[Extracted from the American Journal of the Medical Sciences for October, 1875.] 
CASE OF CHRONIC LARYNGITIS, 
SERVING TO 
ILLUSTRATE HOW THE MUCOUS MEMBRANE 0/ THE VOCAL CORDS 
MAY BE IN AN OBJECTIVE MORBID CONDITION, THOUGH 
THEIR PHYSIOLOGICAL FUNCTIONS/E RESTORED. 
SURGEON TO THE MANHATTAN EYE AND EAR HOSPITAL (DEPARTMENT OF THE THROAT), ETC. 
By BEVERLEY ROBINSON, M.D., 
[Read before the New York Laryngological Society. 
The following case is given verbatim, as it was written out and hteirded 
to me by the patient himself:— 
“ D. S., thirty years of age. My home is in the West. Three years 
ago I came to New York city, and entered Union Theological Seminary, 
and began a course of study for the ministry. Since then and for about 
seven years previous, I have been accustomed to more or less public speak- 
ing, and to a very great deal of public singing. 
“ During my vacation last summer (1874), I engaged in preaching for 
several months on the coast of Maine, and near the close of the summer 
had trouble with my voice. At first it was slight, but soon became quite 
annoying. It was not the ordinary hoarseness, but in speaking there 
would be a catch or break in my voice; and by this I mean that in the 
midst of a sentence I would lose a word, or rather fail to speak it, often- 
times making several attempts to pronounce it before I would succeed. 
This was especially marked in singing; here my voice would fail me in 
the midst of a measure, and I would be unable to complete it. But the 
quality of my voice was not affected, for my tones were as sure and strong 
as they had ever been. 
“ Soon another troublesome symptom developed itself. In the night I 
would be aroused from sleep with a spasm of the throat, and for some 
seconds would be unable to inflate my lungs, and in my attempts to do so 
would whoop like a person with the whooping-cough. In this condition 
I returned to the city, and in October (1875) put myself under the care of 
Dr. Beverley Robinson, who informed me that I had chronic catarrhal 
laryngitis. He began treatment with the sulphate of zinc in the form of 
spray, besides making various applications with the brush three times a 
week. 
“ For a month or six weeks there was little or no improvement, and 
during this period at times even ordinary conversation was difficult and painful. The treatment was continued, and varied from time to time, and 
presently there began to be improvement, and this continued up to three 
weeks ago (February 15), when all treatment was left off. Since then I 
have used my voice both in speaking and singing, and on several occasions 
put it to a severe test; and so far as I am able to judge, I am now 
(March 6, 18if5) entirely well.” 
Remarks.—In the perusal of the above-detailed case, we shall notice 
two symptoms which occasionally present themselves in chronic inflamma- 
tory changes of the throat and air-passages. First, an inability at times 
during speech or singing to articulate certain words or give correct and 
complete tones in familiar measures of musical vocalization. 
These phenomena were present at first temporarily, in a slight degree, 
and only after severe exercise of the vocal organ ; at a subsequent period 
they showed themselves more frequently and persistently, and after a less 
prolonged effort of voice. Pain during ordinary conversation and spas- 
modic paroxysms at night were then superadded to the other evidences of 
trouble, pointing at once to its neurotic origin, as well as to its neuralgic 
character. 
In the beginning and for several weeks general and local treatment, 
varied according to indications and accepted therapeutic action of par- 
ticular drugs, remained without apparent results. Little by little, and 
after a considerable lapse of time, the spasmodic and painful symptoms 
disappeared, and gradually the voice acquired its normal force and flexi- 
bility, till to-day the patient is, so far as he is aware, completely cured. 
In this connection, we are led almost naturally to consider two or three 
interesting facts having a direct relation with clinical study and experience. 
The evening our patient was presented to the members of the New 
York Laryngological Society, the mucous membrane lining his vocal 
cords was still swollen and very red. In fact, there has been little change 
in the aspect of the larynx from the time when treatment was begun. 
And yet this same patient, who talks and sings to-day as well as he ever 
did, a few months since could only speak and sing in a very imperfect 
manner, and was awakened at night with painful spasms of the throat. 
What has taken place ? Evidently the laryngeal mucous membrane has 
not been much changed by local applications. We are therefore obliged 
to take refuge in one of two hypotheses. 1. The muscles were morbidly 
affected. 2. The peripheral extremities of the pneumogastrics were dis- 
eased. 
The painful and spasmodic phenomena at one time manifest, led us to 
the nerves as being the most probable source and seat of the disease, while 
the lack of co-ordinative power in the muscles was doubtless secondary to 
the nerve lesion. 
