great power in severing the attachment of tumors and other outgrowths.
When of a large size, it may be sufficiently powerful to pass through
bony structures, as well as the softer parts of the body. The principle
of the snare has been employed both in the throat, the ear, and the
nose; but when my attention was first directed to this subject the
forms available were too large and heavy for the delicacy of
manipulation demanded in removing small tumors lodged in the narrower
recesses of the nose. Moreover, no snare that I could then find would
permit the galvanic current to pass through the loop at the time it was
being narrowed. I was led, therefore, to inquire into the
practicability of an instrument which would at once be light, be of
small size, and yet be sufficiently powerful to remove that class of
hypertrophied tissues and polypoid growths which are of such frequent
occurrence in the nasal chambers. The instrument shown in Fig. 22
combines these qualifications, and satisfactorily performs the service
for which it was designed. The only feature of an essential character
which may be said to be novel is the fact that the platinum wire (3,
Fig. 22) forming the snare is covered with a uniform coat of copper,
excepting alone the portion forming the loop, which is bare. As a
consequence of this arrangement the current of electricity from the
battery is conducted through a double canula (2, Fig. 22) by means of
the copper. The length of the instrument being about 9½ inches, and its
weight less than ½ ounce, delicacy of manipulation is not interfered
with. Besides possessing all the features of the cold wire snare, it
has the additional advantage of securing a more rapid and painless
operation, without any hemorrhage. Sessile (pyramidal) or resilient
growths may be removed by first burning a groove of any depth into
them, after which the loop is drawn while the current is passing
through it. For this task the cold wire snare is obviously incompetent.
Growths of unusual size or hardness may be destroyed by the same
procedure, and nodules no larger than a grain of wheat may also be
excised with great nicety. {57} It will be seen that failure to remove
at least a portion of the growth attacked is an event exceedingly
unlikely to occur. I have been particularly struck with the facility
with which hypertrophies of the inferior turbinated bone can in this
way be treated; and if cocaine be freely applied before the operation,
it constitutes, in my judgment, the most speedy and the least painful
of any means by which such conditions can be reduced. By using a canula
with a curved end it is easy to snare growths situated on the posterior
portion of the inferior turbinated bone. The current passing through
the battery (Fig. 23, B) to the instrument can be interrupted by any of
the numerous devices with which the practical electrician is familiar;
or the treadle of the battery can be depressed and locked by the
lever-catch, and the interruption of the current be determined by the
pressure of the finger {58} on the knob in the handle (Fig. 23, A).
This is under all circumstances desirable, since the weight of the
cells is sufficient to demand considerable force to be exerted by the
foot--always enough to destroy the delicacy of the manipulation of the
instrument.
[Illustration: FIG. 24. Two Electrodes of peculiar shape in use by the
Author.]
An electrode which is wrapped nearly to its distal end (Fig. 24), and
used either in a straight or a curved form, is of great advantage in
reaching growths within the naso-pharynx. The straight form can be
thrust directly back through the nasal chamber, and the curved form can
be passed from the oro-pharynx to the naso-pharynx without danger of
burning the posterior border of the soft palate.
{59}
NEUROSES OF THE LARYNX.
BY HOSMER A. JOHNSON, M.D., LL.D.
DEFINITION.--Disorders of sensation or motion, or of both sensation and
motion, due to disease, first, of the centres from which the nerves of
the organ are derived; second, to disease along the track of the
nerves; third, to disease in the terminal distribution of the nerves;
fourth, to reflected irritation from neighboring or distant parts; and
fifth, to myopathic change. This last condition is not necessarily a
neurosis; it is nevertheless a cause of modification of the function of
the parts to which the nerves are distributed, often a result of
paresis or paralysis, and therefore inseparably associated with the
neuroses of the organ. Disorders of innervation, depending upon
structural disease of the larynx, such as ulceration or tumor, are not
included in this definition.
