symptoms already described and by the aid of the laryngoscope. The
mirror reveals the fact that the parts are normal in structure and that
there is no foreign body present. The mucous membrane may be hyperæmic
or anæmic, but is not the seat of any active inflammation. The
excessive sensibility and pain of the larynx in ulceration of the parts
will be excluded from this group of troubles by the revelation of the
laryngeal mirror. Cases of pain or perverted sensation dependent upon
the disorders of the nerve-centres usually involve the whole range of
functions supplied by the pneumogastrics, and will generally be
recognized by this fact. Such cases can hardly be called local, and do
not belong to the group of affections embraced in this article.
PROGNOSIS.--The prognosis of simple paræsthesia of the larynx is not
grave. Though it may exist for a long time, it, so far as we know, does
not terminate in death. While it sometimes results in recovery without
treatment, it in a large proportion of cases yields only to both local
and general treatment. Its duration is uncertain. Paræsthesia coming on
after the presence of a foreign body in the organ may last many months
and then gradually disappear. This result will be largely aided by the
moral support which is gained if we can convince the patient that the
sensation is entirely a delusion.
TREATMENT.--For the purpose of meeting local indications in
hyperæsthesia we may apply with a brush or by the means of the atomizer
a solution of morphine and alum of the strength of 15 centigrammes of
morphine and 2 grammes of alum to 50 grammes of water, or to this may
be added 20 centigrammes of carbolic acid and 10 grammes of glycerin.
Of this solution an application may be made each day with the
hand-atomizer. The hand-atomizer is preferable to the steam-atomizer,
for the reason that we know in the use of the former the strength of
the solution. In the use of the steam-atomizer the medicated solution
is diluted with the water of the steam, and we are {65} ignorant as to
the strength of the application. The method of application by the use
of the atomizer is to be preferred to the brush or sponge probang, for
the reason that we produce by it no mechanical irritation of the parts.
The brush or sponge can hardly be used without giving pain or
discomfort. In addition to the solution above indicated, solutions of
borax, of sulphate of zinc, of tannin and glycerin with chloroform, of
nitrate of silver not too concentrated--2 to 10 centigrammes to 30
grammes of distilled water--tincture of aconite, solutions of the
bromides, cocaine and other anæsthetics, may be used with benefit. In
many cases the administration of general tonics along with the local
treatment will be of the greatest value. The application of electricity
to the parts through the surfaces--that is, from one side of the larynx
to the other--will add to the efficacy of other local treatment. The
strength of the current should not be so great as to give rise to any
discomfort. The current should be continuous, and should be repeated
every day for several weeks if the disorder does not yield sooner. In
cases which have been induced by vicious habits of living or of
exercise of the organ there should of course be an entire change of the
habits. The producing cause should, if possible, be removed. The
exposure of the parts to anything which gives rise to pain is to be
avoided. If hyperæsthesia has been induced by unnatural methods of
singing or of speaking, these should be remedied.
In neuralgia the general treatment for that affection is indicated.
Quinine and iron have especially been found useful. In the hysterical
variety of both hyperæsthesia and paræsthesia general treatment is of
more value than local measures. General tonics, moral support, such as
will be secured if we can convince the patient that there is really no
serious trouble with the organ, but that it is only a morbid sensation,
will be of the greatest value. In these cases change of climate, change
of occupation, diversion by new associations, with expectation of
recovery on the part of the patient, often bring about the most
satisfactory results. The diagnosis should be certain and the physician
should be able to speak with confidence in the matter. This will go far
toward effecting a cure. For the purpose of diminishing the general
irritability of the system bromine in some of its combinations,
potassium, sodium, iron, quinine, etc., may be useful.
Anæsthesia.
DEFINITION.--Diminished sensibility of the mucous surfaces dependent
upon lesion of the nerve-centres, alteration of the conductivity of the
nerve-trunks, or upon disease in their terminal distributions. It is
usually bilateral, but may be limited to one side. This alteration of
the sensitive condition of the mucous membranes is usually observed
after diphtheria. It is also met with in bulbar paralysis. In this last
condition it is only one of the phenomena of paresis or paralysis
involving several different organs. It is not, therefore, properly a
disease of the larynx, and the consideration of it will not be embraced
in this article. It has been stated that hysteria is frequently
accompanied with anæsthesia of the larynx. Von Ziemssen, Chairou, and
Schnitzler have published cases. It seems very improbable that this
condition of the organ is so generally present in hysteria as is
claimed by Chairou. It is, however, certain that anæsthesia as well as
hyperæsthesia of the larynx exists as a complication of hysteria. In
the later stages of all exhaustive diseases, as cholera, etc., the
sensibility of this organ is either diminished or abolished. This is
not, however, a true paralysis in the sense in which we generally use
the term. It is only one of the manifestations of the general failure
of the life-forces. The special senses, the reflex functions, all share
in this paresis, this severing of the relationships of life. Anæsthesia
of the larynx is usually {66} confined to the parts supplied by the
superior laryngeal nerves, and is sharply limited by the edges of the
vocal bands. If there is anæsthesia of the parts below these bands, it
is of much less significance and hardly requires our consideration.
