CASES FROM PRIVATE PRACTICE. the stethoscope to the lateral aspect of the larynx, a and a spasmodic paroxysm has supervened. On placing

By JOHN RICHARD WARDELL, M.D., Edin.; Late President of the Royal Physical and Hunterian Medical Societies, Assistant Pathologist in the Royal Infirmary, Edinburgh, &c. &c.

The following cases are not published as presenting features of very great rarity, but rather as being considered of a practical description, and with the nature } and treatment of which the practitioner cannot become - too familiar. Very uncommon examples of disease are not those from which the most useful benefit is derived; but cases that are at times occurring, and the pathology and cure of which are, perhaps, not so well understood as many other affections, are par- ticularly eligible for being placed in a permanent form. There is no kind of medical instruction which is really · so profitable as clinical teaching, which at once renders us acquainted with the often indescribable characters and multifarious features of disease, as witnessed in nature itself; and so it is that accurately detailed cases are, perhaps, really as instructive as any kind of literature in our Journals, and it is much to be - regretted that the country, as well as the metropolitan, and the private, as well as the hospital, practitioner, do not more commonly, in an accurate manner, study and faithfully record such cases of interest as from time to time fall beneath their notice. Every contribution, however small, to the commonwealth of -medical literature, cannot fail to be of some service; and if the system of deducing and compiling facts -were more generally pursued, there would be an aggregation of data highly valuable, and from which many useful and practical conclusions might be drawn. The first example of disease now offered is that of an affection which is but occasionally met with in adults,

and far more commonly occurs in children at an early age, nor was it until of late years fully understood,

Viz.:

SPASMA GLOTTIDIS.

CASE 1.

Esther Cooper, aged 18, servant in a private family; of sanguino-phlegmatic temperament; volume of flesh normal; catamenia recently irregular; has somewhat of ́ ́a chlorotic appearance; health lately has been pretty good.

April 8th, 1846. About six o'clock this evening, laborious and great difficulty of breathing was suddenly experienced, and each inspiration was performed with a croupy, suffocating sound, so loud that it could with distinctness be heard at remote parts of the house. 7 p.m. Questions can only be answered in an indistinct whisper; never had any similar affection; is reported to have had damp feet during a greater portion of the day, but complained of no indisposition whatever until the setting in of the fore-mentioned symptoms. On fully expanding the thorax, some degree of tightness is experienced over the superior and middle thirds of the sternum; pulse 76, of good strength; coun tenance manifests an expression of anxiety, and obstructed circulation; croupy sound becoming louder,

loud whistling sound, resembling the forcible passage of air through a contracted aperture, is most distinctly audible; no anormal sound heard at the thorax, with the exception of increased respiratory murmur, and a greater loudness at the bifurcation of the bronchi.

Venesectio ad deliquium animi. Ordered hot drinks, and to be put to bed.

diately on entering the room; countenance more 11 p.m. Croupy sound still distinctly heard immenatural, and is on the whole improved; no paroxysm since last visit. Hot bottles to be applied to the feet, and a draught given immediately, with thirty drops of the solution of morphia.

9th, 10 a.m. Reported to have passed a tolerable night, being free from any particular difficulty of during which she was loquacious and wandering; breathing, though a good deal disturbed by dreams, tongue clean and moist; pulse 80, of fair strength; bowels not opened; skin moist; the croupy respiration still audible, but does not produce much apparent inconvenience.

R. Pulv. Opii, gr. iss; Camph., gr. ij. Fiant R. Decoct. Aloes Co., pilulæ ij., statim sumendæ. cujus unciam post horas tres capiat et repet. omni oz. ij.; Eth. Sulph., dr, ij.; Aquæ, oz. ij. Sit mist. secunda hora donec alvus soluta fuerit.

