few cases we are able to definitely fix upon something as the occasion
of the attack. It is possible that there may be some central lesion,
and this may be well defined. This is rare, however. It is nevertheless
true that the onset is generally preceded by some derangement of the
general health. There has been for a day, or perhaps only for an hour
or two, a slight cold, a little hyperæmia of the respiratory mucous
surfaces, or disturbances of the digestive tract, or the child has been
unusually fatigued or excited from play or study. The secretions have
in other cases been deranged. No one of these causes has perhaps been
of sufficient gravity to attract the attention of the mother or nurse.
The indisposition, if it has been noticed at all, has been regarded as
only one of the many ephemeral troubles that so often occur in infancy,
and no anxiety has been felt. Of all these possible causes, the one
most frequently invoked after the attack is a cold, slight, it is true,
but nevertheless, in the light of the subsequent history, evidently a
mild form of inflammation of the laryngeal mucous membranes.
SYMPTOMS.--Spasm of the glottis usually takes place at night. It is
true that some authorities deny that this is the case. Stefen says
"that it is quite as likely to occur during the day as night." In a
great majority of instances, however, it will be found that the attack
occurs after the child has been asleep. During the day there has been
perhaps a slight disturbance of the general health, a little
inclination to cough, or there has been a catarrh of the fauces or
bronchial mucous surfaces; nothing, however, of a serious character has
been observed. At midnight or later the little one awakes with a
crowing or {71} whistling inspiration. It starts up in bed, and
evidently experiences great difficulty in breathing; this difficulty is
manifestly in inspiration; expiration is easy and free. The eyes are
prominent, the lips blue, the surface often bathed in perspiration;
pulse frequent, small, at times irregular; there is, if the child be
old enough to reason in the matter, great alarm; there is often cough,
and this cough is characteristic: it is a hoarse, metallic, barking,
peculiar cough, described as croupy. If the spasm is limited to the
larynx, the other muscles not being affected, the patient clutches at
whatever it can reach, and often seizes the throat as though there was
something there to tear away. The general surface becomes cyanotic and
all the symptoms of asphyxia are present. The voice, though not
generally extinct, is altered; it becomes hoarse, or husky, as it is
called; in a few minutes the severity of the attack is passed, and the
little sufferer sinks exhausted into a sleep more or less disturbed. A
second attack may occur the same night, or there may be nothing more to
alarm the attendants till the next night. The second attack, if it
occurs, as it generally does, on the succeeding night, is less severe
than the first; the third still more mild; and this generally ends the
case for the time being. During the intervals--that is, during the
day--the patient in a majority of cases is up, and seems to be but
slightly affected by the seizure of the night before. There will
perhaps be a slight cough, with some loss of appetite and indisposition
to engage in play. This is the most usual type of the disease. In a few
cases there is more marked derangement of the general health. The
spasms are more severe; the cramp is not confined to the laryngeal
muscles, but involves other parts, such as the muscles of the chest and
the extremities. During the intervals of the attack there is perhaps a
little fever, the digestive tract is disordered, the cough may be
marked during the day, there may be an increase in the secretions of
the respiratory surfaces. Attacks may recur during the day and for
several days; the cough may retain its croupy character, and the voice
may continue to be hoarse.
COURSE AND DURATION.--Spasm of the larynx is usually a transient
phenomenon, lasting only from a few seconds in the milder cases to
several minutes in the more severe forms of the disease. The attacks
are intermittent. The seizures are relieved by intervals of comparative
relaxation of the muscles of the parts. Even in the intervals there is,
however, a degree of contraction of the constrictors, so that the
relief is not absolute. Two or three days elapse before the attack may
be said to have entirely ceased. In the severer forms the consequences
of the spasm may continue even for a still longer time. There are
usually no sequelæ. When the patient has recovered there is nothing
left of the disease, though there is often a predisposition to a
recurrence; the same causes that produced the first attack, or even
slighter causes, may produce a second. These causes are generally
persistent; the seizures are therefore usually repeated.
PATHOLOGY.--In cases dependent on central disease the pathological
changes are to be sought for outside of the larynx. In rickets and
other morbid conditions which by reflection produce spasm of the
glottis the pathology proper is distant and not in the organ; there is
only an excess of motility in the nerves and muscular apparatus.
