THE 
AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 
FOR APRIL 1 8 7 0. 
Art. I.— Cases of Aphonia from Paralysis of Intrinsic Muscles of the 
Larynx. Treatment by External Manipulation of the Orgdi% and 
Restoration of the Voice in a Single Sitting. By Henry K. Oliver, 
M. D., Physician to the Massachusetts General Hospital, Boston. (With 
seven wood-cuts.) 
Of the various affections of the larynx, the neuroses have always been 
among the most interesting, and, since the means of inspecting the interior 
of the organ in the living subject have been at our command, the paralyses 
of its intrinsic muscles have excited marked attention. It is now possible 
to say, with a great degree of precision, what particular muscles are de- 
prived of their power in any case, and thus to classify pathological condi- 
tions which were formerly comprehended under the general term, Paralysis 
of the Glottis. 
I purpose suggesting a novel mode of treatment in the form of laryngeal 
paralysis called, by Mackenzie, “Paralysis of the Adductors of the Yocal 
Chords;” and by Tobold, “Phonic Paralysis,” a form bilateral in charac- 
ter, and dependent, in the majority of cases, upon general debility and 
hysteria, or other impairment of the nervous system, but sometimes upon 
emotional influences and a weakened condition of the muscles following 
laryngitis or the straining of the voice, and more rarely upon rheumatism 
and other blood diseases. 
On laryngoscopic examination, either complete or incomplete paralysis 
of the cords will be found. In the former case, these ligaments, on at- 
tempted phonation, remain widely separated. In the latter case they ap- 
proach the median line of the glottic aperture to a greater or less extent; 
they may even come nearly into apposition with each other for the 
No. CXVIII.—April 1870. 306 
Oliver, Aphonia from Paralysis of Muscles of Larynx. [April 
greater portion of their length, but the vocal processes will not be in con- 
tact, and the cartilagiuous glottis will not be wholly closed. In some 
cases the vocal processes will come into apposition with each other, and 
the cartilaginous glottis will be closed ; the parts are then in a position 
suitable for phonation, but when the air is forced against the cords they 
are not able to retain their position, but separate without vibrating. At 
other times the cartilaginous glottis will be partially closed by an incom- 
plete approximation of the arytenoid cartilages, whilst the vocal processes 
and, of course, the vocal cords, remain separated. 
The methods of treatment commonly employed in the affection which 
has been spoken of, are as follows:— 
1st. Galvanism. 
2d. The application of stimulating liquids to the interior of the larynx, 
or the inhalation of stimulating gases. 
3d. The “Gymnastic of the Larynx,” suggested by Von Bruns, of Tu- 
bingen.1 
4th. The employment of an anaesthetic. 
5th. A general course of treatment only, such as change of air, tonics, 
&c. 
It is well known, moreover, that, in this affection, the voice has been 
suddenly restored under some general excitement or mental impression. 
In addition to the methods of treatment above enumerated, I propose 
that by the external manipulation of the larynx. This method consists 
chiefly in the compression of the wings of the thyroid cartilage in their 
posterior and upper part by the thumb and forefinger. Such compression, 
if practised on the dead larynx, will be found to approximate, to a certain 
degree, the arytenoid cartilages, and, as a consequence, the vocal cords. 
These ligaments will also become somewhat tenser. If the compression 
be made in the living subject, the same approximation and stretching of the 
cords may be observed by the laryngoscope. 
In employing this method in paralysis of the adductors, the patient is 
instructed to make an effort to produce a sound, like that of a or ah, or 
any sound of the voice whatever, while compression of the larynx is being 
made. The result generally is that, after a little time, a feeble voice-sound 
is produced, arid this is followed shortly after by the full restoration of the 
voice. 
Many of these cases seem to be dependent upon a lack of power to 
start the machinery of the vocal apparatus completely, if the expression 
1 In this method of treatment the patient is asked to produce simple sounds, as 
of the vowels or diphthongs, while the laryngeal mirror is in position in the 
pharynx. It has been practised by Von Bruns with some success. Occasionally 
the voice has been restored in a single sitting, but generally the treatment has 
extended over a considerable period. 1870.] Oliver, Aphonia from Paralysis of Muscles of Larynx. 
