APSITHURIA. By J. SOLIS COHEN, m. d. LECTURER ON LARYNGOSCOPY, AND DISEASES OF THE THROAT AND CHEST, IN JEFFERSON MEDICAL COLLEGE. [Reprinted from “THE MEDICAL AND SURGICAL REPORTER,” May 1, 1875.] Apsithuria (inability to whisper) is a mani- festation of disease not often encountered. Many patients with aphonia (inability to vocal- ize [phonate]) are supposed to be unable to whisper also, but upon close examination it will be found in the vast majority of instances that the inability to whisper is only apparent. At a short distance from the patient’s mouth, not the slightest indication of a whispering sound can be heard. Still, on placing the ear close to the patient’s mouth, or on using an ear trumpet, a more or less feeble whisper can be detected •, and conversation can even be carried on with the patient in that way, though for the ordinary pur- poses of life the patient is really as bad olf as if the debility of the whisper were an actual in- ability ; and is compelled to resort to tablets or finger-spelling in order to communicate with others. Of cases of this kind I have met seve- ral examples. In some of them, the very evi- dence afforded by the experimental examina- tion just indicated, has restored confidence to the mind ; and the ability to whisper has at once begun to increase, and its full power become re- stored before the aphonia has been overcome. In others, the power of whispering loud enough to be heard in conversation has increased pari passu with the recovery of the voice. In one case under my care, on the other hand, there was no in- crease in the power of the whisper, nor any re- turn of voice. But these cases are not those to which I wish to call attention in this paper. They are alluded to, in advance, in order to separate more definitely those cases to which the term apsithu- ria is applicable to designate the symptom un- der consideration—inability to whisper. Of the latter class of cases I have met but four examples in the entire course of niy practice; two of which came under my care in the ordi- nary way of practice, and two were sent to me for treatment by professional brethren. I will relate these cases briefly. Case 1. April 3d, 1873. An unmarried young lady, about twenty-two years of age, visited me from another State, with a letter from her phy- sician stating that there was aphonia, with in- ability to utter the slightest whisper •, the latter symptom being of ten months’ duration. The most attentive examination with the ear close to the mouth, and with the ear trumpet, enabled me to assure myself that the inability to whisper was real and not apparent. The lady was of rather spare habit, of a consumptive family (two members of which have since died of con- sumption, without, however, any loss of voice or whisper), anaemic, somewhat emaciated, of a costive habit, and with but little appetite. There was no uterine trouble requiring treat- ment. She was feeble, though able to take considerable exercise in walking without much fatigue. She presented no appreciable evidence 2 of a condition which could be denominated hys- teria. Laryngoscopie examination revealed consider- able anaemia of all the structures under inspec- tion. The larynx appeared otherwise normal anatomically. There was complete rigidity of the vocal cords in widest extension, without the slightest power of approximation. The respira- tion was normal in frequence and rhythm, but there was no power of making an audible ex- piration. Motion of lips and tongue was perfect. The local application of an electric current of induction (second coil), one electrode upon the internal surface of the interarytenoid commis- sure, at once restored considerable power in ap- proximation of the vocal cords. The following prescriptions were ordered to be taken, and the patient was instructed to visit me daily, for the purpose of being subjected to electric treatment:— [R. Strychniae sulphatis, grs.ij Aquae, q. s. ad. solve, Syrupi acaciae, ad. M. Sig. A teaspoonful three times a day, be- fore meals. pushed until the patient was taking three- fourths of a grain daily, in divided doses, with- out any evidence of toxic action, and without any evidence of restoration of the voice. . In addition to the local application of elec- tricity to the larynx, the continuous and inter- rupted currents of the battery were employed, in all the approved and disapproved methods, to the sympathetic in the neck, and to the regions of the nerves of respiration, as well as to the external muscles of respiration, all without the slightest local benefit. Treatment was now interrupted for three months, save an occasional visit to the gentle- man who took charge of my patients during my absence, to watch the effect of the strychnia, which was administered in smaller doses with more or less regularity, and to receive an occa- sional repetition of the electric treatment. In October I again took charge of my pa- tient, who was pretty much in the same condi- tion as when I left her. During the interval, she had had some sore throat, and some slight haemoptysis ; and she had been taking iron and cod-liver oil, and had been placed for a while upon milk diet. On resuming treatment the administration of strychnia was stopped, and the following sub- stituted :— R. Podophyllin, gr.j Quin, sulph., grs.xvj Ext. nucis vom., grs.iv “ belladonna, grs.ij 01. month, pip., q. s. M. Ft. mass, in pil. No. viij div. Sig. One, night and morning.] R. Infusi. anthem., f-.lyiij Tr. cinch, co., f-3iy< Sig. A wineglassful, three times a day, be- fore meals. Daily applications of electricity were made to the arytenoid muscle, and to the vocal cords themselves, which eventually efl'cetcd close ap- proximation