there is no appreciable change of structure. This is true, of course, only of those cases which are not complicated. Whether the primary lesion is in the mucous membrane, denuding, pinching, or otherwise modifying the terminal portions of the nervous filaments, or whether there is an alteration of the conducting portion of the sensory nerves, or, in fine, whether there is some lesion of the receptive centres, it is impossible in most instances to say. It is probable, however, that in some cases the first morbid fact has been an alteration in the nerves themselves. The cases induced by unnatural methods of using the vocal organs are apparently of this character.
The diagnosis, prognosis, and treatment will be considered in connection with Paræsthesia.
Paræsthesia.
Closely connected with hyperæsthesia of the larynx is a form of sensory delusion consisting of the impression that some foreign substance is lodged in the organ or that there is some alteration an the structure of the parts. This is known as paræsthesia.
ETIOLOGY.—The first variety of sensory delusion depends on a primary injury to the parts. A bone or pin or some other foreign body, perhaps having lodged in the parts for a short time, has left a persistent impression upon the mucous surfaces. It is possible that in some instances there may have been no foreign body in the parts, as we have in many cases only the statement of the patient. Local inflammations, small in extent, may possibly have left the parts in a morbidly sensitive condition justifying on the part of the subject the hypothesis of a foreign body.
The second variety of paræsthesia is the expression of some disturbance in a distant part. It is usually hysterical in its character or a variety of hysteria associated with neurasthenia. It belongs to the same class of phenomena as the sensory delusions in other parts of the body. The globus hystericus is one of its forms. Thaon5 says that hysteria may give rise to neuralgia as well as to other forms of hyperæsthesia of the larynx. It also, according to this author, produces that form of paræsthesia in which there is a sense of a bone or pin or some foreign substance in the larynx. The general condition of asthenia, and especially of neurasthenia, may be assigned as a predisposing cause. The local injury in the one case and the general hyperæsthetic condition in the other, with some determining fact, such as the mental impression or an apprehension of trouble in the larynx, constitute the exciting causes.
5 Proceedings of the International Congress of Laryngology.
SYMPTOMS.—It usually comes on after an injury or as a result of the presence of a mechanical obstruction or irritation, the presence of a bone or pin being frequently invoked as an explanation of the feeling. In a few cases the sensation is suggestive of an alteration of the structure of the parts. Patients are inclined to think that they have a tumor or that there is some deformity. In the first class of cases there is a sense of pricking or of scratching in the larynx. This is not constant in locality or in intensity. There will be times, occasionally days, in which the sensation may be entirely absent, after which it returns with great severity, the patient insisting that the cause of the trouble has simply changed its location—in other words, that there is a migratory body in the throat. That form of paræsthesia in which the sensation is that of a tumor or malformation is also irregular in the mode of its manifestation or kind of disturbance. Like the other forms, it comes and goes, changes its location, and undergoes modification in its character. It may be associated with neuralgia.
DIAGNOSIS.—Hyperæsthesia and paræsthesia are recognized by the symptoms already described and by the aid of the laryngoscope. The mirror reveals the fact that the parts are normal in structure and that there is no foreign body present. The mucous membrane may be hyperæmic or anæmic, but is not the seat of any active inflammation. The excessive sensibility and pain of the larynx in ulceration of the parts will be excluded from this group of troubles by the revelation of the laryngeal mirror. Cases of pain or perverted sensation dependent upon the disorders of the nerve-centres usually involve the whole range of functions supplied by the pneumogastrics, and will generally be recognized by this fact. Such cases can hardly be called local, and do not belong to the group of affections embraced in this article.
PROGNOSIS.—The prognosis of simple paræsthesia of the larynx is not grave. Though it may exist for a long time, it, so far as we know, does not terminate in death. While it sometimes results in recovery without treatment, it in a large proportion of cases yields only to both local and general treatment. Its duration is uncertain. Paræsthesia coming on after the presence of a foreign body in the organ may last many months and then gradually disappear. This result will be largely aided by the moral support which is gained if we can convince the patient that the sensation is entirely a delusion.
TREATMENT.—For the purpose of meeting local indications in hyperæsthesia we may apply with a brush or by the means of the atomizer a solution of morphine and alum of the strength of 15 centigrammes of morphine and 2 grammes of alum to 50 grammes of water, or to this may be added 20 centigrammes of carbolic acid and 10 grammes of glycerin. Of this solution an application may be made each day with the hand-atomizer. The hand-atomizer is preferable to the steam-atomizer, for the reason that we know in the use of the former the strength of the solution. In the use of the steam-atomizer the medicated solution is diluted with the water of the steam, and we are ignorant as to the strength of the application. The method of application by the use of the atomizer is to be preferred to the brush or sponge probang, for the reason that we produce by it no mechanical irritation of the parts. The brush or sponge can hardly be used without giving pain or discomfort. In addition to the solution above indicated, solutions of borax, of sulphate of zinc, of tannin and glycerin with chloroform, of nitrate of silver not too concentrated—2 to 10 centigrammes to 30 grammes of distilled water—tincture of aconite, solutions of the bromides, cocaine and other anæsthetics, may be used with benefit. In many cases the administration of general tonics along with the local treatment will be of the greatest value. The application of electricity to the parts through the surfaces—that is, from one side of the larynx to the other—will add to the efficacy of other local treatment. The strength of the current should not be so great as to give rise to any discomfort. The current should be continuous, and should be repeated every day for several weeks if the disorder does not yield sooner. In cases which have been induced by vicious habits of living or of exercise of the organ there should of course be an entire change of the habits. The producing cause should, if possible, be removed. The exposure of the parts to anything which gives rise to pain is to be avoided. If hyperæsthesia has been induced by unnatural methods of singing or of speaking, these should be remedied.
