Volume 3 — DISEASES OF THE RESPIRATORY SYSTEM. (continued 3)

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:

1. Paralysis of the whole larynx—of one-half of the larynx;

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.

ACUTE CATARRHAL LARYNGITIS (FALSE OR SPASMODIC CROUP).

BY A. JACOBI, M.D.

PATHOLOGY.—Catarrhal inflammations of the mucous membrane and the submucous tissue of the larynx are of frequent occurrence. They are either general or local; that is, confined to the epiglottis or the vocal cords, etc. The affected parts are red (only less so where the elastic fibres are developed to an unusual degree and capable of compressing the dilating capillaries) and more or less tumefied. Sometimes small hemorrhages occur. The secretion is either changed in character or in quantity. It is either mucous or purulent, or (mainly in passive congestions produced by interrupted venous circulation) serous. The epithelium is either thrown off or accumulated in some spots, particularly on the vocal cords, so as to form whitish conglomerates which may become the abode of schizomycetæ. The muciparous follicles are enlarged and dilated; to this condition is due the granular form of laryngitis, with the nodulated condition of the epiglottis or the fossæ Morgagni or the inferior vocal cords.¹

¹ Ziegler, Pathol. Anat.

When the catarrhal process is of longer duration, the capillaries and small veins become permanently enlarged; round cells are deposited between the epithelium and cellular tissue; the cellular tissue becomes hypertrophied; papillary elevations are formed on the vocal cords. The disintegration of the epithelium and the bursting of the tumefied muciparous glands lead to the formation of erosions and ulcerations; the chronic swelling and hypernutrition of the muciparous follicles to their destruction by cicatrization or simple induration; and to atrophy of the mucous membrane.

Many of the specific causes of inflammation of the larynx exhibit no peculiar alterations of their own. Scarlatina, measles, and exanthematic typhus are complicated with either a catarrhal (in most cases) or a diphtheritic laryngitis. Variola, however, has a peculiar form of its own, with red, pointed, whitish stains or nodules, consisting of a cellular infiltration or of a deposit upon or into the upper layers of the mucous membrane, composed of necrotic epithelia and pus-corpuscles or of coherent membrane. Hemorrhages or abscesses are but rare, and chondritis seldom results from it. Even syphilis has not always changes which are characteristic. The laryngitis accompanying it is often but catarrhal, without anything pathognomonic about it. But whitish papules consisting of granulation-tissue (plaques muqueuses), gummata often changing into sinuous ulcerations, particularly on the epiglottis and posterior wall of the larynx, also perichondritis with loss of cartilage and deep cicatrization, such as are not found in either carcinosis or tuberculosis of the larynx, are frequently met with. Typhoid fever shows different forms of laryngitis, from the catarrhal to the ulcerous. Epithelium is thrown off at an early period of the disease; erosions and ecchymoses follow; rhagades on the margins of the epiglottis, and a deposit on the anterior wall of the larynx and the vocal cords, consisting of epithelium and round cells, are frequent. That they should be mixed with micrococci and bacteria is self-understood. Not so that these bacteria are to be considered as the cause of the disintegration which is taking place, the less so as no specific typhoid bacterium has been demonstrated, and several varieties of them are found both in the mouth and in these ulcerations. These changes are apt to terminate in ulceration of the epiglottis and false vocal cords; these will extend in different directions, and to the deeper tissue down to the cartilage.

In tuberculosis, laryngitis is a frequent occurrence. In most cases it is secondary to the pulmonary affection, and due to the direct influence of the contagious sputum—according to Heinze, however, not to contagion, but to the influence of the infected blood. In other cases it appears to develop spontaneously, before any pulmonary affection is diagnosticated, and may then be due to some poison circulating in either blood or lymph. Tubercular laryngitis, according to Rindfleisch, commences in the excretory ducts of the muciparous glands. That this is so in a great many cases is undoubted. The first changes visible are small cellular subepithelial infiltrations or real subepithelial tubercles, which, while growing, undergo gaseous degenerations and ulcerate. These ulcerations are either flat and small or deeper with an infiltrated edge, and are apt to terminate in secondary nodulated infiltrations and abscesses. Large tumors are not met with, but oedema and phlegmonous inflammations are by no means rare.

