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.