307 
may be allowed. When once started, by any means, the power of keeping 
up the action is pretty easily afforded. The paralysis seems, therefore, to 
be of an unusual character; indeed, the many well-known instances of sud- 
den restoration of the voice, either unaided by any local treatment, or in- 
duced by direct stimulus1 to the interior of the larynx, show a condition 
quite peculiar to the laryngeal muscles. 
It has come to the knowledge of every physician, probably, that quacks 
have succeeded in restoring the voice, immediately, by grasping the throat 
and producing violent compression. The recovery, under such circum- 
stances, may have been owing, in a measure, to the mental impression upon 
the patient, but it may have been aided by such an adaptation of the parts 
of the larynx as I have described, a condition of things unappreciated by 
the operator, but leading none the less to a successful result. 
As an aid to this manipulation of the larynx, I have taken advantage 
of the valvular nature of the vocal cords, an anatomical fact first, so far 
as I am aware, demonstrated by John Wyllie, M. D., M.R.C.S., in a prize 
dissertation entitled “Observations on the Physiology of the Larynx,” 
published in the Edinburgh Medical Journal, vol. xii. (September, 1866). 
Reference to this subject will make a digression necessary. 
Dr. Wyllie shows that the vocal cords, when approximated, constitute 
a valve opening outwards, while the false cords form a valve opening in- 
wards. In the complete glottic closure, when inspiration and expiration 
are impossible, the former act is prevented by the vocal cords, and the lat- 
ter by the false cords. He observes, after describing his experiments upon 
the larynx:— 
“ The conclusion to be derived from these experiments is obvious. There is 
within the lai-ynx a double valve which is capable of controlling both the exit 
and entrance of air. The plan found so commonly throughout the body in such 
structures, in the aortic and ileo-csecal orifices, and in the course of the veins, 
holds good here likewise. In the upper half the resemblance is most obvious. 
Comparing it with the aortic valve, we find the representatives of the sinuses 
of Valsalva in the well-marked ventricles of Morgagni, whilst the cusps are re- 
produced in the two folds of mucous membrane, whose free edges are known as 
the false vocal cords. 
“ The same design may be traced in the lower half of the valve. When the 
true vocal ligaments are brought into apposition, no deep sinus is found on 
either side, but their upper surfaces form together a broad flattened plane, 
slightly hollowed out exterior to the margins of the rima glottidis, and this 
arrangement, owing to the greater density and mobility of the parts, is found 
to act as efficiently as the well-marked ventricles and cusps of the upper valve.” 
A longitudinal section of the larynx, through the middle of the vocal 
cords, shows this valvular arrangement clearly. The annexed Fig. 1 is 
an outline of the representation given by Dr. Wyllie. A is the vocal cord; 
b the false cord; c the wedge-shaped space below the vocal cord; the 
wedge-shaped space above the false cords; e the ventricle of Morgagni. 
1 Either of a single shock of the galvanic current, or the local contact of the 
uncharged sponge. 308 
Oliver, Aphonia from Paralysis of Muscles of Larynx. [April 
Annexed, also, are outlines of the interior of the larynx, taken from 
sections of gypsum casts.1 In the larynx from which the outline Fig. 2 
Fig. 1. 
Fig. 2. 
was taken, the vocal cords and the false cords were brought slightly out 
from the side of the organ. In that from which Fig. 3 was taken the 
ligaments were brought into apposition, while in Fig. 4 the vocal cords, 
only, were approximated. 
Fig. 3. 
Fig. 4. 
It will readily be seen that, on account of the wedge-shaped space below 
the vocal cords, the expired current of air can easily force the vocal cords 
apart, even when they are tightly closed, but that it will find effectual re- 
sistance at the false cords, where the ventricles will be inflated and these 
1 The following method of preparing outlines of the interior of the larynx oc- 
curred to me, and the results have been quite satisfactory:— 
A cast in gypsum of the interior is first made; this is then painted black, and, 
is set upright in a box an inch or two square, and of a height corre- 
sponding to the length of the cast, and into the box is poured liquid gypsum. 
After hardening, a section of the mass is made with a watch-spring saw. The 
outline of the interior is thus clearly represented by the line of black; this line 
is, in fact, an exact counterpart of the mucous membrane in section. 1810.] Oliver, Aphonia from Paralysis of Muscles of Larynx. 
309 
folds be brought firmly into apposition. In the inverse action, namely, in 
inspiration, the air can easily wedge apart the false cords, while the vocal 
cords become the resisting bodies. 