ETIOLOGY.—The predisposition varies according to individuals, ages, and seasons. Some mucous membranes appear to be more sensitive than others. The hereditary transmission of peculiarities of structure of all or some tissues or organs is apparent, in the case of laryngitis, in the fact that many children in the same family or the children of parents who were sufferers themselves are affected. Children are more liable than adults, infants more than children: 20 per cent. of all the cases are met with under a year, 25 from the first to the second, 15 from the second to the third. Not many occur after the twelfth year. The narrowness of the infant larynx and the looseness of its mucous membrane afford full play to injurious influences, such as dust, cold and moist air, changing temperatures, hot vapors and beverages. Colds, though their nature and effects can hardly be said to be understood, are certainly amongst the main causes. Perspiring surfaces afford frequent opportunities. One of the principal causes is insufficient clothing—more amongst the well-to-do than amongst the poor. The latter have this blessing in their misfortune, that they are protected uniformly if at all, and have their skins hardened by exposure. The bare necks and chests, the exposed knees, the low stockings and thin shoes of the children of the rich, old and young, are just as many inlets of laryngeal catarrh, inflammatory disease, and phthisis. Persons suffering from nasal catarrh or pharyngeal catarrh are liable to have laryngitis. Thus, not only rachitis, with its influence on lymphatic glands and the neighboring mucous membranes, but also acute infectious diseases, such as whooping cough, measles, influenza, erysipelas, hay fever, tuberculosis, syphilis, typhoid fever, and variola, are as many causes of laryngitis. That over-exertion of the voice should produce laryngitis seems probable, but experience does not teach that those babies who cry most are most subject to laryngeal catarrh.

SYMPTOMS.—Acute laryngitis is a frequent disease, and has always been. Still, in 1769, Millar mistook it for a sensitive neurosis, considering it as identical with spasm of the glottis, and recommended antispasmodic treatment. Guersant understood its nature better. He first (1829) used the names false croup and stridulous laryngitis. Acute laryngitis is attended with but little fever in the adult, but with a high elevation of temperature in the young. In all, it yields a number of symptoms, part of which are uncomfortable only; others are liable to become dangerous.

Seldom without any catarrhal premonitory symptoms of other parts of the respiratory tract, sometimes, however, without any, there is a burning, tickling, irritating sensation in the larynx—a sense of soreness in it and the lower portion of the pharynx. Sometimes these sensations amount to actual pain, to difficulty of deglutition, and to the sensation of the presence of a foreign body. Speaking, coughing, cold air, increase the discomfort and pain. Hoarseness, sometimes increasing into aphonia, follows soon after, is seldom simultaneous with, the first appearance of cough, but lasts longer than the latter, which is, according to the severity of the case or the stage of the disease, changing between loose and dry, hoarse and barking. Inspiration is apt to become impeded, mainly in infants and children. In these it is often sibilant. It is followed by a reflex paroxysm of cough, with interrupted and brief expirations, during which the forcible compression of the thorax may result in cyanosis. The principal attacks are met with at night amongst children. Quite suddenly they wake up with a dry, barking cough, interrupted by considerable dyspnoea, which is great enough sometimes to give rise to much anxiety. They toss about or cling to a solid body, raise themselves on their knees, breathe with great difficulty, exhibit cyanosis in its different hues, perspire very freely, and yield all the symptoms of the strangulating attacks of membranous croup, its over-exertion of the sterno-cleido-mastoid muscles and supraclavicular and diaphragmatic recessions not excepted. These attacks occur but rarely during the day; on the contrary, well-marked remissions are quite common in the morning. Their occurrence during the night is best explained by the facility with which mucus will enter the larynx from above during the reclining posture, the increasing dryness of the pharynx during sleep, perhaps also the nervous influence depending upon the relative diminution of oxygen and increase of carbonic acid in the respiratory centre, leading to spasmodic contractions.

