[Reprinted from the Medical i.,u Sl ileporter of November 10 and If , 1883.) 
APSFi 111 IMA 
Honorary Professor of Laryngology, Jefferson Medical College; Professor in the Department 
for Diseases of the Throat and Chest. Philadelphia Polyclinic and College for Grad- 
uates in Medicine; Physician to the German Hospital of Philadelphia. 
BV ■>. .SOLIS COHEN, M. D., OF PHILADELPHIA, 
Several years ago (The Medical and Surgical 
a pastime. I begged the lady to write out her 
Reporter, May 1, 1875,) I reported a series of 
own medical history for me up to the period of 
cases of apsithyria or inability to whisper, associated 
with paralytic aphonia or loss of voice. Some 
our first interview, and from the notes she gave 
me I cull the following data: 
come under my observation since that period. 
additional examples of the double infirmity have 
suffered from asthma, to which she attributed her 
From the age of one year to eighteen, she had 
One of these was attended with so much difficulty 
in management, and gives withal such striking 
deafness, which began in her tenth year and in- 
creased with every cold she took. She probably 
evidence of the value of persistence in treatment, 
suffered with a chronic rhino-pharyngitis, which 
that I am tempted to record the circumstances of 
its origin and progress, at some length. 
gradually extended into the middle ear, and also 
excited asthmatic paroxysms of reflex origin from 
occlusions in the nasal passages. 
A farmer’s daughter, unmarried, forty years of 
age, who had at one time taught in a country 
Fifteen years before her visit to me (1865) she 
had an attack of typhoid pneumonia which left 
school, was brought to me November 22, 1881, by 
her physician. For fifteen months her voice and 
her invalided for seven months. Indeed, she 
never fully recovered, having had impaired res- 
whispering power had been absolutely lost, the 
double infirmity compelling resort to tablet and 
piratory power, occasional hemorrhages, and deli- 
cate lungs, ever since. 
pencil as her only means of personal cornmunica- 
In February, 1879, she had been the subject of 
Five years later, during an attack of remittent 
fever, her head was kept bathed with ice water 
pneumonia. Recovery left her aphonic. For about 
eighteen months she had remained able to talk in 
during several days and nights. After recovery, 
the hearing was much worse, and continued fail- 
a whisper; but since that time, “word of mouth” 
had been for her an impossibility. 
Submitted to the most rigorous tests, the 
apsithyria proved to be real. It had no analogy 
ing until at the end of about two years it had 
reached its present deplorable condition. Thirty- 
three months before applying to me (February, 
with the simulated infirmity attending some cases 
1879), while visiting relatives in the Northwest, 
she was, after a ride in the cold wind, seized with 
of so-dubbed hysterical aphonia. Laryngoscopic 
inspection revealed paralysis of the arytenoid mus- 
cle and of both lateral crico-arytenoids. The 
larynx and pharynx were pallid. 
The lady was debilitated, dispirited, languid, 
such intense dyspnoea and severe pain in the 
chest (mediastinal pleuro-pneumonitis ?) that 
her physician remained by her side for four hours 
before he deemed it prudent to withdraw, having 
and hypersensitive. Stomachic digestion was 
good, but appetite was lost. Intestinal digestion 
was imperfect, and decomposition of its products 
despaired of her recovery for three hours. Every 
inspiration seemed a gasp for life, and the pain 
was sharp as though daggers were being plunged 
into the chest. The abdomen and extremities 
frequent. Insomnia was constant. The patient 
asserted that this condition had been of some two 
were cold and numb. The recumbent position 
could not be maintained. For three hours she 
years’duration, and that lor more than a year she 
had to sit propped up in an arm-chair; and for 
had not known what a sound sleep was. To corn- 
plicate matters still further, the unfortunate lady 
was so deaf that she could not distinguish words 
three days thereafter she remained sitting upright 
in bed with supports to her back, breathing being 
absolutely impossible in a reclining posture. Con- 
uttered in unfamiliar tones, even though they 
were shouted close to her ear. Hence, for a long 
finement to bed continued two weeks. During 
the first week of illness, the voice remained nat- 
time, I had to depend upon the voice of her sister 
as my source of communication with her. Occa- 
ural in tone, but very faint. It gradually waned 
to a laryngeal whisper, as had been usual with 
s ion ally even this resource failed, and there was 
no communication save by the pencil. So many 
directions have to be given patients during laryn- 
her, for a time, after every illness. Hence the 
aphonia excited no alarm. It was probably but 
one expression of general muscular debility. 