In cases of bilateral paralysis of the abductors of the vocal cords, viz., 
the posterior crico-arytenoid muscles, the approximation of the cords in 
inspiration, and their separation in expiration, have been frequently noticed 
by the laryngoscope, and, so well do these ligaments act the part of valves, 
under such circumstances, that suffocation is often only averted by the per- 
formance of tracheotomy. The noisy character of inspiration and the 
noiseless character of expiration are also remarked in these cases.1 
It is this action of the vocal cords only which concerns us now. 
In regard to the vibratory function of the vocal cords by the inspired 
current of air, the following remarks are submitted : While it is true that 
the pressure of this current tends to bring the cords more firmly together 
when once they are in contact and the current is suddenly interrupted, yet 
the inflowing column occasions the vibration of the ligaments when they 
are more or less approximated, but not in intimate contact. Again, when 
the vocal cords are not sufficiently approximated to oppose a resistance 
to the air capable of exciting vibration, such an approximation may, by 
virtue of their valvular character already alluded to, be obtained by making 
strong and sudde® inspirations: provided, however, that they are previ- 
ously brought together somewhat, so as to become a material obstacle to 
the passage of air. In other words, there is a degree of approximation 
of the cords insufficient for their vibration, but sufficient for the offering 
of resistance to the air; and the form of the obstructing bodies is such 
that the air tends to approximate them still more rather than to separate 
them, and that to a degree sufficient for vibratory action. In this move- 
ment of approximation the air acts the same part in relation to the cords 
that the blood does in relation to the aortic valves, except as regards the 
degree of closure. This action of the vocal cords with forced inspiration 
during compression of the thyroid cartilage, as described, I have verified 
by auto-laryngoscopal observations. The degree of approximation neces- 
sary for inducing vibration with inspiration seems to be considerably less 
than that required with expiration—a fact which goes to confirm the asser- 
tion that the form of the cords is such as to offer a greater resistance to 
the inflowing than to the outflowing column of air.3 
1 In the pathological conditions which are accompanied by oedema of the larynx, 
in which the ary-epiglottidean fold, which forms the superior aperture of the larynx, 
is often the most affected, the swollen parts form a third valve opening outwards. 
A characteristic symptom of this affection, when the false cords are but little im- 
plicated, is difficulty of inspiration, expiration being comparatively easy. 
2 In hurried breathing the vocal cords may often be observed to move 
slightly outwards in inspiration, thus enlarging the glottic aperture, while they 
return to their former position in expiration. A reasonable explanation of this 310 
Oliver, Aphonia from Paralysis of Muscles of Larynx. [April 
Now, in the method of treatment I have suggested, a degree of approxi- 
mation in the cords sufficient for decided resistance to the air is to be 
obtained by the compression of the wings of the thyroid cartilage, and a 
still further approximation, sufficient for vibration of these ligaments, by 
making strong and sudden inspirations. In the two most obstinate cases 
recorded below, therefore, the patients were instructed to attempt to make 
a sound by strong and sudden inspirations during compression of the 
larynx. The efforts were successful, and in both instances a voice-sound 
could be produced by inspiration before any could be made by expiration 
in the natural way. When, however, the vibration of the cords was once 
excited, their action in the normal way followed in a short time. 
The cases to be presented are six in number, comprising all in which I 
have employed this method. None are instances of complete paralysis, 
and I have not had an opportunity of testing the treatment upon this 
extreme form. I do not, however, doubt its efficacy, inasmuch as these 
cases often yield to a single application of galvanism. 
Case I.—Mrs. C., widow, aged 73 years, came to me in November, 1867. 
Her general health had always been good. In 1857 she lost her voice 
suddenly, no cause therefor being apparent. The voice returned of itself 
three months afterwards, its reappearance being also abrupt. 
In November, 1866, while absent from home, she had 
typhoid fever. Some weeks afterwards* she lost her voice 
suddenly again. At this time she had not fully recovered 
her strength, but was sufficiently strong to return to her 
place of residence. A second time the voice returned of 
itself, and in about four weeks. 
Six months before visiting me aphonia occurred again, 
and she had not spoken a word since. 
