ADDUCTOR VOCAL PARALYSIS. BY LEWIS S. SOMERS, M.D., OF PHILADELPHIA. FROM THE MEDICAL NEWS, June 26, 1897. [Reprinted from The Medical News, June 26, 1897.] ADDUCTOR VOCAL PARALYSIS. By LEWIS S. SOMERS, M.D., OF PHILADELPHIA. Paralysis of the intrinsic muscles of the larynx may result from a central lesion situated at the roots of the spinal accessory nerves in the floor of the fourth ven- tricle ; from peripheral lesions, or may be due to changes in the structure of the muscles themselves. The laryn- geal muscles may be affected in groups, or more rarely, individually. Probably the most frequent cause of ad- ductor vocal paralysis, especially in females, is hysteria. The following case is reported on account of the absence of hysteria in the patient and for the reason that the eti- ology was somewhat obscure, the paralysis occurring after pneumonia. The history is as follows: F. W., female, aged twenty-five years, single, occupa- tion singer and music reader. Was first seen November 3d, 1896. Family history negative. She had had measles when a child; at five years she was said to have had " walking typhoid," and was sick for six months. Subject to headache on excitement for a number of years and also has sick headache when riding in the cars. She is a well-developed, robust, educated woman, and has been strong and healthy since childhood until the early part of December, 1895, at which time when walking with a friend he fell dead. This shock caused a general nervous condition (neurasthenia) of three-weeks' dura- tion, at the end of which period she developed pneu- monia, involving the left lung, being very ill for six weeks. During convalescence from the pulmonary trouble she noticed that her speaking voice was not as strong as be- fore, and was easily fatigued and became husky. On 2 attempting to sing soprano she found it impossible, as she could not produce the notes, and she then placed herself under a physician's care for the vocal paralysis, but without results. At this time her general condition was good, al- though she was slightly nervous and suffered from a mod- erate degree of bronchial irritation, this subacute bron- chitis being especially annoying at night. At irregular intervals attacks would occur resembling those of croup, and on several occasions it became necessary to call in medical assistance. When I first saw the patient she was nervous and wor- ried, as her singing was necessary in gaining her liveli- hood. She complained, in addition to the loss of her singing voice, of a tickling and dryness of the throat, of "catching cold" easily, and of hoarseness, and had a dry, irregular cough. Digestion was not normal, as she sometimes, though rarely, vomited after a full meal. She was moderately constipated, and felt bloated after eating, the tongue being coated, although her appetite was good. Headache was often present, and was most marked in the occipital and temporal regions. She slept well. The heart and lungs, with the exception of the slight bron- chitis, were normal; the reflexes were normal, as was men- struation. On examination of the upper respiratory tract the Schneiderian mucous membrane, especially over the middle and inferior turbinals, was found to be congested, and a moderate degree of turbinal hypertrophy was pres- ent. The pharynx was slightly sclerotic, and the lingual tonsil on the left side hypertrophied, while the faucial ton- sils and postnasal space were normal. The larynx was plainly visible with the aid of the laryngoscope, the upper two rings of the trachea being easily distinguishable. The epiglottis and mucous membrane of the larynx were nor- mal. The laryngeal and faucial reflexes did not differ from the normal, as the sensibility was not altered. The vocal 3 cords were widely separated, being at an equal distance from the median line on both sides, the arytenoid attach- ment of the cords being the most characteristic feature, as they were widely apart. Motion of the cords was nil on respiration, and only by severe effort could move- ment be effected on phonation. The cords were normal in color, concave in appearance, and somewhat flabby. The treatment consisted of deep inhalations of com- pound tincture of benzoin in albolene, and the interrupted electric current twice a week. The faradic current was applied by placing one electrode over the thyroid carti- lage, and the other at some indifferent point. The dura- tion of local treatment was from five to ten minutes at each stance. In addition to the local applications, the pa- tient received one-sixtieth of a grain of sulphate of strych- nin three times a day, the dose gradually being increased until she received one-tenth of a grain per day. Phosphate of soda as a laxative was directed to be used as indi- cated. Improvement of the vocal condition was gradual, the lateral arytenoids responding first, until the 8th of December, when she was decidedly better, the only changes from normal being the remaining paralysis of the arytenoid muscle. At this date the singing voice was nearly normal, slight fatigue after much use of the voice and some inability to reach high notes still being present. On January 5, 1897, the patient had not received local treatment or strychnin for more than two weeks, yet had been able to sing four solos during one day with but little laryngeal fatigue, and said that she never felt better