Some of these grave attacks of sudden dyspnoea are explained by the participation of the submucous tissue in the morbid process. When that occurs, adults also, who as a rule do not suffer from dyspnoea in laryngeal catarrh, are badly affected. The symptoms are rigor, high temperature, pain, hoarseness or aphonia, a barking cough, labored expectoration—which is sometimes bloody—dyspnoea, orthopnoea, cyanosis. In some cases, to which the name of laryngitis gravis or acutissima has been given, the symptoms grow urgent to such a degree that tracheotomy alone is capable of saving life.

Otherwise, the severity of the symptoms does not go parallel with the local lesions. Particularly in children, hoarseness, cough, and dyspnoea are liable to be grave, while the local hyperæmia is not intense at all. A pharyngeal catarrh is very apt to increase the suffering. Complications with tracheitis or bronchitis are liable to prolong the course of the disease and to render respiration—which is not accelerated in laryngeal catarrh—more frequent. Otherwise, the disease runs a favorable course. Remissions of the severe attacks which may occur in several successive nights take place in the morning. Expectoration, which in the beginning was either absent or scanty, becomes soon more copious and mucous; the hard, barking, loud cough grows looser with increasing secretion. In most cases the violence of the affection is broken in from three to five days, and the disease runs its full course in a week or two. But hoarseness may remain behind for some time; in rare cases aphonia has become permanent and relapses are frequent. Not infrequently children are presented who are reported to have had croup five or ten or more times. In some families all the children are subject to laryngeal catarrh, and hereditary influence cannot be doubted.

The very worst complication of laryngitis is oedema of the glottis. It affects both the mucous membrane and the submucous tissue of the larynx. It is met with on the inferior (posterior) surface of the epiglottis, in the ary-epiglottic folds, and on the false (inferior) vocal cords, the submucous tissue of which is of a very loose structure normally. Amongst its causes—which may be various (foreign bodies in the larynx, injuries, mechanical and chemical irritants of any kinds; typhoid, tubercular, variolous, syphilitic ulcerations; erysipelas of the neighborhood, inflammations of the parotids or tonsils, suppuration in the pharynx, thyroid body, and cellular tissue of the neck)—both catarrhal and croupous laryngitis are not at all uncommon. This is particularly so when they are complicated with cardiac and renal anomalies, pulmonary emphysema, and compression of the veins of the neck by glandular swellings; also with changes in the structure of the walls of the blood-vessels. The last-named pathological conditions are alone capable of giving rise to chronic oedema of the larynx, which is by no means so fatal, but still dangerous.

In glottic oedema the dyspnoea is both very great and very sudden. First, it is inspiratory only, but soon becomes both inspiratory and expiratory. The swelling is felt distinctly by the examining finger; the laryngoscope is neither required nor advisable.

