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 {77} spasmodic
expiratory efforts. The patient recovered under treatment by
arsenic.[8]
[Footnote 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]
[Footnote 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 {78} 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; {79}
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 Tourgues[10] 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.
[Footnote 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 {80} 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, {81} 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 {82} 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.