of the vocal cords posteriorly, but failed to overcome a slight bulging of the cen- tre of the glottis. Currents of the battery, continuous and interrupted ; currents of induc- tion from the first and the second coil, all vari- ously modified as to intensity, continuity, and rapidity of interruption, from the very best ap- paratus (Brenner’s battery, Du Bois Rcymond’s and Kidder’s induction coils), and variously modified as to manner of application, failed to produce any improvement upon the condition already described, though made daily until the 7th of June, at which date I left the city for a summer holiday. During this time the tonic and aperient treat- ment had produced an admirable effect upon the general health and the condition of the bowels, so that the pills were kept merely for occasional use. The strychnia was gradually In the course of a few weeks, under the influ- ence of a continuous electric current, passed from the nape of the neck to the cervical re- gions alternately, and to the top of the sternum, the power of whispering was regained, and it has continued to the present time, though there has been no relief to the aphonia. The treatment by electricity was systematically kept up for several months, without any further success, when it was abandoned ; and for about a year I have seen the patient, or heard from her by let- ter at infrequent and irregular intervals. She remains pretty much in the same condition, always feeling better under the influence of some tonic or nervous excitant, such as quinine, iron, strychnia, phosphorus, all of which seem to be of benefit in turn, though incompetent to effect much permanent good. The general health, though far from good, is better than it has been for years. The past 3 severe winter was endured without the usual susceptibility to atmospheric influences, but within the last few weeks there has been a weakness of vision, with photophobia, for which the patient is now under special treat- ment. The larynx is still anaemic; the vocal cords approximate, but there is a lack of longitudinal tension. The whisper is sufficient for the ordi- nary requirements of occasional conversation. There has, at no time, been any indication of voice. Upon some future occasion the subsequent history of this case will be continued. Case 2. October 17th, 1874. On this date I took professional charge of a young lady about twenty years of age, sent to me from the western portion of the United States, with a written his- tory of her case prepared for me by her physi- cian. She was rather slender, bright-fhfced, with a delicate rosy skin, quite languid, unable to bear fatigue, and with a very poor appetite. There was complete aphonia, and complete apsithuria. Communication from her by writing and signs only. Occasionally, while laughing, a short laryngeal inspiratory chirp would be heard, sometimes loud enough to be distin- guished several feet. It could not be produced voluntarily. It was some time before I had an opportunity of hearing this sound, which was clear and entirely free from hoarseness. The history furnished me was, that “ the patient—full faced, with good color, before present attack—has had hysterical symptoms, and lost voice on one occasion for a short time —recovery sudden. “ Last autumn had a slight cold and hoarseness of voice, which in a few houjrs became reduced to a whisper ; cough trifling, and febrile action slight. Active symptoms removed in a few days by warm baths, Dover’s powder, etc., leaving the patient with complete aphonia, great lassi- tude, oppression in chest, and small, nervous cough.” A tonic and local treatment was insti- tuted without effect on the voice. After the catamenial period next ensuing, which, though normal, left the patient “ with increase of lassi- tude and oppression,” ether was adminis- tered diagnostically. There was “ much mus- ! cular excitement, but no loquacity—spoke once in her struggles, with distinct sound.” Local •< treatment, including applications of the current t from a magneto-electric apparatus every second . or third day, was continued, but without im- 1 provement. “ She spoke once or twice during the course of following months, in distinct tone, when excited ; laugh resonant.” Further treatment by derivatives, strychnia, stimulants, local astringents and caustics, inhala- tion of sprays, etc., had proved unavailing. On examining this patient laryngoscopically, I found a bilateral paretic condition of the vocal cords, the parts appearing anatomically normal. I am not certain that this condition was not due simply to emotion, inasmuch as after a very few (not more than three or four certainly) applica- tions of the electric current (interrupted battery current) of a few seconds’ duration each, there was voluntary power of bringing the cords into contact that should have been phonal; but no effort or device was sufficient to throw them into vibration; nor did this take place at any time during the entire course of treatment, which, with infrequent interruptions, was kept up daily until nearly the close of the year. Strychnia was prescribed, and pushed, as in the case already related, and with no better result. The appetite improved a little at times, and then fell off, but the languor and lassitude increased, despite all the attention and comforts which were at the disposal of the patient. Applications of the continuous current, and of the interrupted current of the battery, were made to the external muscles of respiration, to the region of the sympathetic, to the sternum, and alongside the upper portion of the spine upon both sides. The ascending current, from the sides of the dorsal vertebrae to the corres- ponding sides of the upper