DIAGNOSIS.—It is by no means easy in all cases. When laryngeal diphtheria (membranous croup) happens to be frequent, the most experienced diagnostician will meet with occasional difficulties. The sound of the barking, explosive, tickling cough locates its origin in the larynx, but the affection may be very mild or very severe. Expectoration in small children is not pathognomonic; even when it is copious it is not brought up, but swallowed. Fibrinous expectoration would settle the diagnosis of a croupous process. Depressing the tongue with a spoon or spatula and producing the movements of vomiturition often reveals the presence of a tough, viscid mucus rising from the larynx. It renders the catarrhal nature of the laryngitis positively clear. The frequency or volume of the pulse is of no account in diagnosis; it is too variable. Of more importance is the temperature, at least in children. Uncomplicated sporadic croup has no increase, or very little; catarrhal laryngitis is mostly attended with high fever. In very many cases this symptom has guided me safely, in spite of the statements of the books. The stenosis of catarrhal laryngitis comes on very suddenly, in diphtheritic laryngitis mostly slowly. In the former it is not of long duration; remission sets in soon, and is more complete than in membranous croup. An attack of stenosis occurs mostly in the night, and is apt to return with the same vehemence after a fair remission after twenty-four hours. The frequency of relapses in catarrhal laryngitis in children who have been affected before must, however, not prejudice in favor of the catarrhal nature of an individual case, for not infrequently will those who have had many attacks be taken with membranous croup some other time. In the latter the main symptoms—viz. stenosis, hoarseness (or aphonia), and cough—will mostly develop simultaneously and in equal proportion; the unproportionality of these symptoms—for instance, much stenosis and cough, but little hoarseness, or barking cough and hoarseness with little stenosis—would speak for catarrh. The laryngoscope, when it can be used—viz. in the adult and very docile children—reveals redness of the mucous membrane of the pharynx and all or part of the larynx; also tumefaction of the epiglottis or fossæ Morgagni or ary-epiglottic folds. Sometimes the inferior part of the larynx only is affected; Ziemssen has described a severe form under the name of hypoglottic laryngitis. The vocal cords can be watched easily. Their proportionate and parallel contraction is often interfered with.

Tubercular laryngitis, particularly when there is no pulmonary tuberculosis, is not easily diagnosticated by the local changes only. The long duration of hoarseness and fever, increasing emaciation, and the knowledge of the presence of tuberculosis in the family are more conclusive than local examinations can be.

PROGNOSIS.—The termination of catarrhal laryngitis in the adult is almost always favorable. Still, relapses are frequent, and it may become chronic, with permanent tickling of the mucous membrane and submucous tissue. In children it is mostly favorable; still, it is doubtful, because of the frequency of complication with, or transmutation into, bronchitis, pneumonia, or glottic oedema, and because of the facility with which in a prevailing epidemic the catarrhal laryngitis becomes diphtheritic. The elevation of temperature is not a very significant symptom in regard to prognosis. The danger does not increase with the temperature at all. On the contrary, those cases which set in with a high temperature will, as a rule, terminate soon and favorably. When, however, the temperature rises again after having gone down to the normal or nearly normal standard, complications or extension of the catarrhal or inflammatory process must be expected. Catarrhal secretion from the nasal mucous membrane, which was dry in the beginning, is a favorable symptom; so is the looser and moister character of the cough.

TREATMENT.—Whatever plays an important part in the etiology of the disease ought to be carefully avoided. The feet must be kept warm under all circumstances, nothing being more injurious to health in general, and to that of the respiratory organs in particular, than cold and moist feet. Shoes and stockings must be kept dry, the latter changed when wet, and of slowly-conducting material. No part of the body must be kept uncovered, and the dresses of children made the particular object of care on the part of the family physician. Linen must not be in immediate contact with the skin, cotton—or, still better in all seasons, wool—being required for the undergarment. At the same time, the hygiene of the skin requires attention. Regular washing or bathing need not be mentioned as a requisite, as it is self-understood. What, however, cannot be insisted upon too much is this, that the skin must get accustomed to cold water. The whole body must be exposed once a day to cold water—washing or bathing—and well rubbed off afterward with a thick towel. Young infants and those who are very susceptible to colds begin with tepid water, the temperature being lowered from day to day. Even children of three or four years enjoy, finally, a morning bath at sixty or sixty-five degrees F. in winter. Such as do not get easily warmed up under the succeeding friction may mix alcohol with the water they use for washing and sponging purposes, in the proportion of 1:5–8. Sea-bathing also makes the skin more enduring, to such an extent that exposure to cold air has no longer any damaging influence. In fact, cold air without wind is easily tolerated even by those who have a tendency to respiratory disorders, while wind and draught must be avoided. From this point of view the change of climate sometimes required for such as suffer from catarrhal laryngitis must be instituted. It is not always necessary to select a very warm climate; undoubtedly, many of the winter resorts are badly selected, for the very reason that they are too warm. On the other hand, great elevations are not advisable. The sudden atmospheric changes and fogs of high mountains are injurious.

