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

by Unknown

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 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 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.