goscopic examinations, and still more so during 
Several weeks elapsed before strength began to 
mtra-laryngeal manipulations, that treatment of 
- 1 head'd larynges of the deaf is far from being 
be regained. During this period, the loss of voice 
was attributed to genera] nervous exhaustion, 2 
and recovery was predicted as she should increase 
tinuously—so sore at times as to prevent deg- 
lutition. For fifteen months it had been better 
under frequent treatment by sprays ; and more 
comfortable for the last three months than at 
any other portion of the two years. 
in vigor. Six more weeks passed with returning 
health, and still the voice continued to be a mere 
whisper. After careful examination of the throat 
at this time, the physician announced that the 
aphonia was probably irremediable, but suggested 
that my advice should be sought. 
This history was not a very promising one for 
treatment, nor was the patient a favorable subject. 
Nevertheless, basing my opinion chiefly on the in- 
tegrity of the gastric function, which had been 
fairly maintained, I gave a cheerful though 
guarded prognosis, and predicted return of both 
whisper and vofbe as the reward of persistent, 
while necessarily protracted treatment. I had 
the good fortune to secure the thorough confidence 
ot my patient; and this was not withdrawn, 
though disappointments and relapses were fre- 
quent. 
The patient returned to her home in Pennsyl- 
vania during the following June. Her own phy- 
sician encouraged her with hopes of recovery of 
voice, and put her upon general tonic treatment. 
For months the voice showed little change. At 
times it would be an audible whisper; again, 
barely distinguishable. Every attempt at conver- 
sation induced weariness and muscular fatigue. 
A second attack of thoracic pain and dyspnoea 
■iccurred about one year after the attack described. 
It was much less severe, but it left her with so 
weak a voice that she could barely make herself 
heard; and often she could not be understood. 
The plan adopted comprised the internal admin- 
istration of sulphate ot strychnine in gradually- 
increasing doses, and topical applications of cur- 
rents of electricity daily to the paralyzed muscles 
of the larynx, to some of the voluntary muscles 
of respiration, to the orbicular muscles of articu- 
lation, and to the region traversed by the pneumo- 
gastric nerves in the neck—the strychnine being 
.given in aqueous solution, one grain to the ounce, 
commencing with a dose of ten drops thrice a day 
for the first day, eleven drops for the second, 
twelve for the third, with continued daily increase 
of the same quantity until some indication of its 
constitutional influence was manifested, when the 
dose was at once diminished to ten drops, with a 
daily increase of two drops, instead of one as be- 
fore, and so on in permanent medication. 
She now consulted the gentleman who ulti- 
mately transferred her to my care. She remained 
under his immediate attention for five weeks, dur- 
ing which applications of electricity (induced 
current) were made daily to the exterior of the 
throat. The voice became stronger under these 
manipulations, but even then, it was but a low 
and feeble whisper. Efforts to speak were so ex- 
hausting that they were made under compulsion 
only. She was then advised to continue the elec- 
tric treatment at home during the summer, and to 
visit Philadelphia when the weather became 
cool enough, for the purpse of consulting myself. 
Her sensitiveness in approaching strangers, due 
to her hardness of hearing and her difficulty in 
talking, long deterred her from acting on this ad- 
vice. 