ANATOMICO-PHYSIOLOGICAL CONSIDERATIONS.--The framework of the larynx
consists of cartilages securely but rather loosely articulated with
each other. The movements of these cartilages produce changes in the
position and tension of the soft parts. The thyro-cricoid articulation
allows ginglymoid and sliding motion; the aryteno-cricoid, rotatory and
sliding motion; the hyo-thyroid, ginglymoid motion. The physiology of
the muscles of the larynx is quite complex, since nearly all have
fibres taking a number of different directions, and the changes in the
form and positions of the parts depend upon the combined action of
different muscles and parts of muscles which may be individually
brought into action to produce the required results. The muscles may,
however, be roughly divided into groups: 1. Constrictors of the
superior strait; 2. Dilators of the superior strait; 3. Adductors of
the vocal cords; 4. Tensors of the vocal cords, external, internal; 5.
Relaxers of the vocal cords; 6. Abductors of the vocal cords.
The superior strait of the larynx is closed by the action of the
oblique portions of the arytenoideus, acting in conjunction with the
ary-epiglottici, into which some of its fibres are continued, thus
drawing the cartilages of Santorini downward and inward and
approximating the ary-epiglottic folds and depressing the epiglottis;
while the thyro-epiglottici complete the closure by further depressing
the epiglottis. Fibres of the latter muscle, acting alone, may dilate
the superior strait by drawing apart the ary-epiglottic folds.
The transverse portion of the arytenoideus and the superior fibres of
the crico-arytenoidei postici approximate the arytenoid cartilages. The
crico-arytenoidei laterales, and also in a slight degree the external
fibres of the thyro-arytenoidei, rotate these cartilages, turning their
vocal processes inward: the action of the latter two muscles as
adductors is imperfect unless the arytenoids are drawn backward and
fixed by the arytenoidei postici.
The tensor group comprises a number both of the extrinsic and intrinsic
muscles of the larynx. The crico-arytenoidei postici draw the
arytenoids back, external rotation, and consequent abduction, being
prevented by other muscles. The anterior fibres of the crico-thyroid
and those fibres of the {60} sterno-thyroid inserted anterior to the
crico-thyroid articulation approximate the cricoid and thyroid
cartilages, and thus tighten the vocal bands. The posterior fibres of
the crico-thyroid slide the thyroid upon the cricoid, lengthening the
antero-posterior diameter of the larynx. This muscle, acting as a
whole, also compresses the alæ of the thyroid with the same effect. The
constrictors of the pharynx have a similar function. The hyo-thyroidei,
acting in conjunction with the elevators of the hyoid bone, draw the
thyroid forward and tilt it downward upon the cricoid. The form and
internal tension of the vocal bands are greatly influenced by the
thyro-arytenoidei, especially their inner fibres, while the ascending
fibres of the muscle draw the inferior portions of the vocal bands
upward and prevent the sagging of their edges. This muscle, acting
alone, has been thought to cause extreme relaxation of the vocal bands.
Modern research renders this statement of relaxation doubtful. The
contraction of those fibres of the sterno-thyroidei inserted
posteriorly to the crico-thyroid articulation tilts the thyroid upward,
and thus relaxes the tension of the bands.
The crico-arytenoidei postici rotate the arytenoid cartilages outward,
separating the vocal processes, and, acting in conjunction with the
posterior fibres of the crico-arytenoidei laterales, draw the
cartilages outward and downward.
In the cadaveric condition, which is one of relaxation of all the
laryngeal muscles, the glottis is neither closed nor widely open; the
epiglottis is erect against the dorsum of the tongue; the arytenoid
cartilages are slightly separated, so that the glottic opening is a
triangle with the base posteriorly, as in the act of inspiration, but
the separation is much less than in the act of breathing. This
condition is met with in paralysis affecting all the muscles of the
organ.