ETIOLOGY.--So far as we know, there are no predisposing causes. The
chief exciting cause of this affection is unquestionably diphtheria. It
is, in fact, a sequel of diphtheria. It will hardly be necessary to
repeat here what the reader will find fully discussed in the sections
devoted to diphtheritic inflammation of the fauces and adjacent parts:
we are mainly concerned with the phenomena. Just how this morbid
process produces paralysis is not known. It is believed by some
observers that the disease is produced by the alteration of the
nutrition of the parts during the progress of the diphtheria. It is
stated that the parts most nearly related to the seat of the exudation
are most likely to become involved. This is thought to sustain the
theory of the direct propagation of the morbid changes from the mucous
surfaces to the nerves and muscles. That the paralysis following
diphtheria is not, however, produced alone in this manner seems to be
made evident by the fact that distant parts, parts which have not been
at all involved in the disease, do nevertheless become affected with
paralysis. This paralysis develops when the general health and the
nutritive changes are all improving. It is quite evident, therefore,
that the loss of power in the laryngeal muscles, as well as the altered
sensibility, in part at least, must be due to some lesion of the
nerve-centres. In addition to the causes above noted, anything which
impairs or destroys the function of the superior laryngeal nerve may
produce this affection. In the anæsthesia from hysteria we know only
the fact, but do not know just how the derangements of the nerves in a
distant part, or in the nerve-centres perhaps, are so reflected as to
change the function of this organ. The hyperæsthesias, the
paræsthesias, and the anæsthesias of hysterical character are all
probably produced in the same manner. Anæsthesia in bulbar paralysis is
easily understood, but need not, for the reasons already given, engage
our attention.
SYMPTOMS.--This condition is usually associated with paresis or
paralysis of the muscles of the part. One of the first symptoms of loss
of sensibility is, therefore, a failure of the constrictors of the
larynx to protect the organ from the intrusion of foreign substances in
the form of food and drink. Particles swallowed find entrance into the
respiratory tube, and this with no sense of discomfort. If the
paralysis is complete both above and below the glottis, the intrusion
of these substances is not recognized. There may be no cough or spasm
to indicate the fact. In the mean time, the particles of food descend
into the bronchi, and may become the exciting causes of
broncho-pneumonia. It is often noticed after tracheotomy for diphtheria
that food and drinks gaining access to the respiratory tract are
discovered at the tracheal opening. In several cases within the
knowledge of the writer this fact has led the operator to fear that the
posterior wall of the trachea had been opened. In all cases in which
the pharynx is in a state of paresis a careful examination should be
made by means of the laryngeal mirror.
There are no subjective symptoms, and this fact makes it probable that
the affection is more common than has been supposed. The patient
complains neither of pain nor of any other discomfort. This statement
is only true, however, when there is simple loss of sensation. There
may be paræsthesia associated with partial anæsthesia. In such cases
there will be noted the usual symptoms of paræsthesia. In hysterical
forms of anæsthesia the appearance of the parts is often variable from
day to day. The location of the disordered function is well defined at
the time of one examination, while at the next the condition may be
quite different. It is stated by Thaon[6] that {67} in one-sixth of the
cases of hysteria the larynx is in some way affected. The epiglottis is
more usually the seat of the affection in the hysterical variety.
Several authors have noted that with the laryngeal disorder there is
often a zone of modified sensation beneath the chin and on each side of
the larynx. This sometimes amounts to absolute loss of cutaneous
sensibility.
[Footnote 6: _Loc. cit._]
COURSE AND TERMINATION.--According to Mackenzie, Von Ziemssen, and
others, the anæsthesias following diphtheria usually terminate in
recovery. It is quite possible, however, that the literature of the
subject does not give us elements on which to base an opinion. I am
inclined to think that cases die from this disorder in which the nature
of the affection is never recognized. It is quite certain that
paralysis of the fauces is not unattended with danger. It is also
probable that in many of these cases the real danger is not so much
from the loss of muscular power in the pharynx, and consequent
inability to swallow, as from the fact that the larynx is not protected
from the introduction of foreign substances, that the intrusion of
these substances is not recognized, and the consequent disorders of the
lungs become the cause of death more frequently than has been supposed.
DURATION.--Paralysis of the sensory nerves of the larynx usually lasts
only a few weeks. When a result of diphtheria it disappears with the
motor trouble with which it is associated. As a complication of
hysteria, or rather when hysterical in character, it may last
indefinitely. When dependent upon changes in the centres from which the
pneumogastrics are derived it has a history commensurate with that
affection.