The current of the battery, just strong enough 
to move the muscles of my own thumb, was used 
for the intra-laryngeal applications, the positive 
electrode being held over the crico-thyroid mem- 
brane by the patient, and the negative electrode 
being applied under laryngoscopic inspection over 
the arytenoid, and the lateral crico-arytenoid 
muscles. A sponge the size of a silver quarter of 
a dollar was secured to the external electrode, and 
a minute fragment of sponge sewed to a hard rub- 
ber plate, so as to protect the pharynx, was at- 
tached to the intra-laryngeal electrode. Contact 
was maintained tor a tew seconds at each intro- 
duction ot the electrode, and the current closed 
and opened at intervals of about one second by 
means of a spring connection on the handle of the 
intra-laryngeal electrode. The induced current 
was applied to the muscles of the mouth and of 
the thorax, in the customary manner. The con- 
tinuous battery current, very weak, was applied 
over the course of the cervical portion of the pneu- 
Meanwhile, she did not continue the applica- 
tions of electricity ; and within two weeks from 
their cessation, her voice failed her utterly, and 
she could no longer be understood. This failure 
seems to have been the first manifestation of ap- 
sithyria. 
At this time (August, 1880), the patient began 
the use of slate and pencil, which she had not 
been able to discontinue. 
In October, the applications of electricity were 
resumed, and continued for many months, but 
without the slightest benefit to the voice. The 
lungs, however, seemed to improve in respiratory 
power and endurance under the electricity, and 
hemorrhages became much less frequent. Since 
her first attack of painful respiration, she could 
bear neither wind nor cold, and for the last two 
years, the throat had been more or less sore con- 3 
mogastric, the positive electrode to the side of the 
uppermost vertebra, and the negative by means 
of a long, narrow electrode, in front of the sterno- 
cleido-mastoid muscle of the side corresponding. 
These latter applications were endured but for 
a few seconds, and were promptly discontinued, by 
sliding the positive electrode to a more distant 
point before removal, on the approach of dizziness. 
The electric routine was not carried out in full at 
each interview ; the patient could not have 
borne the protracted sitting. Choice was made of 
one or two of the four series of applications, as ap- 
peared most desirable at the moment. Many 
times it became necessary to intermit all applica- 
tions for several days. 
lias remained at command ever since. The pa- 
tient resumes the strychnine occasionally, under 
professional advice. 
A recent letter informs me, with profuse ac- 
knowledgments of gratitude, that sleep and appe- 
tite remain good, and powers of endurance greater 
than for many years. Pluck in the patient, and 
perseverance with strychnine and electricity have, 
save for the permanent impairment of hearing, 
restored a valuable individual to the society of 
family and friends, and enabled her to resume the 
duties and responsibilities of a more active life. 
It may be of service to those interested in the 
topic, to refer briefly to two of the cases reported 
in 1875, and state their subsequent history. 
During this treatment, it occasionally became 
necessary to prescribe for some temporary compli- 
cation, as an attack of pleurisy, an attack of in- 
tense and persistent cephalalgia, or something 
else ; but strychnine and electricity remained the 
therapeutic agents upon which dependence was 
placed. 
1. An unmarried lady, twenty-two years of age. 
came under my care April 3, 1873, with aphonia 
and apsithyria ; the latter of ten months’ dura- 
tion. She was slender, anaemic, and of a phthis- 
ical habit and inheritance. The aphonia was due 
to bilateral paralysis of the lateral crico-arytenoid 
muscles, and paralysis of the arytenoid proper ; 
the vocal bands remaining rigid in extreme ab- 
duction. Respiration was normal in frequency 
and in rhythm. Motion was perfect in lips and 
in tongue. But the ability to utilize the current 
of expiration in making a sound with the lips, wa 
in complete abeyance. 
In some three weeks, the ability to whisper be- 
came restored to such a degree that the tablets 
were interdicted and given away. There has been 
no total loss of whisper since. 