physi- cally. Except for some slight outward rotation and separa- tion of the arytenoid cartilages the larynx was normal. The total absence of any hysteric element in the case, as corroborated by Dr. Henry P. Boyer, opened up some interesting questions regarding the etiology of the paral- ysis, and also the location of the diseased tissue or tis- sues. It is a question whether the lesion was central or 4 peripheral (in the spinal accessory or recurrent laryngeal nerves), or located in the affected muscles themselves. The absence of general or laryngeal evidences of any of the stigmata of hysteria at once eliminated that factor from the etiology, as in hysteria the cords while appar- ently paralyzed on phonation are freely movable during respiration. Cough is usually present in the hysteric form, but generally absent in true paralysis, although it may be present. As a general rule, it may be said that if adductor vocal paralysis comes on suddenly in a healthy woman and is intermittent, it probably is hysteric in or- igin. These cases frequently coexist with some disorder of the genital apparatus. The elimination of disease of the nerve-centers or of the vagus, with the spinal accessory, becomes of impor- tance, as treatment will be influenced greatly by the cause of the laryngeal paralysis. When there is localized dis- ease of the brain or of the nerves already mentioned, other portions of the body besides the larynx are impli- cated, and the history of the case will generally point to some lesion either of the nerve-tissues directly, or, as is usually the case, pressure symptoms will be present. As the superior laryngeal is generally considered to be the sensory nerve of the larynx, and the inferior or recurrent nerve the one of motion, we could readily eliminate dis- ease of the former as a cause by absence of interference with sensation, the laryngeal sensibility in this patient, as before said, being normal. The recurrent laryngeal nerves may be affected as the result of pressure, as from an enlarged thyroid gland, or by changes in their struc- ture. Usually but one nerve is affected as the result of organic changes, more rarely both are involved. Cases have been observed in which the separate peripheral fila- ments of the laryngeal nerves have undergone morbid alterations producing paralysis of the different intrinsic muscles of the larynx. 5 The diagnosis in this case lay between peripheral changes in the inferior laryngeal nerves and alterations in the structure of the muscles involved. Morbid changes of the muscles without involvement of the nerve-fibers has been observed in rheumatism, progressive muscular atrophy and typhoid fever, in some cases the musculature being affected without apparent cause, and giving rise to a so-called idiopathic form. It seems impossible without a microscopic study of the nerves or muscles involved to make an accurate diagnosis, but from the history of the case and a careful study of the larynx, it seems possible that there was some pathologic change in the muscles. The remaining question, as regards the causal relation of the pneumonia to the vocal paralysis, is rendered diffi- cult of solution, as the former element of shock (caused by the sudden death of a friend as related in the history of the case) must be taken into consideration. This shock was followed by a period of nervous prostration of three-weeks' duration, this in turn preceding the attack of pneumonia, which latter lasted for six weeks. During this time her vocal apparatus was in perfect order, as shown by a normal speaking and singing voice, which did not become affected until late during convalesence from the pneumonia. For this reason, and further as the ad- ductor muscles have in cases reported been affected dur- ing convalescence from severe diseases and during ca- tarrhal inflammations, the evidence seems in favor of the paralysis being the direct result of the pulmonary changes, possibly being remotely influenced by the powerful nerv- ous shock which she had received. This form of laryngeal paralysis occurs most frequently in women, and especially in singers or those making pro- longed use of the voice. The subject, in addition to vo- cal fatigue or partial loss of voice, usually complains of a foreign-body sensation referred to the larynx, and the well-known symptom complex of acute or subacute laryn- 6 gitis is present. The respiration is normal, but phona- tion is difficult or impossible. In addition to the local affection, symptoms of anemia or chlorosis are often pres- ent. The prognosis is favorable; although the paralysis may have existed for a number of years, cure may be ef- fected, but the condition yields slowly and relapses are very apt to occur. The treatment must be directed to the larynx, although it is important that the general health be maintained. Stimulating inhalations and the application of the galvanic or faradic current to the larynx, usually intralaryngeal (but in some cases the electricity may be used externally over the region of the larynx), will give the best results. Strychnin is of much value, and unless there are well- marked indications preventing, should be used in increas- ing doses in all cases. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820. A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. 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