For her age, Mrs. C. seemed in excellent general health 
and condition, although she thought she had not been quite 
as strong since the fever as before. She spoke only in a 
whisper, and had become quite discouraged about recover- 
ing the voice again at her age: indeed, she had come to 
consult me with great unwillingness on her part and only 
on the urgent advice of friends. 
On examination with the laryngoscope, the cords were 
seen to approach each other equally well on attempted 
A is the anterior 
insertion of the 
vocal cords; a, a, 
are the arytenoid 
cartilages; v, v, the 
vocal processes; c, 
arytenoid commis- 
sure. 
movement would seem to be the following : Inspiration is the result of strong 
muscular action, and the air consequently enters the passages with considerable 
velocity. Expiration is, however, principally a passive act, being the result of a 
relaxation of muscular action and the contraction of elastic tissues, and there is, 
consequently, less power in the current of air. We might, therefore, expect to 
find, as we do, a temporary enlargement of the glottic aperture with the inspira- 
tory act. But it is not unreasonable to suppose that this movement of the cords 
is a consequence of their peculiar form, a form, by the way, necessary to the best 
phonetic results. These ligaments are, namely, removed during inspiration from 
a position where, otherwise, the current of air would tend to make them approxi- 
mate, and so obstruct respiration. 1810.] Oliver, Aphonia from Paralysis of Aluscles of Larynx. 
311 
phonation, but to a certain extent only, the vocal processes not coming 
iu contact, and the cartilaginous glottis remaining open (Fig. 5.)1 No 
other abnormal appearances of any kind were discovered in the larynx. 
It being evident that the difficulty was paralysis of the adductors, treat- 
ment by manipulation was determined upon, but on account of the mental 
depression, to which allusion has been made, and which was really quite 
marked, it was thought best to endeavour previously to excite the patient’s 
interest, and inspire some degree of hope, by a pretended use of electricity. 
A very feeble electric current was consequently passed through the neck for 
a few seconds, with no effect upon the voice. The wings of the thyroid 
cartilage were then compressed, and the patient was instructed to endea- 
vour to make a sound. In the course of perhaps five minutes a sound 
was produced, and she immediately after spoke in a sufficiently strong voice, 
which continued after the removal of the compression. 
The day following Airs. C. returned to my office and was speaking in a 
loud, strong tone. Since this second visit I have not seen her, but mem- 
bers of her family have informed me that she has continued to retain the 
voice. 
Remarks.—Although the electric current was employed in this case 
there is no reason for believing that it had the slightest influence in the 
restoration of the voice, for while a moderately strong current passed from 
the interior to the exterior of the larynx is often the means of curing the 
aphonia at once, yet the treatment by electricity externally is successful 
only after its employment for a considerable time—days and even weeks 
being required. 
Case II.—Mrs. , aged forty, was brought to me by Dr. Joseph 
Garland, of Gloucester, Mass., November 22, 1867. Her health had been 
pretty good till ten years before, when she had uterine difficulty lasting 
two years. At one time, as Dr. Garland reported, marked ulceration and 
hypertrophy of the neck of the womb existed. Four years subsequently, 
she again had a similar trouble, her health again became affected and she 
had been feeble ever since. Amenorrhoea had existed for some months. 
Some slight hysterical manifestations had been noticed. Two years pre- 
viously to her consulting me aphonia came on suddenly, and although she 
thought she had been able to make a single sound above a whisper, once 
or twice since, there had been no real restoration of the 
voice. 
Her appearance was characteristic of a general and 
marked want of vitality. On making very light pressure 
along the spine, tenderness was complained of, at various 
points. 
On examination with the laryngoscope the larynx had a 
perfectly healthy look. On attempted phonation, the liga- 
mentous glottis closed, the vocal processes being in appo- 
sition, but the cartilaginous glottis remained open (Fig. 6). 
• Manipulation of the larynx was at once resorted to, 
firm pressure being made upon the wings of the thyroid cartilage, as in 
the previous case, and the patient was asked to count one, two, three. 
Fig. 6. 
1 This and the succeeding figures are nearly after Tobold. 312 
Oliver, Aphonia from Paralysis of Muscles of Larynx. [April 
After a trial of a minute or two. merely, a voice-sound was heard, and 
almost immediately afterwards every attempt was successful, so that when 
the compression was discontinued she spoke in a moderately loud tone. 