At the end of about two months the voice began 
to improve ; but again and again, though audible 
at the close of an electric manipulation, it would 
be lost before the patient reached her apartments, 
but three or four minutes’ walk from my house. 
The lady was so rejoiced at recovering her ability 
to whisper, that she would have remained content 
without her voice; but she yielded to my solicita- 
tion to give me every chance I wanted before 
abandoning the treatment. At the end of four 
months the voice remained good, though feeble, 
for several weeks; and I permitted the patient to 
return home, with instructions to continue the 
use of strychnine as she had been doing hitherto. 
Some three weeks later, she returned in an aphonic 
condition, her voice having failed by reason of 
over-taxation in social amenities. There was 
again a failure in the contractions of the lateral 
crico-arytenoid muscles, and insufficiency in the 
contraction of the arytenoid proper. Intra-laryn- 
geal applications of electricity, as before, restored 
the voice; and I detained her for an entire month, 
during which her voice continued to improve, when 
she returned home with a voice much stronger 
than before. 
Electric intra-laryngeal applications of the in- 
duced current of the second coil, soon overcame 
the paresis of the arytenoid muscle ; but currents 
of induction and currents of the battery, failed 
utterly for a long time to overcome the paresis of 
the lateral crico-arytenoids. Thus the aphonia re- 
mained unrelieved after one year’s treatment, at 
the time the case was imported. During this en- 
tire period tonics and aperients were systematic- 
ally employed, with marked improvement in the 
general health. Until this improvement had been 
well advanced, all electric treatment directed to 
the external muscles of respiration and to the 
course of the nerves of respiration, failed to re- 
store the ability to whisper. The apsithyria was 
finally conquered, however, about a year and a 
half before the case was reported, under the influ- 
ence of continuous currents of the battery, passed 
from the nape of the neck to the two cervical 
regions and the top of the sternum, for from two 
to three minutes daily, and persisted in for several 
continuous weeks. 
During last spring paresis of the laryngeal 
muscles again occurred, and the patient presented 
herself voiceless in April. Prompt recovery fol- 
lowed electric treatment as before, and the voice 
From that time to the present, the power of 
whispering has not been lost, though periods of 
great weakness of whisper have intervened. 
This lady has been an occasional visitant at my 
office, sometimes for a few consecirtive days, at in 4 
tervals varying from a few months to as long as i.. o 
years. There has been almost continuous neces- 
sity for tonic treatment, which has doubtless been 
influential in arresting the progress of her phthi- 
sis, and saving her thus far from the fate of her 
consumptive relatives. During one of her visits, 
prolonged for the purpose, in June, 1875, electric- 
ity was again applied daily to the lateral crico- 
arytenoid muscles, with satisfactory restoration of 
voice; but she has been compelled to return to 
me aphonic from time to time, at the irregular 
intervals above indicated, for electric treatment of 
the paretic muscles. A few applications, some- 
times hut one, soon restore the voice for the time 
being, and she goes on for an indefinite period sat- 
isfactorily. She appears to lose the voice by 
allowing herself to run down by omitting her 
tonic constitutional treatment. At every loss of 
voice she is placed under the influence of strych- 
nine, and she has consumed a large amount of that 
drug during more than ten years that she has been 
under my observation. She has never become ro- 
bust, hut has almost always remained able to con- 
tinue at her employment of dress-making, though 
when I last saw her, September 20, 1883, she was 
still sparer in habit than at our first interview, 
April 3, 1873 ; and physical exploration of the 
thorax gave evidence of consolidation at both 
apices, and of a cavity in the lower portion of the 
left upper lobe, anteriorly. 
casional correspondence with lier physician and 
herself. Out-door exercise, tonics, and occasional 
resumption of electric excitations, comprised the 
treatment. During a horseback excursion of 
several days, the voice and whisper became re- 
stored, as gleefully communicated to me by the 
delighted patient; and for aught I have heard to 
the contrary, the recovery has remained perma- 
nent. 