The nerves of the larynx are derived from the pneumogastrics. The
superior laryngeal is mainly a nerve of sensation for the parts above
the edges of the vocal bands. There are some notable exceptions to this
statement: a branch, external, descends to the crico-thyroid muscles
and is motor in its function. Filaments from the superior laryngeal
endowed with motor functions are also distributed to the folds
extending from the arytenoids to the epiglottis; these are the
ary-epiglottidean bands, and are concerned in the movements of the
epiglottis. It is probable that the arytenoids are also in part
supplied by the superior laryngeal; in other words, that both the
superior and inferior laryngeal nerves are mixed, branches from the
spinal accessory, as well as from the pneumogastric proper, entering to
each of these nerves. Beclard[1] states that the one, the spinal
accessory, is a nerve of phonation; the other, the pneumogastric, is a
nerve of respiration. The sensations of the mucous surfaces below the
glottis depend upon filaments from the pneumogastrics returned along
with the motor fibres from the spinal accessory. The two orders of
fibres go to make up the recurrents. The relations of the recurrents
themselves to the large vessels, as well as to the bronchial glands,
are of importance. At the point of their origin they are in close
relation with the aorta and right subclavian; they are also in close
relation with the top of the lungs. Disease of these organs and
structures, especially of the large blood-vessels, such as aneurism of
the aorta or subclavian, disease of the glands, tumors, abscess,
traumatism, etc., may modify or completely destroy the functions of the
laryngeal nerves. In short, anything or any condition by which pressure
may be made upon the pneumogastrics or recurrents may become a cause of
nervous disturbance in the larynx. In addition to this general source
of innervation, Elsberg[2] describes a special centre of sensation for
the throat in the medulla oblongata. He also describes three kinds of
sensibility in the larynx--tactile, dolorous, and reflex. Rossbach[3]
details experiments from which he concludes that there are nerve-cells
in {61} the mucous membrane of the larynx which preside over the
function of secretion. The larynx is endowed with at least two kinds of
sensibility: the one tactile--when exalted it becomes painful; the
other, reflex sensibility, is double. First, there is as a result of
excitement a contraction of the subjacent muscle, and there follows
closure of the glottis. This is seen in the application of irritants to
the parts, such as solutions of nitrate of silver or other escharotics.
There is no cough, but great difficulty of inspiration. Expiration is
free and easy. There may follow some degree of pain for several hours.
It will be seen that the phenomena are the same as those observed in
the irritation of other mucous surfaces. The irritation is immediately
translated into motion; this motion is probably reflex, but not
necessarily through the centres, such as the brain or cord. The motion
is of the subjacent muscles. Second, the mechanical irritation produced
by the presence of a drop of water or a morsel of food in the larynx
results in violent and explosive cough. The cough persists until the
offending drop or body has been removed. This kind of sensibility calls
into action distant muscles. There is no spasm of the adductors of the
glottis, as in the case of the application of caustics. It is probable
that the filaments of the nerves, the irritation of which gives rise to
spasm, are distributed more generally than those which preside over
reflex action at a distance and produce cough. The one set of functions
are designed probably to protect the organ from the intrusion of
foreign bodies; the other for their expulsion, as well as for the
removal of the secretions of the parts or of matter brought up from
below. The hypothesis of a third form of sensibility, as described by
Elsberg--namely, the dolorous--seems hardly to be demanded for the
larynx more than for all other mucous surfaces subject to pain. The
nerve-cells of Rossbach in the mucous membrane may be peculiar to the
larynx and trachea, as he claims, but further observations are required
for the demonstration of this as a special histological fact
distinguishing laryngeal from other mucous surfaces.
[Footnote 1: _Dic. Eng. des Sci. med._]
[Footnote 2: _Int. Med. Cong._, 1881.]
[Footnote 3: _Ibid._]
PERVERSION OF SENSATION OF THE LARYNX.
There is some difficulty in grouping the derangements of the
sensibility of the larynx, for the reason that in many cases the
perversion of this function is only a symptom of some other disease of
the organ. Probably in all cases the trouble is, in fact, an expression
either of disturbance in the structures of the larynx, involving more
than the sensory nerves, or it is the result of change in structure or
function of neighboring or distant parts. Various attempts have been
made to classify these disorders according to the kind of perversion
and also according to the cause of the trouble. Elsberg, in a paper
presented to the International Congress, London, 1881, p. 224. vol.
iii., makes an attempt at a scientific classification based upon
anatomico-physiological facts. That there is yet much to learn in
regard to these facts, especially the physiological facts, will be
admitted by every one at all familiar with the literature of the
subject. Elsberg, under the term of dysæsthesia, makes two principal
divisions--namely, first, disorders having reference to the quantity or
intensity of the sensation; this embraces simple hyperæsthesia and
simple anæsthesia. The second grand division relates to the quality of
the sensation, and includes only paræsthesia or sensory delusions.