The PATHOLOGY AND MORBID ANATOMY have been suggested in the discussion
of the cause and symptomatology of the disorder. The question of the
local or general changes in the diphtheritic variety is noted in the
history of the disease.
The DIAGNOSIS is made mainly by the examination with the laryngoscope.
The probe will at once determine the presence or absence of the
sensibility of the mucous membrane of the parts. In addition to touch,
electricity may be employed. In these cases the alteration involves
both the tactile and reflex sensory functions. There will therefore be
neither cough nor spasm resulting from a mechanical irritation. The
surfaces are usually quite normal in color and form. The epiglottis is
erect, abnormally so, and there will often be more or less paresis, or
even complete paralysis, of the other muscles of the organ. In some
cases the difficulty in deglutition due to derangement of the reflex
functions may be also suggestive of alterations of sensation in the
parts within the larynx, but it is only a suggestion.
The PROGNOSIS is usually favorable, but for the reasons given above
this should be accepted with some degree of reservation. The
diphtheritic varieties share in the uncertainty of other forms of
paralysis in that disorder. The hysterical forms are not dangerous, but
may continue so long as the primary affection persists.
TREATMENT.--This should be both local and general. The local treatment
consists almost entirely in the application of electricity. Both the
galvanic and faradic currents are recommended. In my own practice I
have been accustomed to resort to the galvanic, but modified by the
introduction of a shunt or switch, so as to produce a wave of
electricity. The manner in which this is accomplished is to connect in
the circuit a coil such as that used for the faradic current. This
takes out of the direct current, with each closure of the circuit in
the coil, a portion of the quantity of the current, and without
entirely interrupting the working circuit gives a wave of electricity,
producing, so far as I can judge, the results of both the primary and
secondary currents. There is not the shock of complete interruption,
while there is the stimulus of the irregular quantity. The electrode
which will be found most convenient is that devised by Mackenzie or
some modification of it. It {68} should be applied through the parts
from one side of the larynx to the other by placing the tip or point of
the instrument in one of the pyriform sinuses over the superior
laryngeal nerve. A double electrode will often answer better, placing
one point in one sulcus, while the other is in contact with the mucous
membrane of some other part of the organ or in the opposite sinus; that
is, on the other side of the larynx. The current then passes through
the parts and stimulates all the tissues between the two poles. The
application should be made every day, and for several minutes at each
sitting, interrupted, of course, as required by the variable condition
of the parts. The current should not be so strong as to produce
positive pain. This is not easily reached, however, for the reason that
the response is slow and uncertain. The strength of the current should
be tested upon the normal surfaces of the patient, or, better, upon the
mucous membranes of the operator, before applying it to the morbid
parts.
In case a reliable tangent galvanometer is used, much more certainty
can be reached than when the strength is determined solely by the sense
of touch. With this exhibition of electricity there should also be
administered such remedies as are best calculated to restore the
general strength of the patient--quinia and iron, with the bitter
tonics, and especially strychnia in what would be considered large
doses (.003-.005 grammes), two or three times a day, with interruptions
every few days. In the hysterical cases, as well as those following
diphtheria, electricity is often of great value.
Attention should also be given to the proper treatment of any local
trouble in the viscera of the abdomen or pelvis. Uterine disease, if
present, as it frequently is, demands attention. It is believed by some
authorities that the unilateral disorders of the larynx dependent upon
ovarian irritation generally manifest themselves upon the side
corresponding to the diseased ovary. It is, however, rare to meet with
complete unilateral anæsthesia. In addition to the use of these
measures, change of surroundings, especially in the hysterical variety,
diversion by new associations, new occupations, etc., are to be secured
whenever practicable.
DISORDERS OF MOTION.
Disorders of motion are perhaps more complex than those of sensation.
They may be divided into two general groups--1st, exalted action; 2d,
diminished or arrested action. The first group is susceptible of a
subdivision: first, those in which the sensory functions are exalted as
well as the motor. In some of these cases the real disturbance is very
probably hyperæsthesia rather than increased irritability of the nerves
going to the muscles. Generally, however, the morbid phenomena are
mixed; the two sets of nerves are both in a state of over-action.
Spasm, for instance, may be the result of excessive activity of the
sensory function coupled with the exaltation of the motor impulses, or
exaggerated irritability. Second, the spasm or exalted activity of the
muscles may be entirely independent of sensory impressions, possibly,
in some instances, dependent upon muscular conditions, but generally
only the local expression of some central nervous trouble. Chorea may
be cited as an example. The diminished action of the motor system may
also be due to either a want of the sensory common or special
impressions; or it may be due to failure of the motor centres or some
interruption of the continuity of the conducting media; or, lastly, it
may be for the reason that the muscles themselves are so changed that
they do not respond to the normal stimuli, such as the {69} commands of
the will or reflex impressions. It will be seen from this brief
statement that the subject of motor derangements is one of much
complexity. From the very nature of the complications it is often
impossible to satisfactorily analyze the symptoms and to determine with
certainty, in a given case, whether we have to deal with a simple or a
compound result. We may, it is true, in some instances arrive at
approximately correct conclusions by resorting to the physiological
methods of testing the muscle by galvanism and faradism. In other
instances we may by a careful study of the history of the disease reach
at least a provisional opinion. We must, after all, admit that much
will in many of these derangements remain to be conjectured.