In neuralgia the general treatment for that affection is indicated. Quinine and iron have especially been found useful. In the hysterical variety of both hyperæsthesia and paræsthesia general treatment is of more value than local measures. General tonics, moral support, such as will be secured if we can convince the patient that there is really no serious trouble with the organ, but that it is only a morbid sensation, will be of the greatest value. In these cases change of climate, change of occupation, diversion by new associations, with expectation of recovery on the part of the patient, often bring about the most satisfactory results. The diagnosis should be certain and the physician should be able to speak with confidence in the matter. This will go far toward effecting a cure. For the purpose of diminishing the general irritability of the system bromine in some of its combinations, potassium, sodium, iron, quinine, etc., may be useful.
Anæsthesia.
DEFINITION.—Diminished sensibility of the mucous surfaces dependent upon lesion of the nerve-centres, alteration of the conductivity of the nerve-trunks, or upon disease in their terminal distributions. It is usually bilateral, but may be limited to one side. This alteration of the sensitive condition of the mucous membranes is usually observed after diphtheria. It is also met with in bulbar paralysis. In this last condition it is only one of the phenomena of paresis or paralysis involving several different organs. It is not, therefore, properly a disease of the larynx, and the consideration of it will not be embraced in this article. It has been stated that hysteria is frequently accompanied with anæsthesia of the larynx. Von Ziemssen, Chairou, and Schnitzler have published cases. It seems very improbable that this condition of the organ is so generally present in hysteria as is claimed by Chairou. It is, however, certain that anæsthesia as well as hyperæsthesia of the larynx exists as a complication of hysteria. In the later stages of all exhaustive diseases, as cholera, etc., the sensibility of this organ is either diminished or abolished. This is not, however, a true paralysis in the sense in which we generally use the term. It is only one of the manifestations of the general failure of the life-forces. The special senses, the reflex functions, all share in this paresis, this severing of the relationships of life. Anæsthesia of the larynx is usually confined to the parts supplied by the superior laryngeal nerves, and is sharply limited by the edges of the vocal bands. If there is anæsthesia of the parts below these bands, it is of much less significance and hardly requires our consideration.
ETIOLOGY.—So far as we know, there are no predisposing causes. The chief exciting cause of this affection is unquestionably diphtheria. It is, in fact, a sequel of diphtheria. It will hardly be necessary to repeat here what the reader will find fully discussed in the sections devoted to diphtheritic inflammation of the fauces and adjacent parts: we are mainly concerned with the phenomena. Just how this morbid process produces paralysis is not known. It is believed by some observers that the disease is produced by the alteration of the nutrition of the parts during the progress of the diphtheria. It is stated that the parts most nearly related to the seat of the exudation are most likely to become involved. This is thought to sustain the theory of the direct propagation of the morbid changes from the mucous surfaces to the nerves and muscles. That the paralysis following diphtheria is not, however, produced alone in this manner seems to be made evident by the fact that distant parts, parts which have not been at all involved in the disease, do nevertheless become affected with paralysis. This paralysis develops when the general health and the nutritive changes are all improving. It is quite evident, therefore, that the loss of power in the laryngeal muscles, as well as the altered sensibility, in part at least, must be due to some lesion of the nerve-centres. In addition to the causes above noted, anything which impairs or destroys the function of the superior laryngeal nerve may produce this affection. In the anæsthesia from hysteria we know only the fact, but do not know just how the derangements of the nerves in a distant part, or in the nerve-centres perhaps, are so reflected as to change the function of this organ. The hyperæsthesias, the paræsthesias, and the anæsthesias of hysterical character are all probably produced in the same manner. Anæsthesia in bulbar paralysis is easily understood, but need not, for the reasons already given, engage our attention.
SYMPTOMS.—This condition is usually associated with paresis or paralysis of the muscles of the part. One of the first symptoms of loss of sensibility is, therefore, a failure of the constrictors of the larynx to protect the organ from the intrusion of foreign substances in the form of food and drink. Particles swallowed find entrance into the respiratory tube, and this with no sense of discomfort. If the paralysis is complete both above and below the glottis, the intrusion of these substances is not recognized. There may be no cough or spasm to indicate the fact. In the mean time, the particles of food descend into the bronchi, and may become the exciting causes of broncho-pneumonia. It is often noticed after tracheotomy for diphtheria that food and drinks gaining access to the respiratory tract are discovered at the tracheal opening. In several cases within the knowledge of the writer this fact has led the operator to fear that the posterior wall of the trachea had been opened. In all cases in which the pharynx is in a state of paresis a careful examination should be made by means of the laryngeal mirror.
There are no subjective symptoms, and this fact makes it probable that the affection is more common than has been supposed. The patient complains neither of pain nor of any other discomfort. This statement is only true, however, when there is simple loss of sensation. There may be paræsthesia associated with partial anæsthesia. In such cases there will be noted the usual symptoms of paræsthesia. In hysterical forms of anæsthesia the appearance of the parts is often variable from day to day. The location of the disordered function is well defined at the time of one examination, while at the next the condition may be quite different. It is stated by Thaon6 that in one-sixth of the cases of hysteria the larynx is in some way affected. The epiglottis is more usually the seat of the affection in the hysterical variety. Several authors have noted that with the laryngeal disorder there is often a zone of modified sensation beneath the chin and on each side of the larynx. This sometimes amounts to absolute loss of cutaneous sensibility.