After no doubt existed that the voice was really restored, the patient was 
dismissed with instructions to read aloud daily and cautions to repress 
any tendency to whisper. Tonics, etc. were also advised. 
A week or two after, Dr. Garland informed me personally that the voice 
was still good. Subsequently, I supposed that the case was doing well, 
since I heard nothing to the contrary, but, in reply to a letter of inquiry in 
the spring of 1869, Dr. G. wrote that the voice gradually became weaker 
during the winter of 1861 and 1868, until complete aphonia again occurred. 
A second visit from the patient was requested, but I have not seen her 
since. 
Remarks.—The voice was not permanently restored in this case, but 
this fact does not invalidate the efficacy of the method of treatment em- 
ployed. The relapse would undoubtedly have occurred whatever method 
had been selected, and was due to the want of vitality in the general system. 
It is but just to add that I)r. Garland seems to have done all that was 
possible to improve the condition of the patient after the temporary resto- 
ration of the voice; and in addition to the general course of treatment, he 
employed the inhalation of the spray of stimulating solutions, and elec- 
tricity. 
Case III.—Miss W , seamstress, aged 31, was brought to me by 
Dr. I). McB. Thaxter, of South Boston, June It, 1868. Her health had 
never been very good; she had always been “ subject to lung troubles 
had also had menstrual difficulties, the menses having been sometimes ab- 
sent for six months at a time. In the fall of 1858, she had lung fever. In 
the spring of 1859, she contracted a “ cold,” was hoarse and had some in- 
definite pulmonary symptoms. At this time her voice left her and was 
absent three months, returning suddenly. In March, 1860, she had an 
attack of “ congestion of the lungs.” Towards the latter part of this ill- 
ness she lost her voice again, this time suddenly, and she had not spoken a 
loud word since then, a period of eight years. 
On several occasions in the two years previous, Miss W. had raised 
blood in slight amount, mixed with “phlegm at these times there was 
no menstrual irregularity. Her general health had, however, rather im- 
proved in these two years, and she had gained in flesh and strength. Of 
late, too, she had had less menstrual disturbance. On the other hand, 
during the last four months she had had more cough than formerly, with 
expectoration of varied character and some pain in upper part of chest. 
At the time of the consultation, Miss W. had a delicate look, but was 
in pretty good flesh. Appetite, good ; pulse, 80. She articulated in a 
smooth whisper, and with all her efforts, a voice-sound could not be pro- 
duced. Tenderness was found at various points in the length of the spine, 
even when the pressure was very light. General tenderness of the larynx 
on pressure was also complained of. An examination of the lungs revealed 
no definite sign of disease of any kind. With the laryngoscope no inflam- 
matory or other abnormal appearances were discovered in the larynx. On 
attempted phonation, however, complete closure of the glottis did not take 
place. The shape of the glottic aperture varied. At one time the vocal 1810.] Oliver, Aphonia from Paralysis of Muscles of Larynx. 
313 
cords would be approximated for the greater part of their length, the vocal 
processes remaining somewhat separated, and the cartilaginous glottis 
being open. The appearance then was much as represented in Fig. 5, 
Case I. At another time the arytenoid cartilages would be 
approximated in such a way that the posterior portion of 
the cartilaginous glottis was closed, while the vocal pro- 
cesses were far apart and the ligamentous glottis, conse- 
quently, open (Fig. t). 
Notwithstanding the aphonia had existed for so long a 
period, I determined to try the effect of compressing the 
thyroid cartilage. This was done, with simultaneous attempts 
at the production of sound on the part of the patient. In 
ten or fifteen minutes (including intervals of respite), a voice- 
sound was heard, although weak in character. After becoming 
convinced by repeated trials that the cords were vibrating, and having been 
obliged to exercise considerable pressure upon the larynx, I desisted from 
further treatment for the day, but urged the patient to endeavour to continue 
speaking aloud. The following day she again visited me. The larynx 
was somewhat more tender, the result, perhaps, of the compression. She 
could, however, speak in a moderately loud tone and no further manipula- 
tion of the larynx was made. There was a tendency to whisper at every 
few words, while a necessity existed for taking breath frequently, the result 
of the feeble approximation of the cords, which allowed the air to escape 
too freely. Daily exercises in reading aloud, open air exercise, and tonics 
were advised. Meanwhile she visited me daily for a week. The tendency 
to whisper and to take breath frequently, diminished steadily, while the 
voice became stronger. In the latter part of July she left Boston for her 
native town in New Hampshire for the improvement of the general health, 
the voice continuing good. 