Exalted Action.
There is quite a difference among authorities as to the place in the
classification of disease of the larynx which should be assigned to
spasm as met with in childhood, and which is also occasionally
encountered in adult life. It is not possible, perhaps, in the present
state of knowledge, to separate in every instance those cases in which
there is disorder of the circulation and nutrition of the larynx from
those in which the spasm is the result of disturbance simply of
innervation, or in other cases the reflex manifestations of nervous
irritation elsewhere. Generally, however, this can be done. I have for
a long time been accustomed to consider the affection known as
spasmodic croup to be a mild inflammation of the larynx, and that it
differs from the same affection in the adult for the reason that the
lumen of the tube is smaller, the cartilages are more yielding, and the
susceptibility of the parts is greater, and further for the reason that
the nervous system in childhood is always more prone to spasm than in
the adult. Stridulous laryngitis, however, is a real disease, and is
for the reasons above given a neurosis, even though it is an
inflammation. It is entitled to a separate description for the reason
that the symptoms are so well marked and differ in so many particulars
from those of ordinary inflammations. That there is, besides, a true
spasm of the muscles of the larynx, independent of inflammation, by
which the vocal cords and the constrictors are brought into action and
possibly kept in a state of tonic contraction, is possible.
In a majority of instances of laryngeal spasm there is a degree of
inflammation, as above stated, or at least a degree of congestion of
the mucous membranes. It is certainly true, however, that in
exceptional cases there are no indications of such a condition of the
parts, so far as we can determine by ante- or post-mortem study. It
seems to be evident, then, that under this name of spasm of the larynx
or of some synonym of it many careful observers have recorded facts and
have grouped them with the thought that the functional derangement was
the main trouble. The real difficulty appears to be that the spasm is
in fact a symptom--a symptom of perhaps several different disorders,
but so prominent and creating so much alarm that it has seemed for the
time being to be the disease itself; and yet in most cases there is a
mild form of inflammation, local in its extent, and producing, so long
as there is no interference with the function of respiration, no
general disturbance. It is perhaps appropriate to include in the
discussion not only the purely nervous cases, but also those conditions
in which, while there is hyperæmia, and probably always some
derangement of secretion, nevertheless the symptoms and dangers concern
mainly the motility of the muscles of the organ.
The disease occurs both in children and in adults. There is, however,
in its etiology, course, and terminations quite a marked difference, as
observed before and after puberty. We shall therefore consider, first,
spasm of the glottis in children; second, in adults.
{70} Spasm in Children.
SYNONYMS.--Laryngismus stridulus, False croup, etc.
ETIOLOGY.--Predisposing Causes.--The disease occurs most frequently in
children from a few months to two or three years old. It is
occasionally met with in those still older and up to puberty. It seems
to be more often encountered in patients of a strumous habit than in
those of a healthy constitution. Rickety children are especially liable
to the affection: the German pathologists especially insist upon this
factor. Patients of a nervous temperament predisposed to general spasms
are especially predisposed to this affection in the larynx. It is a
general law that muscles weakened either by disease or by fatigue or by
deficient nutrition are especially irritable. In them mechanical as
well as other forms of stimuli produce local contraction with great
readiness. These contractions are, it is true, rather the expression of
the condition of the muscles than of the nerves. The muscular condition
must, however, be regarded as a predisposing cause of the spasm. In the
same way, perhaps--namely, by the inherited tendency to lower forms of
vitality, weakened muscular power--we may account for the fact that
family history of similar conditions, such as false croup in other
members or in the parents, should be considered as among the evidences
of predisposing tendencies to spasm of the glottis.
Sex has in this affection, as well as in most laryngeal diseases of
children, a predisposing influence. Mackenzie has collected in all,
from different sources, 8248 cases. Of these, 5378 were boys and 2870
girls--a proportion of nearly 2 boys to 1 girl. In adults the reverse
holds good, females being much more frequently seized than males. It is
certain that season has something to do with the development of the
disease, but this influence should be regarded rather as a producing
than a predisposing cause.
Dentition, worms, weaning, or anything which produces an irritation of
the alimentary canal may also, by exciting the reflex irritability of
the nervous system, become predisposing causes of laryngismus. The
influence of dentition has, however, been probably over-estimated.