A system of practical medicine. By American authors. Vol. 3

by Unknown

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.