In February, 1869, I received a letter from Miss W., in which she says, 
“ My voice is comparatively strong. * * I can sing a little. My cough 
is still troublesome and there is some weakness through the lungs and 
shoulders, but I ought not to complain when I compare my condition with 
that of a year ago. Society then was a dread to me, now it is a pleasure.” 
Fig. 7. 
Case IY.—Jolin P., aged 13, was brought to me by his parents Dec. 
23, 1868. They reported that he had had fair general health, but had 
always been a “nervous and very uneasy boy.” Three months before, he 
had lost his voice suddenly while at school, and had since then made no 
sound above a whisper. For a few days previous to the aphonia he had 
a slight “cold,” but no hoarseness. Treatment of various kinds had been 
employed, by the family physician and others, directed to a supposed in- 
flammatory condition of the larynx. 
The boy had a general feeble look and exhibited decided marks of ner- 
vousness. On being shown the laryngeal mirror and requested to examine 
it, he first hesitated to touch it, and then laughed and cried alternately. 
Laryngoscopy was nevertheless easy. No inflammatory appearances were 
observed in the larynx. On attempted phonation, the vocal cords were ap- 
proximated in the normal way, but were immediately forced apart again 
by the current of air, without vibrating. The left cord seemed to yield 
somewhat more readily than the right. 
Manipulation was resorted to, and a voice-sound was produced in a 
few minutes, and full restoration of the voice within fifteen minutes. A 314 
Oliver, Aphonia from Paralysis of Muscles of Larynx. [April 
disposition to whisper the first word of each sentence existed during his 
stay at my office, but he was made, in each case, to commence the sentence 
anew, and this tendency constantly lessened. Tonics, &c., were advised, 
and his parents were counselled to remove him from school for a time. 
This patient I have seen once since, and have heard from him many 
times. His general health is much improved, and the restoration of the 
voice has been permanent. 
Case V.—Adeline L., aged 14 years, was brought to me by her mother, 
Feb. 13th, 1869. She had always been in good health. Had menstru- 
ated once only, and that five weeks previously. Never manifested hysterical 
symptoms. In April, 1868, she had a “cold” and was a little hoarse: this 
passed away gradually in a few days. Two or three days after apparent 
recovery, her voice left her suddenly and she had not spoken aloud since. 
She had been obliged to give up school, and had been under medical treat- 
ment, but had been told that nothing more could be done to restore the 
voice. 
She appeared to be in good general health. On examination with the 
laryngoscope, the larynx appeared to be perfectly healthy. On attempted 
phonation, the vocal cords approached the median line equally, but did not 
come in contact with each other, and the cartilaginous glottis remained 
open, the appearance being much as in Fig. 5, Case I. The current of 
air, moreover, immediately forced the cords apart. There was, therefore, 
marked weakness of the adducting power, and on account of this circum- 
stance and of the probability, also, that this weakened condition of the 
muscles was due to the inflammation of the parts which had immediately 
preceded the aphonia, I anticipated considerable difficulty in restoring the 
voice, and so expressed myself to the mother. Manipulation of the larynx 
was, however, immediately begun, with the usual instructions to the patient 
to attempt to make a sound. For a time her efforts were quite futile, and 
no sound indicating the vibration of the cords could be heard. It was at 
this juncture that it occurred to me that advantage might be taken of the 
valvular character of the cords, to which allusion has been made at some 
length. She was, therefore, instructed, during compression of the thyroid, 
to make sudden and strong inspirations, and to endeavour to make the 
breathing noisy. The inspirations soon disclosed a marked noisy charac- 
ter, the expirations much less so. She was then asked to make a sound, 
either with inspiration or with expiration. Gradually the inspiratory act 
seemed to acquire a vocal character, and it was not long before it was cer- 
tain that the cords were in action. Subsequently, attempts to produce a sound 
with the expired current of air were successful, the larynx being still com- 
pressed, while shortly after the voice was completely restored. She was 
made to read aloud for some minutes after the recovery of the voice, which 
became notably stronger as she progressed. There was, however, in con- 
versation, some tendency to whisper occasionally. Her mother was de- 
sired to make her read aloud many times daily, and not to allow whisper- 
ing without reproof. 