6 Loc. cit.
COURSE AND TERMINATION.—According to Mackenzie, Von Ziemssen, and others, the anæsthesias following diphtheria usually terminate in recovery. It is quite possible, however, that the literature of the subject does not give us elements on which to base an opinion. I am inclined to think that cases die from this disorder in which the nature of the affection is never recognized. It is quite certain that paralysis of the fauces is not unattended with danger. It is also probable that in many of these cases the real danger is not so much from the loss of muscular power in the pharynx, and consequent inability to swallow, as from the fact that the larynx is not protected from the introduction of foreign substances, that the intrusion of these substances is not recognized, and the consequent disorders of the lungs become the cause of death more frequently than has been supposed.
DURATION.—Paralysis of the sensory nerves of the larynx usually lasts only a few weeks. When a result of diphtheria it disappears with the motor trouble with which it is associated. As a complication of hysteria, or rather when hysterical in character, it may last indefinitely. When dependent upon changes in the centres from which the pneumogastrics are derived it has a history commensurate with that affection.
The PATHOLOGY AND MORBID ANATOMY have been suggested in the discussion of the cause and symptomatology of the disorder. The question of the local or general changes in the diphtheritic variety is noted in the history of the disease.
The DIAGNOSIS is made mainly by the examination with the laryngoscope. The probe will at once determine the presence or absence of the sensibility of the mucous membrane of the parts. In addition to touch, electricity may be employed. In these cases the alteration involves both the tactile and reflex sensory functions. There will therefore be neither cough nor spasm resulting from a mechanical irritation. The surfaces are usually quite normal in color and form. The epiglottis is erect, abnormally so, and there will often be more or less paresis, or even complete paralysis, of the other muscles of the organ. In some cases the difficulty in deglutition due to derangement of the reflex functions may be also suggestive of alterations of sensation in the parts within the larynx, but it is only a suggestion.
The PROGNOSIS is usually favorable, but for the reasons given above this should be accepted with some degree of reservation. The diphtheritic varieties share in the uncertainty of other forms of paralysis in that disorder. The hysterical forms are not dangerous, but may continue so long as the primary affection persists.
TREATMENT.—This should be both local and general. The local treatment consists almost entirely in the application of electricity. Both the galvanic and faradic currents are recommended. In my own practice I have been accustomed to resort to the galvanic, but modified by the introduction of a shunt or switch, so as to produce a wave of electricity. The manner in which this is accomplished is to connect in the circuit a coil such as that used for the faradic current. This takes out of the direct current, with each closure of the circuit in the coil, a portion of the quantity of the current, and without entirely interrupting the working circuit gives a wave of electricity, producing, so far as I can judge, the results of both the primary and secondary currents. There is not the shock of complete interruption, while there is the stimulus of the irregular quantity. The electrode which will be found most convenient is that devised by Mackenzie or some modification of it. It should be applied through the parts from one side of the larynx to the other by placing the tip or point of the instrument in one of the pyriform sinuses over the superior laryngeal nerve. A double electrode will often answer better, placing one point in one sulcus, while the other is in contact with the mucous membrane of some other part of the organ or in the opposite sinus; that is, on the other side of the larynx. The current then passes through the parts and stimulates all the tissues between the two poles. The application should be made every day, and for several minutes at each sitting, interrupted, of course, as required by the variable condition of the parts. The current should not be so strong as to produce positive pain. This is not easily reached, however, for the reason that the response is slow and uncertain. The strength of the current should be tested upon the normal surfaces of the patient, or, better, upon the mucous membranes of the operator, before applying it to the morbid parts.
In case a reliable tangent galvanometer is used, much more certainty can be reached than when the strength is determined solely by the sense of touch. With this exhibition of electricity there should also be administered such remedies as are best calculated to restore the general strength of the patient—quinia and iron, with the bitter tonics, and especially strychnia in what would be considered large doses (.003–.005 grammes), two or three times a day, with interruptions every few days. In the hysterical cases, as well as those following diphtheria, electricity is often of great value.
Attention should also be given to the proper treatment of any local trouble in the viscera of the abdomen or pelvis. Uterine disease, if present, as it frequently is, demands attention. It is believed by some authorities that the unilateral disorders of the larynx dependent upon ovarian irritation generally manifest themselves upon the side corresponding to the diseased ovary. It is, however, rare to meet with complete unilateral anæsthesia. In addition to the use of these measures, change of surroundings, especially in the hysterical variety, diversion by new associations, new occupations, etc., are to be secured whenever practicable.
DISORDERS OF MOTION.
Disorders of motion are perhaps more complex than those of sensation. They may be divided into two general groups—1st, exalted action; 2d, diminished or arrested action. The first group is susceptible of a subdivision: first, those in which the sensory functions are exalted as well as the motor. In some of these cases the real disturbance is very probably hyperæsthesia rather than increased irritability of the nerves going to the muscles. Generally, however, the morbid phenomena are mixed; the two sets of nerves are both in a state of over-action. Spasm, for instance, may be the result of excessive activity of the sensory function coupled with the exaltation of the motor impulses, or exaggerated irritability. Second, the spasm or exalted activity of the muscles may be entirely independent of sensory impressions, possibly, in some instances, dependent upon muscular conditions, but generally only the local expression of some central nervous trouble. Chorea may be cited as an example. The diminished action of the motor system may also be due to either a want of the sensory common or special impressions; or it may be due to failure of the motor centres or some interruption of the continuity of the conducting media; or, lastly, it may be for the reason that the muscles themselves are so changed that they do not respond to the normal stimuli, such as the commands of the will or reflex impressions. It will be seen from this brief statement that the subject of motor derangements is one of much complexity. From the very nature of the complications it is often impossible to satisfactorily analyze the symptoms and to determine with certainty, in a given case, whether we have to deal with a simple or a compound result. We may, it is true, in some instances arrive at approximately correct conclusions by resorting to the physiological methods of testing the muscle by galvanism and faradism. In other instances we may by a careful study of the history of the disease reach at least a provisional opinion. We must, after all, admit that much will in many of these derangements remain to be conjectured.