Patients suffering from catarrhal laryngitis or a tendency in that direction must avoid all irritation of the pharynx and larynx. They must not smoke, or talk too much or too loud. Those few clergymen who suffer from clergymen's sore throat in consequence of speaking only will remember that they can speak just as forcibly when speaking less vehemently. The use of alcoholic beverages, unless greatly diluted, is prohibited. Catarrh of the nares and pharynx must get cured. The former will get well in most cases under the use of salt water. A tepid solution of 1 or ½ per cent. of table-salt in water, snuffed up copiously (a tumblerful) from the hand of an adult patient, or a similar solution in a small quantity injected through each nostril of a child, twice or three times a day for weeks and months in succession, will often remove a laryngeal as well as a pharyngeal catarrh. Care must be taken that the fluid passes the whole length of the nasal canal. It must be applied in the fauces, and will then be ejected through the mouth or a small portion of it swallowed. Many a severe nasal catarrh requires no other treatment. Some chronic ones require the use of a spray of nitrate of silver in a solution of ½–1 per cent. every other day, or of a 2 per cent. solution of alum daily. Where both the pharyngeal and nasal catarrh are complicated with, or kept up by, enlarged or ulcerated tonsils, these organs must be resected. The combination of these two measures, exsection of the tonsils and nasal injections, has proved very beneficial in a great many cases.

The treatment of an acute case requires great care. Avoid injurious influences. The patient must keep silent and quiet in bed. The temperature of the room is to be about 70° F., the air moistened by vapor, which must not be allowed to get cold before it reaches the patient.

When swelling and dyspnoea are considerable, particularly in those grave cases attended with swelling of the submucous tissue, the application of an ice-bladder or ice-cloths will be found beneficial and agreeable. But the cases in which these applications are indispensable are but few. In most of them the necessity of subduing intense inflammation is less urgent than the advisability of increasing the secretion of the congested larynx. For that purpose warm poultices, but of light weight, act very favorably. Inhalation of warm vapors either constantly or at short intervals, or of muriate of ammonium or spirits of turpentine, will prove beneficial. The latter is evaporated from the surface of boiling water, on which a small quantity, from a teaspoonful to a tablespoonful, may be poured every one or two hours. The hydrochlorate of ammonium is evaporated, 10 or 20 grains (1.0 gramme), every one or two hours by heating it on a hot stove or otherwise. The white cloud penetrates the air of the whole room, and, while not uncomfortable to the well, serves a good purpose in liquefying the viscid and tough secretion of the mucous membrane. The internal administration of liquefying and resolvent remedies may properly accompany the external applications and inhalations. Amongst them I count the alkalies, mainly bicarbonate and chlorate of potassium or sodium and the hydrochlorate of ammonium. A child of two years will take daily a scruple (gramme 1.0–1.5). The iodide of potassium will also have a good effect and counteract many a predisposition to chronicity. A child may take from 8 to 15 grains a day (gramme 0.5–1.0). Hydrochlorate of apomorphine, gr. ¹/50–¹/30 (0.001–0.002), dissolved in water, a dose to be given every two hours or every hour, is quite sufficient to act as a fair expectorant without being enough to produce emesis. Antimonii et potassii tartras has been used more extensively in former times than at present. An adult would take gr. ¹/20–¹/15 every two hours. Children ought to be spared the drug, as it is depressing, produces unnecessary vomiting now and then, even in small doses, and, what is still worse, diarrhoea. The other antimonial preparations, such as kermes mineral and the oxysulphuret of antimony, are less depressing and less purging, but also less effective; and there are but few cases where a good substitute could not be found. For the purpose of increasing secretion the hydrochlorate of pilocarpine has been recommended. It certainly has that effect, but its indications become doubtful in many cases where the saving of strength is of paramount importance. I shall return to this subject in my remarks on the therapeutics of membranous laryngitis.