The whole time occupied in the restoration of the voice was a little short 
of an hour, including respites. I have seen this patient once or twice since, 
and have heard from her frequently. The recovery has been permanent. 
Case VI.—A. B., a female domestic, aged 26 years, was brought to me 
by Dr. 0. 0. Davis, of North Audover, Mass., Sept. 27th, 1869. Her 1870.] Oliver, Aphonia from Paralysis of Muscles of Larynx. 
315 
general health had been fair, but she had had at times leucorrhoea and 
dysmenorrhoea, although the monthly periods had been regular. She was 
reported to be of a nervous temperament, but no hysterical symptoms had 
ever been noticed. During the second week of January preceding, she 
contracted a cold and had pafn in swallowing, hoarseness, cough, and some 
expectoration. These symptoms passed away gradually, but there was 
general prostration of strength remaining, and the voice was weak. In 
the early part of the day she could often not speak loud at all, but the 
voice would appear in the course of the day. Complete aphonia occurred 
in the latter part of February. There was a time in the spring following, 
when she could occasionally, by extra effort, make a sound in a low un- 
natural tone; but, except that, she had spoken only in whisper since Feb- 
ruary. 
This patient had a pale and “ flabby” appearance. Light pressure along 
the spine caused complaint at several different points. The larynx was 
also somewhat tender on pressure. On examination with the laryngoscope, 
nothing abnormal was seen beyond a slight redness of the mucous mem- 
brane of the vocal cords near the opening to the ventricles : the greater 
portion of these ligaments were of the normal colour. On attempted pho- 
nation, the cords were nearly or quite approximated at the median line, 
but the vocal processes did not come into complete contact with each other, 
and the cartilaginous glottis was not closed : and when the air was forced 
against the cords they immediately separated without vibrating.- Mani- 
pulation was at once resorted to. For a time the patient entirely failed 
to make a sound with expiration, and attempts with inspiration were ad- 
vised. A few minutes only elapsed before a sound was heard, rough in- 
deed, but evidently produced by the vocal cords. This sound gradually 
improved in strength and quality, and, in a short time, a sound with expi- 
ration was made. Finally, in about twenty minutes from the commence- 
ment of treatment, the full voice appeared, and she spoke without the aid 
of compression. There was a slight tendency, for a time, to whisper in 
conversing, as in some of the previous cases, but this did not exist in read- 
ing, the tone being clear and loud. The disposition to whisper, moreover, 
nearly or quite disappeared before the patient left my office. 
The usual instructions with regard to reading aloud daily were given, 
and tonics were advised. The recovery has been permanent. 
Remarks.—In these last two cases, it was certain that a voice-sound 
could be produced with inspiration, before it was possible with expiration : 
and it was also many times demonstrated, before complete restoration of 
the voice took place, that this sound was easily made, both in expiration 
and inspiration, with the aid of compression of the thyroid, when nothing 
above a whisper was possible without such aid. During the treatment of 
the last case these facts were brought to the notice of Dr. Davis. 
It is perhaps unnecessary to say, that no local treatment for aphonia 
ought to be employed without a preliminary laryngoscopic examination 
and diagnosis. Especially should Manipulation not be attempted without 
such examination, for this treatment would not only be useless in most 
cases of unilateral or “constant” paralysis, but might be positively injuri- 
ous, this form of paralysis being, generally, due to compression of the re- 
current laryngeal nerve by an aneurism, by enlarged bronchial glands, or 316 
Oliver, Aphonia from Paralysis of Muscles of Larynx. [April 
by malignant growths, or to organic disease of the pneumogastric nerve 
itself. When, moreover, the examination shows the case to be one of 
paralysis of the adductors, it should be made reasonably certain that the 
cause does not lie at the nervous centre: thisjs, however, of extreme rarity. 
Excessive general debility may also contraindicate Manipulation, as may 
a decided tendency to haemoptysis. 
Finally, the normal action of the vocal cords is often obstructed by 
organic changes in the tissues of the larynx, in which case treatment of 
the accompanying aphonia by compression would be injurious. 
If any doubt should be entertained of the safety of Manipulation, I 
answer that experience has not devoloped any ill effects from its employ- 
ment in suitable cases, and that old age as well as youth has offered sub- 
jects for the trial. It is understood that the force exercised should be 
confined to reasonable limits ; it is, of course, possible to do injury to the 
larynx by the employment of great force. 