Efforts have been made to differentiate spasm and false croup, but the
confusion is only equalled by the disagreement as to the relation of
diphtheria to true croup. It is probably true that the cramp is
generally due to some excess of motility in the system at large, and
that the larynx is the seat of pathological changes that determine the
spasm in that organ. This is especially true in those cases associated
with rickets, derangement of the alimentary canal, etc. It seems to be
a fact, nevertheless, that in a majority of cases the mucous membranes
are, as already stated, the seat of a very mild inflammation. Or
perhaps we should say they are slightly hyperæmic. So far as we can
judge from {72} examination in cases which have terminated fatally, as
well as from ante-mortem observation, there is no structural change of
tissue to be recognized by the naked eye, unless it be, during life, a
slight fulness of the vessels. There is a change, however, in the form
of the organ, at least at the entrance to the larynx. The constrictors
are in a state of action, so as to partly close the superior opening to
the larynx, and the epiglottis is rolled so as, in some instances, to
become almost a tube. I have repeatedly recognized this in the image
seen in the laryngeal mirror. Cohn reports a case of impaction even of
the epiglottis in the vestibule of the larynx (p. 627). This fact is
also suggested by the difficult inspiration and the altered voice and
cough. In young children the yielding character of the cartilages
probably adds largely to the obstruction produced by spasm of the
muscles about the vestibule.
DIAGNOSIS.--The diseases with which spasm of the larynx is most likely
to be confounded are true croup, simple inflammation of the larynx,
foreign bodies in the larynx, and possibly, in the absence of the
history of the case, tumor situated in the glottis or along the vocal
cords.
It will readily be distinguished from true croup by the fact that in
the one case, true croup, the attack is insidious: the patient has been
sick some time, usually several days before spasm occurs; there is also
fever, with usually more cough; the voice is altered before the
appearance of spasm; the first seizure is slight, almost imperceptible,
and the subsequent attacks become more and more severe; dyspnoea is
continuous. All these facts are in marked contrast with the picture of
an attack of spasm of the glottis as we have attempted to describe it.
In the one case the most alarming symptoms are at the beginning. There
is an explosion of morbid phenomena, each recurrence less alarming till
complete convalescence is established. In the other disease the
symptoms and dangers are constantly increasing in severity, till at
last the spasms become as fearful as the initial seizure in
laryngismus. The morbid anatomy of the two diseases is also widely
different; and this difference can be recognized during life. Simple
ordinary inflammation of the larynx may give rise to hoarseness and
cough; the hoarseness is, however, different from that in laryngismus.
There is fever, and the hyperæmia of the organ can be readily
recognized. The disease is progressive, does not present its most
alarming symptoms at the beginning, and spasm, if it occurs, is a late
event.
It is possible that spasm of the larynx might be mistaken for a foreign
body in the organ. It will be remembered that the attacks of spasm
usually occur at night after the child has been asleep. The history of
foreign bodies in the larynx reveals what we should expect--namely,
that the accident almost always occurs during the day. In a great
majority of cases this history also furnishes reliable information of
some substance or object which was in possession of the child, and
which has disappeared. The dyspnoea is more continuous and the course
and symptoms more variable. There will therefore be no great difficulty
in any case, and in most cases no difficulty at all, in making a
certain diagnosis as between these two conditions. In a few cases of
laryngeal tumor the symptoms are very similar to those of the disease
under consideration. The attacks in the case of a pedunculated tumor on
the vocal cords may take place at night and may be intermittent. The
rarity of this affection in children in comparison with spasm of the
larynx, and the further fact that in the case of tumor there is a more
continuous disturbance of respiration, make the differentiation easy.
Paralysis of the adductors gives rise to more dyspnoea during sleep,
but the history and laryngeal mirror make the diagnosis easy and
certain.
PROGNOSIS.--The large majority of cases of spasm of the larynx recover.
Statistics show that there are deaths from this disease, but in
proportion to {73} the number attacked I think the mortality is small;
how small we do not know. The confusion in classification is so great
that we cannot place much dependence upon published statistics. In our
climate I think most observers will admit that a patient seldom dies
from this affection unless there be associated with it some morbid
condition of a serious nature.
TREATMENT.--The immediate and pressing indication in spasm of the
larynx is for something to relax the constrictors and allow the act of
inspiration to be accomplished without embarrassment. For the
accomplishment of this purpose three methods of treatment may be
resorted to: First, heat; second, emetics if there be time; third,
anæsthetics and antispasmodics. Of all these measures, the first is the
most easily applied, and will probably in a great majority of cases
prove efficient. It is usually within the reach of the attendant or
nurse. It can in any event do no harm. This fact is not to be
overlooked, as the symptoms are so alarming that friends and physicians
are often tempted to do too much. Heat may be applied by means of
cloths dipped in hot water (110° F., or even more) applied to the neck
and chest of the patient, or the child may be placed in a bath of 105°
F., while the head is kept cool by cloths wet with cold water. This
treatment may be continued till the spasms yield. The second of the
measures suggested is usually safe, and may be resorted to along with
the first. Those agents should be selected which act with most
promptness, and the doses should be adapted to the age and condition of
the patient. Alum, sulphate of zinc, sulphate of copper, are perhaps
the best, but by no means the only ones. Ipecacuanha, by the relaxing
effect which it has upon the muscular and nervous system, may be useful
not only in overcoming the spasm, but in preventing the recurrence of
the attack. Antimony is unsafe, and the other emetics are quite as
useful in relaxing the muscles. The third of the measures suggested
should be used with great caution. It may be doubtful whether, in fact,
anæsthesia is ever indicated in simple spasm of the muscles of the
larynx. The dyspnoea renders it very difficult to produce full
anæsthesia, and without this the relaxing effect is not reached. In
cases in which there is serious disease outside of the larynx there
should be appropriate treatment directed to the extrinsic trouble.