Exalted Action.
There is quite a difference among authorities as to the place in the classification of disease of the larynx which should be assigned to spasm as met with in childhood, and which is also occasionally encountered in adult life. It is not possible, perhaps, in the present state of knowledge, to separate in every instance those cases in which there is disorder of the circulation and nutrition of the larynx from those in which the spasm is the result of disturbance simply of innervation, or in other cases the reflex manifestations of nervous irritation elsewhere. Generally, however, this can be done. I have for a long time been accustomed to consider the affection known as spasmodic croup to be a mild inflammation of the larynx, and that it differs from the same affection in the adult for the reason that the lumen of the tube is smaller, the cartilages are more yielding, and the susceptibility of the parts is greater, and further for the reason that the nervous system in childhood is always more prone to spasm than in the adult. Stridulous laryngitis, however, is a real disease, and is for the reasons above given a neurosis, even though it is an inflammation. It is entitled to a separate description for the reason that the symptoms are so well marked and differ in so many particulars from those of ordinary inflammations. That there is, besides, a true spasm of the muscles of the larynx, independent of inflammation, by which the vocal cords and the constrictors are brought into action and possibly kept in a state of tonic contraction, is possible.
In a majority of instances of laryngeal spasm there is a degree of inflammation, as above stated, or at least a degree of congestion of the mucous membranes. It is certainly true, however, that in exceptional cases there are no indications of such a condition of the parts, so far as we can determine by ante- or post-mortem study. It seems to be evident, then, that under this name of spasm of the larynx or of some synonym of it many careful observers have recorded facts and have grouped them with the thought that the functional derangement was the main trouble. The real difficulty appears to be that the spasm is in fact a symptom—a symptom of perhaps several different disorders, but so prominent and creating so much alarm that it has seemed for the time being to be the disease itself; and yet in most cases there is a mild form of inflammation, local in its extent, and producing, so long as there is no interference with the function of respiration, no general disturbance. It is perhaps appropriate to include in the discussion not only the purely nervous cases, but also those conditions in which, while there is hyperæmia, and probably always some derangement of secretion, nevertheless the symptoms and dangers concern mainly the motility of the muscles of the organ.
The disease occurs both in children and in adults. There is, however, in its etiology, course, and terminations quite a marked difference, as observed before and after puberty. We shall therefore consider, first, spasm of the glottis in children; second, in adults.
Spasm in Children.
SYNONYMS.—Laryngismus stridulus, False croup, etc.
ETIOLOGY.—Predisposing Causes.—The disease occurs most frequently in children from a few months to two or three years old. It is occasionally met with in those still older and up to puberty. It seems to be more often encountered in patients of a strumous habit than in those of a healthy constitution. Rickety children are especially liable to the affection: the German pathologists especially insist upon this factor. Patients of a nervous temperament predisposed to general spasms are especially predisposed to this affection in the larynx. It is a general law that muscles weakened either by disease or by fatigue or by deficient nutrition are especially irritable. In them mechanical as well as other forms of stimuli produce local contraction with great readiness. These contractions are, it is true, rather the expression of the condition of the muscles than of the nerves. The muscular condition must, however, be regarded as a predisposing cause of the spasm. In the same way, perhaps—namely, by the inherited tendency to lower forms of vitality, weakened muscular power—we may account for the fact that family history of similar conditions, such as false croup in other members or in the parents, should be considered as among the evidences of predisposing tendencies to spasm of the glottis.
Sex has in this affection, as well as in most laryngeal diseases of children, a predisposing influence. Mackenzie has collected in all, from different sources, 8248 cases. Of these, 5378 were boys and 2870 girls—a proportion of nearly 2 boys to 1 girl. In adults the reverse holds good, females being much more frequently seized than males. It is certain that season has something to do with the development of the disease, but this influence should be regarded rather as a producing than a predisposing cause.
Dentition, worms, weaning, or anything which produces an irritation of the alimentary canal may also, by exciting the reflex irritability of the nervous system, become predisposing causes of laryngismus. The influence of dentition has, however, been probably over-estimated.
The exciting causes of spasm of the glottis are not well defined. In a few cases we are able to definitely fix upon something as the occasion of the attack. It is possible that there may be some central lesion, and this may be well defined. This is rare, however. It is nevertheless true that the onset is generally preceded by some derangement of the general health. There has been for a day, or perhaps only for an hour or two, a slight cold, a little hyperæmia of the respiratory mucous surfaces, or disturbances of the digestive tract, or the child has been unusually fatigued or excited from play or study. The secretions have in other cases been deranged. No one of these causes has perhaps been of sufficient gravity to attract the attention of the mother or nurse. The indisposition, if it has been noticed at all, has been regarded as only one of the many ephemeral troubles that so often occur in infancy, and no anxiety has been felt. Of all these possible causes, the one most frequently invoked after the attack is a cold, slight, it is true, but nevertheless, in the light of the subsequent history, evidently a mild form of inflammation of the laryngeal mucous membranes.