These grand divisions are still further subdivided.
In fact, we have to do with exaltation of sensibility simply, with
sometimes pain; second, with delusion of sensation; and, third, with
lost or diminished {62} sensation. For all practical purposes,
therefore, we may adopt this arrangement, but should consider it as
only provisional, as has been well observed by Schnitzler. These
conditions are described under the terms hyperæsthesia, with or without
pain; paræsthesia; anæsthesia.
Hyperæsthesia.
DEFINITION.--Exalted sensibility of the larynx, not necessarily
associated with pain or other disorders of function. This condition is
rare, but it is nevertheless met with. We sometimes find that the
larynx is abnormally sensitive to touch or to an irritant, even though
there is no marked inflammation. The symptoms and history justify the
consideration of the condition apart.
ETIOLOGY.--Predisposing causes are probably to be found in the general
condition of the nervous system. Persons of a highly susceptible
nervous organization are, other things being equal, more prone to this
affection. Certain habits of life, such as confinement to the house or
want of exercise in the open air, excessive use of the voice in
singing, especially in unnatural keys or after unnatural methods, have
seemed to me to predispose to the exaltation of the sensibility of the
organ. It must be confessed, however, that so little is accurately
known of the history of the disease that we are left in much doubt as
to the rôle of these conditions in the production of the abnormal
state. The exciting causes of hyperæsthesia of the larynx are the
long-continued action of the predisposing causes--acute and chronic
inflammation, mechanical and chemical irritants, etc. So far as my own
experience goes, the use of the voice in an unnatural key, or perhaps
rather the strain upon the parts by efforts to force the organ to
perform the function of phonation in an abnormal manner, has more
frequently been assigned by the patient as the cause than any other one
thing. I have seen quite a number of singers who have by an effort of
the muscles, apparently, produced an intensified irritability of the
mucous surfaces. It is possible that in rare instances there may be an
exalted activity of the receptive centres, and that the local trouble
in the larynx is only a manifestation, in the distribution of the
nerves, of the central disease. In such cases, however, the disorder
should reach all the parts supplied by the pneumogastrics. Inflammation
of the pharynx, soft palate, posterior nares, and perhaps of the
structures of the ear, have an influence over the sensibility of the
parts below, probably through the relations of the glosso-pharyngeal
and other nerves to the laryngeal branches of the pneumogastrics. E. F.
Ingals of Chicago has seen a case of laryngeal hyperæsthesia produced
apparently by a varicose condition of the vessels about the base of the
tongue. Frankel, Tornwaldt, Bayer, Schnitzler, A. H. Smith, Glasgow,
and others have reported cases in which there were symptoms of
hyperæsthesia or of reflex motor disturbances due to trouble in the
nose or pharynx. The general health has much to do with the development
of the local trouble. Asthenia is associated so frequently with
hyperæsthesia of other parts that we should expect to find this
relation also in the larynx.
SYMPTOMS.--The symptoms of hyperæsthesia of the larynx are in part
involved in the definition of the affection--exalted susceptibility to
the touch, intolerance to the presence of mechanical irritants, a
sensation of discomfort in the presence of chemical agents, such as
gases or impure air, and, when the exaltation is excessive, positive
pain. This pain may be only a soreness or tenderness or it may amount
to neuralgia. This last form of exaltation is rare. When present it has
been considered a special disease and treated as a separate affection.
Von Ziemssen and Mackenzie regard it as a variety of hyperæsthesia.
Schnitzler, Jones, Wagner, and Mackenzie report cases. The {63} pain is
said to be not confined to the larynx, but to extend up toward the ear
and along the course of the superior laryngeal nerve. In two cases
observed by the writer the pain not only extended along the course of
this nerve, but into the pharynx and posterior nares as well. In these
cases the patients were both singers, and both had adopted with great
enthusiasm a new method by which the abdominal muscles were brought
into action at the expense of the muscles of the thorax. The pain was
always aggravated by any effort to sing, but more especially by any
return to the method noted. The pain not unfrequently extended to the
face as well as to the ear.