Derivation is of great service when well directed. Local depletion must be avoided. A purgative in the beginning is beneficial—a dose of calomel as good as, or mostly better than, anything else. Diaphoretics and diuretics act quite well; the best of them all are warm beverages of any kind. They need not come from the apothecary's nor be very unpleasant to take—water not too cold, Apollinaris, Selters, or Vichy, hot milk, tepid lemonade in large quantities and very often. Sinapisms have a good effect. When not kept on longer than a few minutes—long enough to give the surface a pink hue—they may be applied every hour or two.

Some urgent symptoms may require symptomatic treatment. When secretion is copious, but too tough, and expectoration insufficient because of both the character of the mucus and the incompetency of the respiratory muscles, ipecac in small doses or camphor is indicated. A child's dose of the latter would be gr. ¼–½(gramme 0.015–0.03) every one or two hours. In these cases the hydrochlorate of ammonium may be combined with the carbonate (ammon. chlorid. drachm ss. (2.0); ammon. carbonat. scruple j (1.25); extr. glycyrrh. pur. scruple ij (2.5); aq. pur. fluidounce iij (grammes 100.0)—teaspoonful every hour). When the difficulty of expectoration is excessive an emetic may be resorted to. It is true that infants and children vomit with less straining and difficulty than adults, but, still, the practice of flinging emetics around is too common. The unpleasantness of getting up in the night because of a pseudo-croup in a distant patient's baby is not a correct indication for encouraging the indiscriminate use of emetics. When they are required, antimonials ought to be excluded from the list. Ipecac, sulphate of zinc, sulphate of copper, turpeth mineral are preferable.

In urgent cases the hydrochlorate of apomorphia may be used hypodermically (six or ten drops of a 1 per cent. solution in water). Cases of such urgency, and so excessive dyspnoea coupled with cyanosis, as to necessitate tracheotomy are but very rare. But once in thirty years and in many more than four hundred tracheotomies have I been compelled to operate for a case of catarrhal laryngitis. Still, a few such cases are on record. The best-known amongst them is that of Scoutetten, who operated successfully on his own daughter six weeks old.

Narcotics prove quite beneficial, particularly in complications with pharyngeal catarrh. A dose of gr. j–jss of Dover's powder (gramme 0.05–0.1) at night will secure rest for several or many hours to a child of two or three years; an adult is welcome to a dose of 10 or 12 grains (0.6–0.75). When the irritation is great during the day, it is advisable to add a narcotic (acid. hydrocyan. dil., min. j; vin opii, min. viij–xij; codeine gr. ¹/3–½, or extr. hyoscyam. gr. ij–iij—daily) to whatever medicine was given. I am partial to the latter, giving it up to gr. viij–x (0.5–0.6) to adults daily in their mixture, retaining the single dose of opium or morphine to be taken for the night. At that time a single larger dose is rather better than several small ones. Narcotics cannot be dispensed with in all those cases in which—as, for instance, in tubercular laryngitis—deglutition is very painful because of the catarrhal and ulcerous pharyngitis. Bromide of potassium has a fair effect, but frequently fails, and the administration of morphia before each meal is sometimes an absolute necessity.

That complications, such as bronchitis, have their own indications is self-understood. The general rules controlling the treatment of laryngitis are not interfered with by them. Oedema of the glottis, however, when occurring during an attack of laryngitis, has its own indications, and very urgent ones indeed in all acute cases. In chronic cases a causal treatment is required according to the etiology of the affection as specified above. In acute cases it is not permitted because of want of time. The danger of immediate strangulation is often averted only by a deep scarification or the performance of tracheotomy.