SYMPTOMS.—Spasm of the glottis usually takes place at night. It is true that some authorities deny that this is the case. Stefen says "that it is quite as likely to occur during the day as night." In a great majority of instances, however, it will be found that the attack occurs after the child has been asleep. During the day there has been perhaps a slight disturbance of the general health, a little inclination to cough, or there has been a catarrh of the fauces or bronchial mucous surfaces; nothing, however, of a serious character has been observed. At midnight or later the little one awakes with a crowing or whistling inspiration. It starts up in bed, and evidently experiences great difficulty in breathing; this difficulty is manifestly in inspiration; expiration is easy and free. The eyes are prominent, the lips blue, the surface often bathed in perspiration; pulse frequent, small, at times irregular; there is, if the child be old enough to reason in the matter, great alarm; there is often cough, and this cough is characteristic: it is a hoarse, metallic, barking, peculiar cough, described as croupy. If the spasm is limited to the larynx, the other muscles not being affected, the patient clutches at whatever it can reach, and often seizes the throat as though there was something there to tear away. The general surface becomes cyanotic and all the symptoms of asphyxia are present. The voice, though not generally extinct, is altered; it becomes hoarse, or husky, as it is called; in a few minutes the severity of the attack is passed, and the little sufferer sinks exhausted into a sleep more or less disturbed. A second attack may occur the same night, or there may be nothing more to alarm the attendants till the next night. The second attack, if it occurs, as it generally does, on the succeeding night, is less severe than the first; the third still more mild; and this generally ends the case for the time being. During the intervals—that is, during the day—the patient in a majority of cases is up, and seems to be but slightly affected by the seizure of the night before. There will perhaps be a slight cough, with some loss of appetite and indisposition to engage in play. This is the most usual type of the disease. In a few cases there is more marked derangement of the general health. The spasms are more severe; the cramp is not confined to the laryngeal muscles, but involves other parts, such as the muscles of the chest and the extremities. During the intervals of the attack there is perhaps a little fever, the digestive tract is disordered, the cough may be marked during the day, there may be an increase in the secretions of the respiratory surfaces. Attacks may recur during the day and for several days; the cough may retain its croupy character, and the voice may continue to be hoarse.
COURSE AND DURATION.—Spasm of the larynx is usually a transient phenomenon, lasting only from a few seconds in the milder cases to several minutes in the more severe forms of the disease. The attacks are intermittent. The seizures are relieved by intervals of comparative relaxation of the muscles of the parts. Even in the intervals there is, however, a degree of contraction of the constrictors, so that the relief is not absolute. Two or three days elapse before the attack may be said to have entirely ceased. In the severer forms the consequences of the spasm may continue even for a still longer time. There are usually no sequelæ. When the patient has recovered there is nothing left of the disease, though there is often a predisposition to a recurrence; the same causes that produced the first attack, or even slighter causes, may produce a second. These causes are generally persistent; the seizures are therefore usually repeated.
PATHOLOGY.—In cases dependent on central disease the pathological changes are to be sought for outside of the larynx. In rickets and other morbid conditions which by reflection produce spasm of the glottis the pathology proper is distant and not in the organ; there is only an excess of motility in the nerves and muscular apparatus. Efforts have been made to differentiate spasm and false croup, but the confusion is only equalled by the disagreement as to the relation of diphtheria to true croup. It is probably true that the cramp is generally due to some excess of motility in the system at large, and that the larynx is the seat of pathological changes that determine the spasm in that organ. This is especially true in those cases associated with rickets, derangement of the alimentary canal, etc. It seems to be a fact, nevertheless, that in a majority of cases the mucous membranes are, as already stated, the seat of a very mild inflammation. Or perhaps we should say they are slightly hyperæmic. So far as we can judge from examination in cases which have terminated fatally, as well as from ante-mortem observation, there is no structural change of tissue to be recognized by the naked eye, unless it be, during life, a slight fulness of the vessels. There is a change, however, in the form of the organ, at least at the entrance to the larynx. The constrictors are in a state of action, so as to partly close the superior opening to the larynx, and the epiglottis is rolled so as, in some instances, to become almost a tube. I have repeatedly recognized this in the image seen in the laryngeal mirror. Cohn reports a case of impaction even of the epiglottis in the vestibule of the larynx (p. 627). This fact is also suggested by the difficult inspiration and the altered voice and cough. In young children the yielding character of the cartilages probably adds largely to the obstruction produced by spasm of the muscles about the vestibule.
DIAGNOSIS.—The diseases with which spasm of the larynx is most likely to be confounded are true croup, simple inflammation of the larynx, foreign bodies in the larynx, and possibly, in the absence of the history of the case, tumor situated in the glottis or along the vocal cords.
It will readily be distinguished from true croup by the fact that in the one case, true croup, the attack is insidious: the patient has been sick some time, usually several days before spasm occurs; there is also fever, with usually more cough; the voice is altered before the appearance of spasm; the first seizure is slight, almost imperceptible, and the subsequent attacks become more and more severe; dyspnoea is continuous. All these facts are in marked contrast with the picture of an attack of spasm of the glottis as we have attempted to describe it. In the one case the most alarming symptoms are at the beginning. There is an explosion of morbid phenomena, each recurrence less alarming till complete convalescence is established. In the other disease the symptoms and dangers are constantly increasing in severity, till at last the spasms become as fearful as the initial seizure in laryngismus. The morbid anatomy of the two diseases is also widely different; and this difference can be recognized during life. Simple ordinary inflammation of the larynx may give rise to hoarseness and cough; the hoarseness is, however, different from that in laryngismus. There is fever, and the hyperæmia of the organ can be readily recognized. The disease is progressive, does not present its most alarming symptoms at the beginning, and spasm, if it occurs, is a late event.
