Aphonia: manipulation in larynx.
Case 518. (O’Malley, May, 1916.)
A corporal, 28, had a bullet pass through his neck from a point in the middle line at the upper border of the thyroid cartilage to a point behind the right sternomastoid muscle, two inches below the point of entry. The corporal lost his voice at the time of injury, spat up a teaspoonful of blood, and thereafter was able to whisper only. The laryngoscopic examination betrayed no intralaryngeal lesion. Treatment as described below enabled the patient to speak. O’Malley describes his technique as follows:
The patient is placed in the common position for the examination of the larynx, the tip of the tongue being seized in a piece of linen by the left hand fingers and the laryngeal mirror introduced with the right hand. The patient is then requested to say “e” or cough, and if the cords do not approximate, they can be made to do so by using moderate friction on the fauces and pharynx with the mirror to excite secretion. The latter begins to drop into the larynx, and acting as a foreign body, a protective reflex is at once excited which adducts the cords to prevent the secretion from entering the trachea. At the same time an involuntary cough is produced to expel the mucus, and if the friction and flow of secretion are maintained and the patient is urged to cough vigorously, voluntary coughing and a tendency to retching with forced laryngeal notes will rapidly follow. It is usually best to persist until retching occurs, as the cords are then forced together to protect the larynx and trachea from the possible entrance of regurgitated stomach contents. Involuntary laryngeal sounds are thus produced and the patient is conscious of laryngeal effort. Some of these cases are at the moment very shallow breathers, which can be demonstrated by X-ray screening, but the act of retching causes a wide excursion of the diaphragm with a more pronounced expiratory blast, to be rapidly followed by deeper inspirations. This method of treatment is best carried out just before a meal, as the stomach is then practically empty and the unpleasant effects of the sudden regurgitation of food are avoided. When the explosive sounds accompanying retching have occurred two or three times the mirror is withdrawn, the tongue released, and the patient is requested to swallow, take a deep breath, and cough, and then urged to count up to ten, directing his voice to a certain point on the ceiling. This method has given me uniformly good results, and was rapidly effective in all cases coming under treatment soon after the onset of the neurosis.
Re methods for curing aphonia, Muck has a method called the “ball” method. A ball is put into the larynx to cause a temporary suffocation, which produces a reflex that starts the adductors. He would apply the method as soon as the man was well over the shock that produced aphonia. Muck states that he has applied the ball method, not only to cases of aphonia, but to cases of mutism and deafness, with success.
Tilly mentions a case in which the patient refused to open his mouth, so the device was adopted of passing an electrode through the left nostril so that it finally reached the larynx. A spasm was produced, which was carried to the point of considerable cyanosis, but the aphonia was relieved and for the first time in three months the man spoke. Incidentally he began to hear also.
Re treatment of aphonia, Schultz has used the electric current externally over the larynx, all the while carrying on a laryngoscopy. Schultz remarks upon the fatigue that may come during the first few sittings. Roussy and Lhermitte remark that, although aphonia sometimes exists from the outset of shock, it is often a phase in recovery from mutism.
Liébault notes that, not only cases of true nervous aphonia but cases of laryngitis, apparently of infectious origin, and cases of true voice strain, may also turn up for treatment. Some men have been improperly discharged from the army for aphonia actually due to voice strain.