BILATERAL PARALYSIS 
OF THE POSTERIOR 
CRICOARYTENOID 
MUSCLES OF THE 
LARYNX, WITH 
REPORT OF* A CASE 
By Albert Rufus Baker, M. D., 
Cleveland 
Professor of Diseases of the Eye, Ear and 
Throat, in the Cleveland College of Phy- 
sicians and Surgeons; Oculist and 
Aurist to the Cleveland General, 
St. Alexis and City 
Hospitals BILATERAL PARALYSIS OF THE POSTERIOR CRICO- 
ARYTENOID MUSCLES OF THE LARYNX, 
WITH REPORT OF A CASE 
ALBERT RUFUS BAKER, M. D., CLEVELAND 
Professor of Diseases of the Eye, Ear and Throat, in the Cleveland Colleye of 
Physicians and Surgeons; Oculist and Aurist to the Cleveland 
General, St. Alexis and City Hospitals 
Although the literature of bilateral paralysis of the ad- 
ductors of the larynx is more extensive than that of any 
other laryngeal neurosis, the number of cases reported is 
small. Indeed it is a rare disease. The case I wish to report 
is the only one I have ever seen. A cursory examination of 
the literature at my command leads me to think that not 
more than fifty cases have been reported. Cases must have 
occurred before laryngoscopic -days, but were never recog- 
nized until comparatively recent times. 
I was called in consultation with Dr. J. Perrier on the 
evening of November 7, 1895, to see Mr. A. J. , 
aged 42 years; superintendent of a large manufacturing es- 
tablishment. Married; no children. Always enjoyed good 
health with the exception of the ataxia, and no specific 
history, although he has led a somewhat irregular life and 
during his youth had probably had sufficient opportunity 
to contract specific disease. Mr. D. has been under the care 
of Dr. Perrier for several years for posterior spinal sclero- 
sis. Has complete absence of knee-jerk; is unable to stand 
with his eyes closed; obliged to walk with a cane, and has 
severe lightning pains in the legs; a feeling of a tight band 
around the abdomen, and typical Argyll-Robertson pupil; 
no atrophy of the optic discs. During the past year Mr. D. 
has suffered repeated attacks of dyspnea, usually coming on 
suddenly after some unusual expiratory effort, either in 
sneezing, coughing, laughing, hiccough or shouting. At 
first the attacks were rather infrequent and were not so 
severe, but during the last two or three months they have 4 
been occurring almost daily, and sometimes two or three 
times a day. 
During the attack there seemed to be no obstruction 
to expiration, but the most violent efforts at inspiration were 
made, the eyes becoming fixed, the lips and face purple. 
Normal respiration was only restored upon his fellow-work' 
men placing him upon the ground, rolling him over a barrel 
“walking all over him” to quote his own words. These at- 
tempts at artificial respiration were usually successful in a 
few minutes, sometimes requiring half an hour, after which 
lie would return to work as though nothing had happened. 
His speaking or singing voice was not affected. 
A laryngoscopie examination showed the vocal cords, 
when at rest, to be slightly separated; it would seem scarce- 
ly enough to permit free respiration. During phonation 
they closed normally, but during respiration they did not 
separate widely so as to form a triangle as they do in health. 
A diagnosis of paralysis of the posterior arytenocricoid 
muscle was made, and it was suggested that lie go to the 
hospital and have a tracheotomy performed as soon as pos- 
sible. 
He was admitted to the Cleveland General Hospital on 
the next day, and on the morning olf November 9, an at- 
tempt was made to administer a general anesthetic, but re- 
sulted in an immediate interruption of respiration, so that 
the general anesthetic was discontinued and tracheotomy 
performed under cocain anesthesia. There was no special 
difficulty met with in the operation, and the patient made 
an uninterrupted recovery, and immediately returned to his 
occupation, which he has followed up to the present time 
with scarcely the loss of a day. 
He wears the tracheotomy tube constantly, with a cork 
in it, tied to a string. Whenever one of these suffocative at- 
tacks comes on he pulls out the cork and normal respiration 
is immediately restored, lie then replaces the cork and soon 
goes on about his work as usual. His wife tells me that 5 
these attacks occasionally come on in the night, when he 
pulls out the cork and replaces it without waking. The 
ataxia has apparently remained stationary—no better, no 
worse. A few weeks ago he secured a life insurance policy 
for $2,000, in an industrial life insurance company. 
During the first year after the operation he had some 
difficulty in securing a satisfactory tracheotomy tube; 
they would break and get out of repair, and it be- 
came necessary to have a new one at short intervals, and 
they were also hard to keep clean, and from their 
irritating properties would frequently cause excessive 
granulations to spring up around the tube; so that we re- 
placed the metal tube by a soft-rubber one, a sam- 
ple of which I present to the Society. I am indebted to my 
colleague, Dr. George W. Crile, for the suggestion as to us- 
ing soft-rubber tubes instead of those of hard rubber, or of 
metal as hitherto. I have never yet met a case in which 
they have not given better satisfaction to the patient as well 
as myself, and I believe that they should come into more 
general use than the older style tubes which have been in 
use since time immemorial. 