It is possible that spasm of the larynx might be mistaken for a foreign body in the organ. It will be remembered that the attacks of spasm usually occur at night after the child has been asleep. The history of foreign bodies in the larynx reveals what we should expect—namely, that the accident almost always occurs during the day. In a great majority of cases this history also furnishes reliable information of some substance or object which was in possession of the child, and which has disappeared. The dyspnoea is more continuous and the course and symptoms more variable. There will therefore be no great difficulty in any case, and in most cases no difficulty at all, in making a certain diagnosis as between these two conditions. In a few cases of laryngeal tumor the symptoms are very similar to those of the disease under consideration. The attacks in the case of a pedunculated tumor on the vocal cords may take place at night and may be intermittent. The rarity of this affection in children in comparison with spasm of the larynx, and the further fact that in the case of tumor there is a more continuous disturbance of respiration, make the differentiation easy. Paralysis of the adductors gives rise to more dyspnoea during sleep, but the history and laryngeal mirror make the diagnosis easy and certain.
PROGNOSIS.—The large majority of cases of spasm of the larynx recover. Statistics show that there are deaths from this disease, but in proportion to the number attacked I think the mortality is small; how small we do not know. The confusion in classification is so great that we cannot place much dependence upon published statistics. In our climate I think most observers will admit that a patient seldom dies from this affection unless there be associated with it some morbid condition of a serious nature.
TREATMENT.—The immediate and pressing indication in spasm of the larynx is for something to relax the constrictors and allow the act of inspiration to be accomplished without embarrassment. For the accomplishment of this purpose three methods of treatment may be resorted to: First, heat; second, emetics if there be time; third, anæsthetics and antispasmodics. Of all these measures, the first is the most easily applied, and will probably in a great majority of cases prove efficient. It is usually within the reach of the attendant or nurse. It can in any event do no harm. This fact is not to be overlooked, as the symptoms are so alarming that friends and physicians are often tempted to do too much. Heat may be applied by means of cloths dipped in hot water (110° F., or even more) applied to the neck and chest of the patient, or the child may be placed in a bath of 105° F., while the head is kept cool by cloths wet with cold water. This treatment may be continued till the spasms yield. The second of the measures suggested is usually safe, and may be resorted to along with the first. Those agents should be selected which act with most promptness, and the doses should be adapted to the age and condition of the patient. Alum, sulphate of zinc, sulphate of copper, are perhaps the best, but by no means the only ones. Ipecacuanha, by the relaxing effect which it has upon the muscular and nervous system, may be useful not only in overcoming the spasm, but in preventing the recurrence of the attack. Antimony is unsafe, and the other emetics are quite as useful in relaxing the muscles. The third of the measures suggested should be used with great caution. It may be doubtful whether, in fact, anæsthesia is ever indicated in simple spasm of the muscles of the larynx. The dyspnoea renders it very difficult to produce full anæsthesia, and without this the relaxing effect is not reached. In cases in which there is serious disease outside of the larynx there should be appropriate treatment directed to the extrinsic trouble. During the intermission—that is, during the day following the spasm—attention should be directed to the condition of the digestive and excreting organs as well as to the respiratory tract. In malarial districts I have thought that quinia given in antiperiodic doses the morning after the seizure has been of benefit in preventing or diminishing the severity of the next spasm. In addition to these measures, for the prevention of the subsequent attacks bromide of potassium or bromide of sodium in 3 to 5 grain doses may be given once in three to six hours after the spasm has ceased. Five grains of chloral, as advised by Mackenzie, given at bedtime the night after the attack, will also diminish in a certain number of cases the severity of subsequent seizures, or possibly entirely prevent them. Musk, myrrh, camphor, castor, and other similar antispasmodics are theoretically indicated, but, in fact, are of but little if any value. If the disease is central, involving the floor of the fourth ventricle, the local and general spasms are only symptoms, and the treatment must be directed entirely to the preservation of life. It should be remembered in this connection that in the floor of the fourth ventricle the pneumogastric and the glosso-pharyngeal, as well as filaments of the spinal accessory, have their origin. The range of distribution of these nerves marks to some extent the range of the morbid phenomena in disease of central origin. It may of course be true in any given case that only a small portion of the central gray matter is involved, but as a rule the organic change in one of the nerves at the point of origin does give rise to disorder of function of one or both of the others.
General tonics and attention to hygienic conditions are of great importance for the purpose of giving vigor and regularity to all forms of nervous and muscular activity.
Spasm of the Glottis in the Adult.
The affection is usually bilateral; that is, all the muscles guarding the vestibule of the larynx, and probably in most cases the adductors of the vocal cords, are involved. That this is not always true, however, I am convinced by a case now under observation in my own practice. The patient is an adult, and I have been able to determine by laryngoscopic examination that the muscles on the left side are the seat of the spasm. The epiglottis is drawn downward and backward on that side. The top of the left arytenoid cartilage is drawn forward, while the similar parts of the right side remain in their normal position except the change necessarily produced in the epiglottis. This condition is not constant, and is not a paralysis of the opposite side. This is the only case that I have seen, and I do not know of any similar case on record. Nothnägel7 reports a case of spasm of the adductors upon making an effort to phonate. The cords were normally separated in inspiration, but at the first effort to speak they closed firmly, leaving no line of opening between them. The attack seemed to have been produced by a powerful impression made upon the nervous centres. It seems probable that it was hysteria. Krishaber describes a form of what he calls spasm of the larynx in adults, which seems to be rather a local manifestation of a central disease than a neurosis of the larynx. It is in many respects similar to epilepsy. The danger, even in cases in which life is threatened, is not from asphyxia, but from the arrest of the functions of circulation and respiration—an arrest of the effort even to breathe. It hardly seems proper to include this among the troubles of which we are treating. He calls it ictus laryngé.