During the intermission--that is, during the day following the
spasm--attention should be directed to the condition of the digestive
and excreting organs as well as to the respiratory tract. In malarial
districts I have thought that quinia given in antiperiodic doses the
morning after the seizure has been of benefit in preventing or
diminishing the severity of the next spasm. In addition to these
measures, for the prevention of the subsequent attacks bromide of
potassium or bromide of sodium in 3 to 5 grain doses may be given once
in three to six hours after the spasm has ceased. Five grains of
chloral, as advised by Mackenzie, given at bedtime the night after the
attack, will also diminish in a certain number of cases the severity of
subsequent seizures, or possibly entirely prevent them. Musk, myrrh,
camphor, castor, and other similar antispasmodics are theoretically
indicated, but, in fact, are of but little if any value. If the disease
is central, involving the floor of the fourth ventricle, the local and
general spasms are only symptoms, and the treatment must be directed
entirely to the preservation of life. It should be remembered in this
connection that in the floor of the fourth ventricle the pneumogastric
and the glosso-pharyngeal, as well as filaments of the spinal
accessory, have their origin. The range of distribution of these nerves
marks to some extent the range of the morbid phenomena in disease of
central origin. It may of course be true in any given case that only a
small portion of the central gray matter is involved, but as a rule the
organic change in one of the nerves at the point of origin does give
rise to disorder of function of one or both of the others.
General tonics and attention to hygienic conditions are of great {74}
importance for the purpose of giving vigor and regularity to all forms
of nervous and muscular activity.
Spasm of the Glottis in the Adult.
The affection is usually bilateral; that is, all the muscles guarding
the vestibule of the larynx, and probably in most cases the adductors
of the vocal cords, are involved. That this is not always true,
however, I am convinced by a case now under observation in my own
practice. The patient is an adult, and I have been able to determine by
laryngoscopic examination that the muscles on the left side are the
seat of the spasm. The epiglottis is drawn downward and backward on
that side. The top of the left arytenoid cartilage is drawn forward,
while the similar parts of the right side remain in their normal
position except the change necessarily produced in the epiglottis. This
condition is not constant, and is not a paralysis of the opposite side.
This is the only case that I have seen, and I do not know of any
similar case on record. Nothnägel[7] reports a case of spasm of the
adductors upon making an effort to phonate. The cords were normally
separated in inspiration, but at the first effort to speak they closed
firmly, leaving no line of opening between them. The attack seemed to
have been produced by a powerful impression made upon the nervous
centres. It seems probable that it was hysteria. Krishaber describes a
form of what he calls spasm of the larynx in adults, which seems to be
rather a local manifestation of a central disease than a neurosis of
the larynx. It is in many respects similar to epilepsy. The danger,
even in cases in which life is threatened, is not from asphyxia, but
from the arrest of the functions of circulation and respiration--an
arrest of the effort even to breathe. It hardly seems proper to include
this among the troubles of which we are treating. He calls it ictus
laryngé.
[Footnote 7: _Deutsch. Arch. für klin. Med._]
ETIOLOGY.--It is certain that the same causes that produce spasm in
childhood are efficient in the adult, though there is an absence of
some of the conditions that render the disease so frequent in infancy.
The cartilages have become more firm, and consequently are not so
easily moved by the action of the constrictor of the vestibule of the
glottis; the size of the cavity in proportion to the necessities of the
body for air is larger; the control of the voluntary over the automatic
actions of the muscles of mixed function is greater; the reflex
irritability of the nervous apparatus is less. These facts all render
the probability of spasm in the adult much less than in the child. On
the other hand, the development of the generative organs, and the
widespread influence which they have upon the respiratory and
circulatory as well as upon the central nervous system, introduces a
new factor as a cause of motor disturbances of the larynx. This new
element is a reason for the fact that in adults the predisposing
influence of sex is reversed: after puberty the disease occurs more
frequently among females than among males. The hysterical character of
many of these cases may be inferred from this preponderance of one sex
over the other among the subjects attacked.
This fact has been seen and described by Charcot, Lefferts, and others.
Irritation along the track of the nerves, morbid conditions of the
mucous surfaces, or muscular irritability, may be each a cause of
spasm.