Our astringent applications within the larynx, and the medicaments 
administered by the mouth, have doubtless, therefore, brought back a norma] condition in nerve force, and the muscles again act synergetically and 
with a healthy degree of vigour. Want of vocal power is no infrequent 
occurrence, we are well aware, during and subsequent to catarrhal inflam- 
mations of the throat, either of an acute or chronic order. And for this 
loss of functional tonicity to show itself, it is not essential that the mor- 
bid processes should affect directly the mucous membrane lining the vocal 
organ itself. The inflammatory condition may only be obvious in the 
pharynx, and the larynx be apparently healthy. Such facts are explained 
by us in attributing the change of voice to abnormal circulation or dis- 
eased structure in or about the pneumogastric trunks. 
In these cases, however, the tones of the voice become, as a rule, pure, 
as the parts adjacent to the larynx are favourably modified by local reme- 
dies. True it is, as Krishaber has demonstrated, that after catarrhal or 
other inflammations and changes of the vocal cords, the voice may remain 
hoarse and weak for a greater or less period of time, and the muscles be 
deficient in contractility, although their visible condition is healthy. In 
our case the mucous membrane of the glottis continues to be red and in- 
filtrated, and the voice, singularly enough, is completely restored. 
Happily our interpretation, which follows, is sufficient to give a rational 
explanation of a clinical state rigorously observed. All gynaecologists 
are familiar with facts of an analogous description. In nervous, hysteri- 
cal, neuralgic women, do they not find that neuralgia affecting the lumbo- 
abdominal nerves frequently leads to congestive disorder of the interior 
surface of the womb, and also to concomitant dysmenorrhoea, amenorrhcea, 
and metrorrhagia ? 
Our patient was evidently labouring under nerve disorder of the throat 
from the time when his voice first began to fail him. 
And now that the other manifestations of disordered innervation of 
functional or organic origin have disappeared, chronic thickening and 
congestion of the laryngeal mucous membrane still remain. 
Will it disappear ? In time it may. Having regard, however, to the 
nature of his profession and to the frequent calls made upon his voice, 
in fact to the exaggerated use of this organ which he is almost of neces- 
sity forced to make, we can hope for no speedy change in this respect 
unless he should guard relative or absolute repose from speaking aloud 
and vocalization. 
There is still a point to which we claim attention. Modern physiology 
teaches us that the inner borders of the true cords alone furnish sonorous 
vibrations when air escapes from the lungs through the glottis during an 
expiratory movement. 
It would, therefore, seem as if, and we believe it is thus generally 
understood, the vocal cords should be altogether normal in structure and 
appearance at this margin in order to make the act of perfect phonation 
possible. And, without doubt, this received opinion is usually the cor- rect one, for the rule is that, whenever the interior lining of the glottis is 
even slightly congested, thickened, or in any manner altered, articulate 
speech is notably modified. 
In our case, reported above, we have, nevertheless, an instance of a 
departure from healthy appearances, and yet the timbre and strength of the 
voice are to-day what they were when it was believed to be, and it pro- 
bably was, in a normal state. Such an example must tend to establish 
the belief that integrity of the peripheral extremities of the laryngeal 
nerves and well adjusted action of the muscles are quite as important to 
the proper and accurate production of vocal sounds as the condition of 
the mucous membrane. 
We find also this view corroborated by analogy with certain instruments 
of music. Take for example the violin or violoncello. Do we not know 
that although the cords may be somewhat worn by use, if the proper ten- 
sion be given them, and the instrument is otherwise perfect, under the bow 
of a skilled artist the sweetest and purest notes can be produced ? 
Now most facts in medical science are true with limitations. And this 
is certainly correct with respect to what we have endeavoured to prove. 
Manifestly we have no wish to affirm that the laryngeal mucous membrane, 
when morbidly affected to an exaggerated extent, will not occasion more 
or less complete aphonia. 
Too frequent instances, with few or no exceptions, where growths or 
deep ulcerations upon the vocal cords have been the proximate and effi- 
cient cause of similar trouble, are present to our mind for the truth of 
such a statement to be admitted. We would merely point out and lay 
stress upon this important clinical fact, not in our knowledge sufficiently 
made known to us by recognized authorities in like matter, that good and 
strong if not perfect power of articulation in speech and singing, may 
exist though the vocal cords are congested and somewhat thickened. 
Finally, we offer the following proposition as being the expression of 
what in our estimation should be received as a probable truth, viz., actors, 
singers, public speakers, hawkers, etc., acquire, after a period of time 
more or less prolonged, a chronic inflammatory condition of the laryngeal 
mucous membrane, and especially of that portion of it lining the vocal 
cords, which, although treated actively and with the result of ridding them 
of painful or unpleasant symptoms, will continue to exist for a long 
while, and for this state, general or topical, remedial agents are inefficacious. 
Change of occupation would no doubt eventually bring about such effect 
in the nutrition of the parts as to restore them gradually to normal ap- 
pearance as well as to normal function. Unless this indication be practi- 
cally dealt with, it is probable that everything else in the way of treat- 
ment, prophylactic, hygienic, or poly-pharmaceutic, will in some cases be 
to no purpose. 
37 West 35th Street, New York.