Neuralgia of hysterical origin, according to Thaon,[4] is more
frequently met with on the left side than on the right. Instead of
being general, it is not unfrequently limited to points or
circumscribed patches.
[Footnote 4: _Proceedings Laryng. Cong._, Milan.]
COURSE AND TERMINATION.--The course of the affection is very uncertain.
In the neuralgic variety the pain may be transient, passing away in a
few days or hours even, but generally there are frequent recurrences
extending through weeks or months. Simple exaltation of the common
sensibility is much more persistent and more uniform in its character.
Hyperæsthesia of the larynx is so largely dependent upon the general
health that not only is it very irregular in its course and duration,
but its termination is equally uncertain. It can hardly be said to be a
cause of death, as it does not involve structures necessary to life. It
disappears occasionally without treatment. When complicated with other
affections, such as acute or chronic inflammation, alterations of the
function of the pneumogastrics, with disease of the thoracic viscera or
with general derangements of the nervous system, its course and
termination must depend largely upon the persistence of these
complications.
PATHOLOGY.--So far as the pathology and morbid anatomy have been
studied, there is no appreciable change of structure. This is true, of
course, only of those cases which are not complicated. Whether the
primary lesion is in the mucous membrane, denuding, pinching, or
otherwise modifying the terminal portions of the nervous filaments, or
whether there is an alteration of the conducting portion of the sensory
nerves, or, in fine, whether there is some lesion of the receptive
centres, it is impossible in most instances to say. It is probable,
however, that in some cases the first morbid fact has been an
alteration in the nerves themselves. The cases induced by unnatural
methods of using the vocal organs are apparently of this character.
The diagnosis, prognosis, and treatment will be considered in
connection with Paræsthesia.
Paræsthesia.
Closely connected with hyperæsthesia of the larynx is a form of sensory
delusion consisting of the impression that some foreign substance is
lodged in the organ or that there is some alteration an the structure
of the parts. This is known as paræsthesia.
ETIOLOGY.--The first variety of sensory delusion depends on a primary
injury to the parts. A bone or pin or some other foreign body, perhaps
having lodged in the parts for a short time, has left a persistent
impression upon the mucous surfaces. It is possible that in some
instances there may have been no foreign body in the parts, as we have
in many cases only the statement of the patient. Local inflammations,
small in extent, may possibly have left the parts in a morbidly
sensitive condition justifying on the part of the subject the
hypothesis of a foreign body.
The second variety of paræsthesia is the expression of some disturbance
in {64} a distant part. It is usually hysterical in its character or a
variety of hysteria associated with neurasthenia. It belongs to the
same class of phenomena as the sensory delusions in other parts of the
body. The globus hystericus is one of its forms. Thaon[5] says that
hysteria may give rise to neuralgia as well as to other forms of
hyperæsthesia of the larynx. It also, according to this author,
produces that form of paræsthesia in which there is a sense of a bone
or pin or some foreign substance in the larynx. The general condition
of asthenia, and especially of neurasthenia, may be assigned as a
predisposing cause. The local injury in the one case and the general
hyperæsthetic condition in the other, with some determining fact, such
as the mental impression or an apprehension of trouble in the larynx,
constitute the exciting causes.
[Footnote 5: _Proceedings of the International Congress of
Laryngology_.]
SYMPTOMS.--It usually comes on after an injury or as a result of the
presence of a mechanical obstruction or irritation, the presence of a
bone or pin being frequently invoked as an explanation of the feeling.
In a few cases the sensation is suggestive of an alteration of the
structure of the parts. Patients are inclined to think that they have a
tumor or that there is some deformity. In the first class of cases
there is a sense of pricking or of scratching in the larynx. This is
not constant in locality or in intensity. There will be times,
occasionally days, in which the sensation may be entirely absent, after
which it returns with great severity, the patient insisting that the
cause of the trouble has simply changed its location--in other words,
that there is a migratory body in the throat. That form of paræsthesia
in which the sensation is that of a tumor or malformation is also
irregular in the mode of its manifestation or kind of disturbance. Like
the other forms, it comes and goes, changes its location, and undergoes
modification in its character. It may be associated with neuralgia.