SYMPTOMS.--The symptomatology of spasm in the adult does not differ in
any material respect from the phenomena observed in children. It is in
the rarity and the comparatively milder character of these symptoms
that the difference is to be found. The attacks occur at night, as in
children, but, so far as I have observed them, they may also take place
during the day. When very severe they occasion great alarm to the
patient, and for this reason {75} produce a profound impression, not
only upon the physical, but also upon the mental and emotional, state.
The duration and termination of the affection are about the same as in
children. In the mortality-tables we find every year a certain number
of deaths from spasm of the larynx in adults. It is probable that among
these there are quite a number which should be placed elsewhere. A
patient may die from spasm of the larynx, which spasm is produced by an
ulceration, by a tumor, by the presence of a foreign body in the organ.
As in children it is quite certain that the deaths reported as from
spasm of the larynx include many that should be referred to central or
other diseases, so here the immediate cause of death is not
unfrequently given instead of the real and essential cause. This fact
makes it difficult to reach anything like a definite conclusion as to
the termination of the disease; only this can be said: the great
majority of cases recover.
PATHOLOGY.--With the exception of those cases in which there is disease
of the central nervous system or along the course of the nerves, we
know nothing of the morbid anatomy of this affection. In fact, there is
no appreciable alteration of the tissues or of the relations of parts;
the spasm is to be considered as a symptom of disease, and not as the
disease itself, or necessarily even as a sign of morbid structure in
the organ.
DIAGNOSIS.--In adults we can make the diagnosis certain by the aid of
the laryngoscope. This can be done in a certain number of cases in
childhood, it is true, but not with the same ease as in those who have
reached more mature years. Ulcerations, benign and malignant growths,
and foreign bodies may each or all produce spasm, but the existence of
such causes is revealed by the mirror, and excludes such cases from the
group under consideration.
TREATMENT.--This does not differ in any essential respect from that
suggested in spasm of the larynx in children. Attention to the
condition which has been instrumental in the production of the
affection, the use of antispasmodics, such as bromides, chloral, myrrh,
musk, camphor, ether, chloroform, etc., will meet the urgent symptoms,
while the use of tonics, such as vegetable bitters, quinine, iron,
cod-liver oil, with attention to a proper hygiene, constitutes the
general treatment.
The question of tracheotomy in spasm of the larynx should be
considered. It is sometimes stated that there is never in simple spasm
a justification for this operation, and that the other means at our
control are always adequate to meet the indication. Krishaber, Thaon,
and others are of this opinion. Gougenheim and Schnitzler think it is
sometimes required. While in a very large majority of cases of
uncomplicated spasm of the larynx the spasm will yield to the measures
recommended, it is nevertheless true that there are cases in which this
result is not realized. The slowness of the action of some of the
drugs, the difficulty in securing their introduction into the system,
their absence at the time of the attack, and the delay in their
administration,--all these facts may render it absolutely necessary to
resort to an operation for the purpose of saving the life of the
patient. It is, however, rare that this necessity will occur. In one
case recently in my own practice I think a life was lost for want of
the operation. The trouble was, as I thought, of hysterical origin, and
at the time of the consultation did not threaten life. There was free
movement of the vocal cords, and the vestibule of the larynx was not
obstructed. Spasm of the constrictors occurred at night, and did not
continue for a great length of time. There was certainly not paralysis
of the abductors of the glottis. I directed an antispasmodic, and
advised that if the spasm returned the next night a physician in the
neighborhood should be sent for. The spasm did recur, and the physician
was called, but before he reached the house the patient was dead. No
post-mortem was held, and {76} the question of the morbid anatomy could
not be determined with any degree of certainty. From the fact that
there had not been spasm till the night previous to the consultation,
that she was an adult female previously in good health, with no organic
disease, no tumor, no ulceration, no paralysis, and with a perfectly
healthy condition of all the parts of the organ as revealed by the
mirror, I am led to believe that the cause of death was simple spasm of
the larynx. It is possible that this was one of those cases described
by Krishaber and Charcot under the name of ictus laryngé or laryngeal
vertigo, and that the death was due to some central disease; but the
description given by the attendants was that of true spasm of the
muscles of the larynx, and it is more probable that, as in Cohen's
case, there was impaction of the epiglottis in the vestibule. The
question of the operation should be considered in severe spasm which
does not readily yield to the ordinary means. It is certain, I think,
that life may sometimes be saved by a timely opening of the trachea.
E. F. Ingals suggests tubage of the larynx in cases of spasm
threatening death. If the physician is present at the time of the
dangerous symptoms, this may be attempted. A large-sized catheter or
one of Schrötter's dilators may be used with no danger to the patient,
and possibly with the result of saving life.
Chorea of the Larynx.