7 Deutsch. Arch. für klin. Med.
ETIOLOGY.—It is certain that the same causes that produce spasm in childhood are efficient in the adult, though there is an absence of some of the conditions that render the disease so frequent in infancy. The cartilages have become more firm, and consequently are not so easily moved by the action of the constrictor of the vestibule of the glottis; the size of the cavity in proportion to the necessities of the body for air is larger; the control of the voluntary over the automatic actions of the muscles of mixed function is greater; the reflex irritability of the nervous apparatus is less. These facts all render the probability of spasm in the adult much less than in the child. On the other hand, the development of the generative organs, and the widespread influence which they have upon the respiratory and circulatory as well as upon the central nervous system, introduces a new factor as a cause of motor disturbances of the larynx. This new element is a reason for the fact that in adults the predisposing influence of sex is reversed: after puberty the disease occurs more frequently among females than among males. The hysterical character of many of these cases may be inferred from this preponderance of one sex over the other among the subjects attacked.
This fact has been seen and described by Charcot, Lefferts, and others. Irritation along the track of the nerves, morbid conditions of the mucous surfaces, or muscular irritability, may be each a cause of spasm.
SYMPTOMS.—The symptomatology of spasm in the adult does not differ in any material respect from the phenomena observed in children. It is in the rarity and the comparatively milder character of these symptoms that the difference is to be found. The attacks occur at night, as in children, but, so far as I have observed them, they may also take place during the day. When very severe they occasion great alarm to the patient, and for this reason produce a profound impression, not only upon the physical, but also upon the mental and emotional, state.
The duration and termination of the affection are about the same as in children. In the mortality-tables we find every year a certain number of deaths from spasm of the larynx in adults. It is probable that among these there are quite a number which should be placed elsewhere. A patient may die from spasm of the larynx, which spasm is produced by an ulceration, by a tumor, by the presence of a foreign body in the organ. As in children it is quite certain that the deaths reported as from spasm of the larynx include many that should be referred to central or other diseases, so here the immediate cause of death is not unfrequently given instead of the real and essential cause. This fact makes it difficult to reach anything like a definite conclusion as to the termination of the disease; only this can be said: the great majority of cases recover.
PATHOLOGY.—With the exception of those cases in which there is disease of the central nervous system or along the course of the nerves, we know nothing of the morbid anatomy of this affection. In fact, there is no appreciable alteration of the tissues or of the relations of parts; the spasm is to be considered as a symptom of disease, and not as the disease itself, or necessarily even as a sign of morbid structure in the organ.
DIAGNOSIS.—In adults we can make the diagnosis certain by the aid of the laryngoscope. This can be done in a certain number of cases in childhood, it is true, but not with the same ease as in those who have reached more mature years. Ulcerations, benign and malignant growths, and foreign bodies may each or all produce spasm, but the existence of such causes is revealed by the mirror, and excludes such cases from the group under consideration.
TREATMENT.—This does not differ in any essential respect from that suggested in spasm of the larynx in children. Attention to the condition which has been instrumental in the production of the affection, the use of antispasmodics, such as bromides, chloral, myrrh, musk, camphor, ether, chloroform, etc., will meet the urgent symptoms, while the use of tonics, such as vegetable bitters, quinine, iron, cod-liver oil, with attention to a proper hygiene, constitutes the general treatment.
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 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 spasmodic expiratory efforts. The patient recovered under treatment by arsenic.8
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
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 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:
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 Tourgues10 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.
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 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, 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 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.
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 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 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 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 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 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 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.
Cases dependent upon malignant growths within the cranium are absolutely beyond the reach of treatment. Paralysis dependent upon bony tumors, even though they are benign in character, are also for the most part beyond the reach of surgical interference. If the paralysis is complete—that is, if all the muscles are involved—there are no indications for any operative procedure. If, however, only the nerves that supply the posterior crico-arytenoids are involved, as occasionally happens, tracheotomy should be resorted to even though the dyspnoea is not urgent. This operation places the patient in a condition of temporary safety, and gives time to resort to other means if the indications for their use can be found.
The second group of cases includes all those in which the cause of the paralysis is due to the presence of disease of the nerve-trunks, or to pressure upon the nerves between their emergence from the cranium and their terminations in the muscles of the larynx. Malignant growths and benign tumors situated along the tract of the nerves, and pinching them, are readily recognized, and when not contraindicated by other facts they should be removed. Enlargement of the thyroid gland may in some cases press upon the nerve and cause paralysis. This is occasionally relieved by appropriate treatment directed to it. Among those means which have occasionally been found efficacious for this purpose iodine or some of its compounds, and especially electricity in the form of galvanism, seem to be entitled to the most confidence. For paralysis dependent upon cicatricial pinching of the recurrent nerve-trunks relief may possibly be obtained by dissecting out the bands by which the nerves are compressed. This is hardly indicated for the partial derangements which do not endanger life, as in unilateral paralysis of the recurrent. Where the trunk of the nerve is entirely obliterated nothing can be done, and in many cases of injuries along the trunk of the recurrent it will be impossible to know that the nerve has not been destroyed in the mechanical lesion.