But I am not disposed to claim for this method of treatment advantages 
over some other methods: on the contrary, I am free to acknowledge that, 
where there is a prospect of restoring the voice at once, or even within a 
reasonable time, by stimulating injections, by the employment of electricity, 
or by the “gymnastic” of Yon Bruns, these methods might be, in many 
cases, preferable : I simply suggest a method not before, to my knowledge, 
described, and feel justified in saying that it is efficient and safe: it is 
certainly not without interest in a physiological point of view. 
In the cases above-recorded, none of the usual methods of treatment 
were employed, because I desired to test the value of Manipulation ; so 
that it is not certain that a single electric shock in the larynx would 
not have restored the voice immediately in all the six cases. I am, how- 
ever, inclined strongly to the belief that in Case III., in which the affection 
was of eight years’ duration, and in Case Y., the most obstinate of the 
number, a prolonged course of treatment would have been necessary. 
It is not unusual for physicians to advise patients with aphonia which 
they, often rightly, deem to be due to a debilitated condition of the general 
system, to make a change of residence, or to travel, telling them that the 
voice will return when the health improves. Recovery will undoubtedly 
be the result in many of such cases, but the loss of the voice is a serious 
infirmity, and has a constant depressing effect upon the individual. The 
more rational plan would seem to be to advise, first, an attempt to restore 
the voice, and if the result be successful, travel and other means of im- 
proving the health, to insure the permanency of the cure. 
Since the foregoing pages were written, a striking proof of the influence 
of the inspiratory act upon phonation has presented itself to me, confirm- 
ing the views expressed therein. 
A lady, sixty years of age, came to me with an almost total inability to 
speak in the usual manner with the expired current of air : a condition of 1870.] Mitchell, Poisoning with Rattlesnake Venom. 
317 
six or seven years’ duration. A single sound could be thus made, and 
monosyllables spoken, but with great difficulty and uncertainty, while it 
was impossible for her to speak a short sentence, or even to pronounce a 
word of more than one syllable. Each syllable, namely, required a sepa- 
rate and marked effort, while sometimes a double effort was required, as 
ma-an for man. The difficulty was not so much an inability to approxi- 
mate the cords, as the want of power to maintain the approximation ; 
and the adductor muscles were the ones at fault. Now this lady had dis- 
covered that she could speak while drawing in the breath, and had become 
accustomed to use the voice wholly in this way. There was an evident 
effort about it, as may be supposed, but speaking in the usual way, with 
expiration, was quite impracticable. In this instance the air passing in 
one direction, forced apart the weakened cords, while, when passing in 
the opposite direction, it tended to keep them in position, both influences 
being dependent purely upon the anatomical formation of the parts. 
It will be naturally inferred that, if the compression of the thyroid 
wings produces the results above-mentioned, some aid might be afforded 
in derangements of the voice dependent on moderate loss of power of the 
adductor muscles; and such I have found to be the case, the voice be- 
coming notably stronger during compression. 
It may not be irrelevant in this connection to remark, that, in some 
cases of weakness of the voice apparently dependent upon a want of 
proper tension of the vocal cords, I have found material aid to be afforded 
by imitating the action of the crico-thyroid muscles, which are tensors of 
these ligaments. This is done by raising the anterior portion of the cri- 
coid cartilage, approximating it to the lower front border of the thyroid 
cartilage. 
Art. II.—Observations on Poisoning with Rattlesnake Venom. By S. 
Weir Mitchell, M. D. With Microscopical Notes by Jos. Gf. 
Richardson, M. D. 
I have been able during the past summer to make observations upon 
certain points connected with snake poisons, which serve to complete 
portions of my former studies. I have also afforded to Dr. Richardson 
an opportunity of studying with higher powers than those formerly 
used by me, the blood of animals which were sick or dead from snake 
venom. His observations prove to my entire satisfaction the correctness 
of the belief I have already published as to the peculiar corpuscles de- 
scribed by Dr. Halford. Although I had long since criticized this gentle- 
man’s views, and pointed out that what he saw were probably Leucocytes, 
no one as yet has shown how it is that these come to assume the appear- 
ances described by Halford. Thus far all observers have failed to see the