As remarked in my former communication (May 
1, 1875), apsithyria is usually manifested in fe- 
males. I there recorded its appearance, treat- 
ment, and cure, in a male religious fanatic. I 
heard of this man indirectly for a year or two, 
and there had been no return of the difficulty. 
I have no knowledge of his subsequent history. 
This case was strongly one of emotional, so-called 
hysterical origin, so far as the term hysterical is 
applicable to the male subject. I have since seen 
but one case in a male. In that instance the 
patient was not at all hysterical. He had been 
practicing dentistry for a number of years in the 
West, and had come to Philadelphia to attend a 
dental college. As I remember him, for I cannot 
place my hand on my memorandum of his case, 
he was some thirty odd years of age, stout, well- 
nourished, not all excitable, and in general good 
health. The apsithyria was positive; the aphonia 
was due to paresis of the arytenoid muscle. A 
highly favorable prognosis was given, and a course 
of tonic and electric treatment recommended. I 
learned subsequently from the late Prof. Buck- 
ingham, who had brought the man to me in con- 
sultation, that he had recovered both whisper 
and voice. 
In the instances narrated, and in all others 
that I have seen, the ability to whisper was last 
lost and first regained, as would be naturally ex- 
pected. 
The aphonia with which apsithyria becomes 
associated is always manifested as a functional 
paresis, whatever may have been its origin. At 
least it has not been myopathic in any instance, 
the features of which I can recall. The seat of 
the phonic paralysis can be inferred from observ- 
ing the contour of the glottis on laryngoscopic 
inspection, and from observing the effect of electric 
excitation of the quiescent muscles. The apsi- 
thyria is apparently paretic too, but where then 
is the seat of the paresis ? Can it be in the mus- 
cle of the diaphragm ? It is not in the other 
muscles of involuntary respiration, for their func- 
tions in many instances exhibit no evidence of 
impairment. It is not in the muscles of the 
tongue and lips, for voluntary control over these 
muscles is sufficiently well maintained. Volun- 
tary expiration can usually be effected, but the 
expiratory current cannot be emitted with a force 
sufficient to make a sound. 
2. This was a rosy Western maiden, twenty 
years of age, and brought up on the plains. She 
came to me October 17, 1874; aphonia and apsi- 
thyria were complete ; the aphonia was of a year’s 
duration, and had followed a mild laryngo-bron- 
chrtis; occasional momentary production of voice 
had occurred under emotion, but nothing further. 
On laryngoscopic inspection and application of the 
electric test, the aphonia was seen to be due to 
bilateral paralysis of the thyro-arytenoid muscles, 
with paresis of the arytenoid proper, and of both 
lateral crico-arytenoids. The treatment pursued 
consisted in persistent administration of strych- 
nine, and applications of electricity. A few applica- 
tions of the interrupted current of the battery over- 
came the paresis of the arytenoid and lateral crico- 
arytenoids ; but the thyro-arytenoids remained 
uninfluenced at the end of two months’ treatment, 
and the aphonia continued. All electric treat- 
ment to the muscles of respiration and along the 
course of the pneumogastrics failed to impress the 
apsithyria. 
The lady passed the winter in Florida with 
great advantage to her general health, but re- 
turned to the West without voice and without 
whisper. 
To adopt the language of Professor Paget, of 
London, perhaps the patients “cannot will’’ to 
whisper. But they do seem to make the effort 
consciously and conscientiously, and they fail. 
The only serious difficulty essential to the con- 
dition of apsithyria is the forced communication by 
pencil or by signs. This is troublesome and an- 
noying. It often subjects the patients to h nug 
unpleasant remarks, based upon the opin I 
bystanders who deem them deal as well a 
1431 Walnut Street, Philadehhia. 
I have not seen her since, but have been in oc-