A system of practical medicine. By American authors. Vol. 3

by Unknown

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 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 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 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. Nothnägel⁷ 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.

⁷ Deutsch. Arch. für klin. Med.