Paralysis caused by pressure upon the intra-thoracic portion of nerve is beyond the reach of surgical interference. When this is aneurism, disease of the apex of the lung, or pleuritis, as may possibly happen, the paralysis or paresis must of course have a history coeval with the thoracic disease. The causes themselves are unfortunately persistent and tend to terminate in death; the paralyses are therefore persistent and beyond the reach of medical or surgical relief. In cases where the posterior crico-arytenoids are especially involved, tracheotomy, as in the same condition from intra-cranial disease, should be performed. It is certainly true that there may be a morbid condition of one or both of the pneumogastrics or recurrent nerves without macroscopic changes in their structure; in such cases the use of the faradic current together with general tonics is indicated.
The third group is made up of those cases in which there is disease of the nerves or muscles of the larynx itself. It seems to be true that in most of these patients there is a derangement of the general nutrition; but this is not all: there is also a special morbid condition of these special structures. For degeneration of the muscles of the larynx there is probably no remedy; for atrophy there may be something done by different methods of exercising the muscles. The use of electricity when the muscles are still responsive to the current should be attempted. Regular applications by which they are thrown into action may result in the improvement of their nutrition. The use of them so far as they are phonators, without carrying it to the extent of producing fatigue, is also indicated. In addition to these local measures, tonics for the purpose of improving the general condition may be administered. Strychnia, with the purpose of stimulating the centres, will also be found in some cases useful. When the disease is partial, as in the case of the posterior crico-arytenoids, such operative measures as have been already indicated must be resorted to. The purpose is to prolong life, even though we cannot cure the disease.
The fourth group, the paralyses of reflex origin, are generally within the reach of treatment; at least, they usually recover. They depend for the most part, as will be remembered, upon some disorder of distant organs. There is primarily no disease of the larynx, and not necessarily even a secondary disorder of its structures. It is true that long inaction may result in atrophy of the muscular structure, but this is, I am convinced, a rare exception to the rule that in hysterical paralysis there is maintained a complete integrity of the muscles of the organ, even though the parts have been for years in a state of inaction. For some reason, the nutrition is maintained much better than in paralysis from other cases. The trophic nerves are evidently not involved. The treatment should be both local and general. It should be directed to the larynx and to the distant part upon which the motor disorder of the larynx depends. So far as the larynx is concerned, we know of nothing better than electricity. The faradic current, by which the muscles are stimulated and the nervous energies awakened, seems to be most useful. The method of applying electricity to the larynx may be varied according to the nature of the case and the age of the patient. In young children the current should be directed through the walls of the larynx from side to side or from before backward. It should be repeated every day if possible. In adults the current may with advantage be passed through the larynx from within outward or from one side to the other. This may be accomplished by the use of Mackenzie's laryngeal electrode. The instrument is either single or double. Armed with a sponge and bent to the proper curve, one pole is introduced into the larynx, the other placed upon the neck, and then by pressing a spring the circuit is closed, permitting the current to pass through the parts from one pole to the other. In using the instrument with two electrodes, as in paralysis of the arytenoids and constrictors, the instrument with two branches, each armed with a sponge, and to which the two poles are attached, is introduced with one branch in one of the depressions in one side of the larynx, and the other on the opposite side in the corresponding depression. The circuit is now closed as before, with the muscles between the two poles as part of the circuit. The electrodes may be carried down into the organ and the stimulus applied directly to the vocal bands. In some cases the first shock is followed by distinct phonation; in others repeated applications are necessary; while in still others all efforts of this kind fail entirely. Both the galvanic and the faradic current may be used. When the object is to stimulate the dormant energies of the nerves or muscles, the faradic is probably the more useful; if it is desired to modify the nutrition of the parts, the galvanic is preferable. The strength of the current should be carefully tried upon the surface of the hand of the operator before introducing it into the larynx. The shock to the nervous system from the dread of the operation has sometimes resulted in the recovery of the voice before anything has been done. The morbid spell is broken and the patient speaks. This is true in spasm even, as shown in a case reported by Lefferts, where it was thought that tracheotomy was necessary for the purpose of saving life. The patient, frightened at the thought of the operation, recovered, and respiration became easy. There was no reason to think that the case was one of simulation.
For the general condition, which is usually one of asthenia, nerve-stimulants are indicated, and the bitter tonics, with iron and strychnia, good generous diet, outdoor exercise, change of surroundings, travel, moral impressions, in short everything that tends to promote general good health,—these are among the most important requirements. If there is local uterine trouble, this of course requires attention, or if there is any other derangement which serves as the point of departure for the morbid phenomena, this will also demand consideration. In fact, no organ suffers alone. There is a community of function and there is a community of suffering. This subject has been perhaps sufficiently discussed in the consideration of the treatment of hysterical disorders of sensation and of spasm, to which the reader is referred.
The fifth group comprises paralyses toxic in their origin. When the cause is typhoid fever or diphtheria, we may confidently expect the paralysis to disappear with the other manifestations of adynamia. Time and tonics, with attention to diet, and in the more protracted cases electricity, will generally be all that is required. Cases depending upon the toxic effects of lead or arsenic demand the treatment appropriate for the other manifestations of these forms of paralyses. The iodide of potassium internally, with attention to the general health, and especially to the functions of the excreting organs, constitute the most important measures. In addition, strychnia may be administered, and the faradic current applied through the larynx. It is certainly possible that laryngeal paralysis may be produced by arsenic, as shown in the case reported by Mackenzie, and probably also by copper or mercury. Such cases, however, must be exceedingly rare. The potassium iodide, as suggested for lead-paralysis, may be resorted to in case mercury is supposed to be the cause. For arsenic- and copper-poisoning the reader is referred to articles upon these subjects elsewhere. Cases in which there is evidence of a local lesion due to syphilitic intoxication should receive both local and general treatment.