portion of the neck, seemed at times to lessen the languor, but the improvement was very evanescent. The appli- cation of the battery current, whether continu- ous or interrupted, almost always induced slight headache. But few cells (8-12) could be used. In this case, as in the other, I had the hearty co-operation of the patient in my attempts for her relief. W hen the weather became cold .it was con- sidered prudent to send this patient to a warm climate, where she could be out a good deal in the open air. She has spent the winter in Florida, with improvement to her general health, but she is still unable to whisper. Case 3. December 21stf, 1874. A married man, about forty years of age, of highly nervous temperament, illiterate, and a religious fanatic. Aphonia and apsithuria, both complete, and both of several months’ duration, during which 4 the other hand, the power of phonation has continued but a few hours, and sometimes but a few minutes. It is almost always possible to restore the voice by the manipulation mentioned, by external electrization (with any current) of the cricp-thyroid muscles on both sides, and by internal electrization (any current) of the vocal cords. The patient was placed upon the use of sul- phate of strychnia from the first, and her gene- ral health has improved greatly under its inflif- ence. It is given in doses of one twenty-fourth of a grain, three times a day, and increased daily until there is some evidence of toxic ac- tion, when it is intermitted for a day, and then resumed in the same manner as before, always returning to the minimum dose. Other reme- dies have been used at times, but nothing has given results comparable to the strychnia ad- ministered in this manner. A peculiarity of the case exists in this: when the voice is gone the throat feels well; when the voice is present the throat is sore. The sore points are the corpuscles of Santorini. Local treatment with astringents and caustics has had no effect; on this peculiarity. While this patient has been under treatment, the condition of apsithuria has become devel- oped, and now, when she loses her voice, she very frequently loses the power of whispering also ; and this continues until voice and whis- per are regained, under some of the manipula- tions already mentioned. No abnormal appear- ance of the vocal cords is apparent, unless it is too great tension on attempts at voluntary phonation, which close the glottis so much that a very minute linear aperture remains, through which, on forced effort, a sound of exceedingly high pitch is made ; but even when this attempt succeeds 'there is no power, often, to use the voice after the experiment, even though it may be successfully repeated several times consecutively. The case is still under treatment, and will be more fully reported at some future time. These cases are laid before the profession in the hope of eliciting some records of similar experience which may throw light on the ob- scure portion of their pathology. I have been unable to obtain any satisfactory insight into the pathology of loss of whispering power with intact preservation of voluntary expiration, and voluntary consentaneous movement of the muscles employed in speech. 1431 Walnut St., Phila., April 16th, 1875. time the inability to speak aloud and to whisper had been absolute and continuous. The man was very much afraid of being hurt, and it was with difficulty he submitted to a laryngoscopic exami- nation. There was bilateral paresis of the vocal cords, with general congestion of the laryngeal and contiguous structures. A guarded prognosis was given, on the basis of the two cases already narrated. Treatment was begun at once by local application of the interrupted battery cur- rent (20 cells) to the vocal cords, one electrode being held externally. The treatment cured the aphonia and apsithuria at once, much to my own gratification and to that of the patient, who has since remained in full possession of voice and whisper. lie was directed to give up attendance upon religious meetings, and to take, three times a day, a pill containing one- sixth of a grain of phosphide of zinc, and half a grain of extract of ignatii amara. Under this treatment his nervous and mental condition improved very rapidly. There is no doubt as to the hysterical nature of this case. It is the only case of hysterical aphonia that I can recall, at the moment, in the grown-up male ; and the only case of apsithuria that I have seen in the sex. Case 4. An unmarried lady, of about twenty- two years of age. September 28th, 1874. This pa- tient consulted me for complete loss of voice of several months’ duration. She was able to whisper satisfactorily at this time. She was moderately well developed, but weak. Her organic functions were in good order. Laryngo- scopic examination revealed a congested larynx, with velvety condition of the supra-arytenoid structures, and bilateral phonal paresis of both vocal cords, their respiratory movements being normal. The application of the interrupted current, from twenty cells, at once caused the vocal cords to approximate, but did not over- come the want of longitudinal tension of the cords ; so that there was no phonal sound. To render the cords tense I fixed the cricoid cartil- age between my two middle fingers, and with the thumb and index finger of each hand upon the thyroid cartilage, pressed that structure down toward the cricoid; and while the parts were maintained in this position, the phonal sound could be made. This manipulation suc- ceeded at many subsequent interviews, and finally the voice returned ; but it has never re- mained for more than a few consecutive days, from that time to this. On many occasions, on