As to the pathology of these cases there has been con- 
siderable diversity of opinion, some authors maintaining 
that the disease was a local one, probably due to an injury 
of t'he posterior cricoarytenoid muscles from swallowing 
fish-bones, artificial teeth or other hard substances. Others 
have reported cases due to lesions in the course of the re- 
current laryngeal nerves, such as aneurism and tumor. The 
more commonly accepted explanation of this exceedingly 
interesting and curious malady, is that of a morbid condi- 
tion of the nerve-centers. 
It is probable that a more careful postmortem examin- 
ation of tabetic patients will demonstrate that the opening 
of the glottis is presided over by an independent ganglionic 
center in the upper portion of the medulla, and degenerative 
changes of this center like those of the posterior columns 6 
of the cords, or the optic nerves, will be recognized as the 
pathologic lesion in the vast majority of these cases. 
I am quite willing to concede in view of the clinical 
evidence already accumulated that there are other etiologic 
factors which must not be overlooked in these cases, such as 
pressure on the recurrent laryngeal nerves, hysteria and 
traumatism of the posterior cricoarytenoid muscles. 
DISCUSSION 
Dr. Kinsman, Columbus: This case has three features 
which should be noticed. , • 
First, the patient is tabetic. Second, the paralysis. 
Third, the paroxysms of suffocation. 
Tabes and paralysis are not unusual, but, so far as my 
experience goes, laryngeal crises are quite uncommon. 
'Crises of the stomach, bladder or genital's, as well as 
crises of the larynx are characteristic symptoms of tabes. 
Charcot and his school have reported many such cases. 
The distress in the case under consideration is not due ,to 
the paralysis, but to an irritation which has its origin in the 
sensory nerves. 
Paralysis is a continuous symptom in this case, the suf- 
focative attacks come at intervals. 
This is a very good illustration of laryngeal crises in 
tabes. 
If I were to name the case I would say it was paralysis 
of the vocal cords with tabetic laryngeal crises. 
Dr. P. J. Kline, Portsmouth: As my friend, Dr. Kins- 
man, has remarked, there are some points in the case re- 
ported by Dr. Baker, that I do not understand, and I do not 
know that I should have taken time to try to understand 
them. The most interesting thing to his patient was to get 
some wind. When his wind was cut off, the matter of living 
became quite a vital point with him. What interested me a 
great deal in his paper was the manner in which this relief 
was given him, since he had to wear a tube permanently. 
I piet, soimetime ago, a patient under somewhat the same 
condition. I found an adult with a tracheotomy tube in his 
throat. 'It happened to be a double one, and I removed part 
tabes. 7 
of it ,at first and soon got the man resuscitated. He con- 
tinued to wear it a number of years after I visited him that 
night. I do not believe he wore any cork in the for 
he needed about all the air he could get. When he wanted 
to talk, he would place his finger over the tube, for you know 
our conversation is carried on with the expired air. These 
cases, that are obliged to wear metallic tubes, are liable to 
have some difficulty in the region of the tube, due to its pres- 
sure and its constant presence on the inside of the trachea 
against the soft membrane there. I think the tube sug- 
gested by the Doctor is well worthy of iconsideration. I 
do mot know What finally became of my patient. 
Dr. A. R. Baker, Cleveland, in closing: I might say 
there has been considerable discussion with regard to these 
cases. Some German authors have insisted, and do still 
insist, I believe, that it is a spasmodic difficulty and not a 
paralytic one. But anyone who has examined a case and 
watched it as I have this one, two years and a half, would 
certainly entertain a different opinion. I suppose I have 
examined him with the laryngoscope fifty or more times, 
and I have never seen the vocal cords separate more than 
a quarter of an inch. You know the vocal cords naturally 
open up three-quarters of an inch, but these are parallel and 
nearly immovable in that position. He never has this diffi- 
culty of respiration unless he does something that gives 
extra effort to the chest, such as laughing, hiccoughing or 
coughing. He is not relieved until he pulls out the cork, 
and then is relieved instantly. I think the anatomic con- 
struction of the larynx explains this. You can take the 
larynx, bring the cords together and it will hold water as 
tight as the aortic valves. Ordinarily they are separated 
slightly so the patient breathes along 'without any trouble, 
but when the amount of air is slightly reduced below, then 
they are closed up and are fixed in that position. These 
patients die in these attacks. When one has seen a patient 
at one of these times, he will be surprised that they live as 
long as they do. They will wear these tracheotomy tubes 
a long time. Doctor Cohen, of Philadelphia, I believe, has 
reported a case where a man has worn a tube 24 years, and a 
number of cases have worn them ten or twelve years after 
the tube was inserted.