[From the American Practitioner and News, April 8, 1893.] 
PARALYSIS OF LARYNGEAL MUSCLES, WITH CASES.* 
BY WM. CHEATHAM, M. D. 
Professor of Diseases of the Eye, Ear, "Ttlroat, and Nose, Louisville Medical College. 
The larynx has nine muscles, four pairs and a single. Besides these 
there are three pairs belonging to the epiglottis: the thyro-epiglottis, 
inferior aryteno-epiglottis, and the superior aryteno-epiglottis. The 
posterior crico-arytenoidei widen the aperture of the larynx. The 
crico-arytenoidei laterales and the arytenoideus, assisted by the muscles 
of the epiglottis and the aryteno-epiglottis, close the aperture of the 
larynx. Those governing the pitch of the voice are the crico-thyroidei, 
assisted by the crico-arytenoidei postici, making the cords tense. The 
thyro-arytenoidei externi shorten, relax, and bring the vocal cords 
together. 
The nerves of the larynx are the superior laryngeal and the inferior 
or recurrent laryngeal, both branches of the pneumogastric. The supe- 
rior laryngeal supplies the mucous membrane with sensation, and the 
crico-thyroid, the thyro-epiglottic, and the aryteno-epiglottici muscles; 
the other supplies the other muscles, the arytenoideus receiving fibers 
from both. 
Neuroses of the larynx may be either sensory or motor. Those of 
sensation may be anesthesia, hyperesthesia, paraesthesia, and neuralgia. 
Gottstein and Lefferts have given a clinical classification of paralysis 
of the muscles of the larynx, and Mackenzie a pathological one. 
I have seen cases of paralysis of the recurrent laryngeals, unilateral 
and bilateral, of the adductors, unilateral and bilateral, of the abductors, 
unilateral and bilateral, and of the arytenoideus. 
One case of hysterical paralysis of the adductors, which I believe I 
reported to this Society before, was in the person of a merchant from one 
of our interior towns. As in most similar cases the muscles of the lips 
were also involved. A strong interrupted current with one pole in the 
larynx soon restored him his voice. I have seen several cases in females, 
some of them hysterical, and some catarrhal. Rheumatism may pro- 
duce it, or it may be toxic in its character, depending upon lead or 
arsenic; lead here affects the adductors alone, as it does the extensors 
of the forearm. Anemia is a common cause. I have seen sometimes 
persistent but more often intermittent paralysis of one or both adductors 
-Read before the Louisville Clinical Society, February 21, 1893. 2 
in cases of lung phthisis, lasting for several years. Diagnosis is usually 
easily made with the laryngoscope. Prognosis in adductor paralysis is 
usually favorable. A brush applied to the larynx or sometimes the 
simple act of laryngoscopic examination gives relief. Emotional influ- 
ences give relief frequently. Mackenzie cites a case taken from Herod- 
otus, who speaks of a son of Croesus who was dumb, but whose voice 
was restored when some one not recognizing his father was about to kill 
him. Paralysis of the abductors is a much more serious matter. Here 
we have the " Gate of Life " about to be closed. The cause may be 
neuropathic or myopathic. In three cases seen by Mackenzie during 
life changes were found in the muscles after death, while the nerves 
and brain were normal. 
My object in presenting this paper this evening is to report four cases, 
one positively paralysis of the posterior crico-arytenoidei; another I am 
not so positive of, as it is in the person of a child but six months old, ren- 
dering a laryngoscopic examination almost impossible, and two cases of 
paralysis of the recurrent laryngeal nerves, the result of large aortic aneu- 
risms. The .last two cases mentioned died in a few days after I saw 
them of rupture of the aneurism. In these cases no operative interfer- 
ence was indicated, as the cords took the " cadaveric position " in which 
voice is partially lost, but respiration not much interfered with. These 
are all the cases of this trouble I can at present recall as having seen. 
The child referred to above was brought to me about one week ago. 
The mother said it had had the trouble all its life. As I stated before, 
the child is but six months old, and its only trouble is on inspiration; 
expiration is perfectly free; symptoms worse when asleep. The noise 
it makes then in breathing can be heard all over the house. Its cry and 
crow are natural. It has no trouble in feeding; its mother says it is as 
healthy as any other child. After several efforts I could see the epiglot- 
tis and the vestibule of the larynx; the epiglottis is an exaggerated 
omega shape; I could discover no growth of the larynx. A growth of 
the larynx could give about the same symptoms. I have seen two sim- 
ilar cases in babies, or cases with similar symptoms, which were relieved 
by pulling the tongue well out, or by holding the children with their 
faces down. Both of these children had trouble in nursing, this child 
has none. The present symptoms are those indicative of paralysis or 
paresis of the cord abductors. I have never heard of a congenital case, 
unless this is one. Some one may suggest anesthesia for a laryngo- 
scopic examination. There would be great danger attending it; any 3 
one undertaking it should be prepared for an intubation or a rapid 
tracheotomy. 
The second case is in a woman, forty-five years of age, otherwise 
healthy. She has been examined several times by different doctors, 
and no cause for the abductor paralysis discovered. The trouble has 
been coming on for months. She has been treated for hysteria, so she 
says, having taken a gallon or two of asafetida and valerian. The 
breathing is so bad at night that policemen have rung the family up 
and asked if any one was being murdered. When she came to see me 
about six weeks ago I found expiration free, but inspiration very diffi- 
cult ; voice not much affected. She had had electric and other treat- 
ment with no relief. Symptoms made worse by exertion. The laryn- 
goscope gave a perfect picture of paralysis of the post-crico-arytenoidei; 
the cords were nearly together; the chink enlarged somewhat on expira- 
tion, but nearly closed in inspiration; the shape of the cords and the 
difference in the rarity of the expired and inspired air accounts for this. 
I suggested that she again try electricity and add to it hypodermatics of 
strychnia nitrate. She reported in a few days with her trouble much 
increased; the cords looked some thickened and red; her lips were a 
little blue; she could not sleep well, and while talking to any one she 
would fall asleep. Believing the case now to be quite a serious one I 
suggested to the family either intubation or tracheotomy; they, of 
course, preferred the former. 
This narrowing of the glottis leads to much damage in other organs. 
This interference of change of gases in the lungs drives the blood back 
to the right side of the heart, resulting in much damage to distant 
organs. I did intubation last Thursday afternoon, four weeks, assisted by 
Dr. H. M. Goodman, her family physician, and Drs. Pusey and Moorman. 
I inserted with but little trouble an adult hard rubber tube. Vulcanite 
is better for the adult tubes, especially when used in such a case as 
this, as there is no membrane to plug them, consequently they are not so 
liable to be coughed out, weight to prevent it not, being necessary, and 
calcareous deposits are not so liable to form on them, consequently they 
can be worn longer without a change being necessary ; the weight being 
so much less they are not so liable to irritate the vestibule. The patient 
complained a good deal of the tube for several days; said she now gets 
too much air. There was some soreness on swallowing for a few days. 
Temperature for four or five days was ioo° F. To-day, February 21st 
(Tuesday), temperature is normal; there is but little soreness on swal- 4 
lowing, and she says she sleeps better than she has for months; all 
drowsiness has disappeared, and color is good. She says she feels like 
a new woman. She eats solids and semi-solids sitting erect, bnt has to 
take fluids with chest lower than the rest of the body. 
What is the future of this case ? I am inclined to use the intuba- 
tion tube as long as it can be worn, changing the tube for cleansing, 
and to utilize new points of pressure every four, six, or eight weeks, by 
this hoping in some months to get the cords fixed in the " cadaveric 
position," or if this can not be done, to nick or cut through each cord, 
then put the tube back. Whether or not this can be done without a 
preliminary tracheotomy I can not say. I will of course try it later on. 
I know of no measure of relief that will not destroy or partially destroy 
the voice; now, with the tube in position, the patient can make herselt 
understood across a large bedroom. I believe, then, that the patient 
can, should no accident occur, by operative interference get free breath- 
ing with partial loss of voice. No book that I know of speaks of intu- 
bation for the relief of this difficulty. Tracheotomy is advised. Intu- 
bation has been successfully used in similar cases by O'Dwyer and 
others. Dr. O'Dwyer for one of his cases had a cylindrical tube made, 
so as to get more lateral pressure. 
These cases are fortunately rare. A majority of them die of their 
own neglect, refusing operative interference, and others of neglect of 
their physicians, who turn them away as hopeless. A strange coinci- 
dence, if the baby's case is one of abductor paralysis, is that both cases 
live in the same neighborhood, within a square of each other. 
While speaking of paralysis, I would state that in the last ten days 
I have seen two cases of one-sided mydriasis, one of the cases with 
myosis of the fellow eye, one case of right third and fourth nerve 
paralysis, one of left third nerve paralysis, with atrophy of the right 
optic nerve with some of the muscles of deglutition involved, and 
another with paralysis of the right third, fourth, fifth, and sixth nerves. 
I also have besides the patient reported, which promises to be a lengthy 
one for intubation, a child, three years old, who has been wearing a 
tube twenty-three weeks for a growth of the larynx, the tube staying 
in at one time seven weeks without being changed, and a woman with 
phthisical laryngitis, who has been wearing a tracheotomy tube for nine 
months with perfect comfort. 
Louisville.