11 a.m. Summoned in great haste, difficulty of breathing having very suddenly increased, and she now labours under very painful feelings of suffocation; tosses about in bed, sometimes quickly rising into the semi-erect position, and in a very distressing manner gasps for breath; countenance presents an asphyxial condition; eyes partly closed, or rather, lids droop in passiveness partially over the eye, and an obvious delineation of suffering is depicted in the countenance; pills were taken, and retained; pulse 90, of good strength; croupy respiration more audible than ever; arms firmly placed on either side, thus giving a fixity to the muscles of respiration. The finger has been

quickly introduced into the throat, and rotated in the fauces, which produced an immediate effort to vomit, after which action, a long and deep inspiration has been obtained, that momentarily produced relief. This expedient has been repeated with like effect two or three times, and afterwards the neck and throat, rubbed with Liq. Ammon. Fort. et Tinct. Opii, which rapidly produced redness. A mustard cataplasm has also been applied, and the urgent symptoms have thus been much alleviated. As soon as she could safely perform deglutition, the following draught was taken :

R. Æth. Sulph. Rect., Sp. Ammon. Co., utrq., gtt. xxx.; Mist. Camph., oz. j. Sit haustus statim sumendus. Hot bottles applied to the feet, more coverlets thrown on the bed, and a little hot brandy and water given every ten minutes. From this time she kept pretty easy, nor had she any return of the paroxysmal dyspnoea until―

3 p.m. Another fit of difficulty of breathing has come on in as abrupt a manner as before, and the croupy noise is almost as great as it was at 11 o'clock; is tossing about in bed, and seems partially insensible to her present position, violently seizing hold of those who are near her, as if in the extremity of suffering; countenance as before, presents the appearance of

Continuing to improve, the mustard plasters were not be, and is generally, present without any accompanyapplied to the spine. Skin rather dry.

R. Liq. Ammon. Acet,, oz. j.; Vin. Ipecac., dr. iss.; Mist. Camph.,` oz. v. Sit mist. cujus sumat cochl. ampl. duo quarta quaque hora.

Vespere. No return of difficult breathing, pulse 80; voice clearer, and is in all respects better.

February 22nd. Continues to improve; bowels not opened since yesterday evening.

ing pyrexia or catarrhal complication, and the antiphlogistic treatment would be more likely to augment than cut short its course; but there are cases not only in children, but adults, where the diagnostic marks are of a mixed and indefinite character, rendering it thus less easy to decide as to the kind of remedial measures. Cheyne and Clark are of opinion that the

R. Pulv. Jalapa Co., dr. ss.; Syr. Rhoad, dr. ij.; brain is the seat of the disease, but like many other Aquæ, dr. x. Sit haustus statim sumend.

23rd. Improves.

24th. Convalescent.

REMARKS.

Spasm of the glottis is much more frequently met with in children than in adults; indeed in the latter it comes but seldom under our notice. Until within the last thirty years it was confounded in the young with croup, and treated upon the general principles acknowledged as necessary in that form of disease. The appearances on dissection shewed that the ordinary characteristics of inflammatory action were not present in the larynx, nor were there the concomitant pyrexial symptoms of inflammation during life; hence it very properly became regarded as of purely nervous origin, and subsequent observation and experience have rendered manifest that it is produced by irritation in the great nervous centres. Various are the names which the complaint has received, when occurring in children,—as bastard croup, asthma of infants, catarrh suffocante,† laryngismus stridulus,‡ child crowing, § etc., all of which, however, are the various appellations of one disease. When occurring in the very young, the litttle patients will unexpectedly die in the most sudden manner; and from the great fatality by which it is marked, our endeavours for alleviation should never be procrastinated. Those children which are passionate and irritable, and especially such as are of a scrofulous tendency, are most commonly those

affections incident to the nervous system, it is not satisfactorily proved in what the radical pathology really consists. Any irritative action produced at the different nervous extremities, as during the process of dentition, may thus give rise to a morbid state in the cerebro-spinal axis sufficient for its development, and the same applied to other parts has been known to institute the affection. Irritation in the neighbouring parts, or in such organs as are known to have a peculiar sympathy with the larynx, as the uterine organs in the female, and the generative in man, has been observed to give rise to spasmodic closure of the glottideal fissure. Irritation, it is true, may be considered as an obscure term-a designation devoid of any real or specific meaning; yet, conceding this, it is quite indisputable that it differs essentially from inflammation, as evinced not only by occular demontration, but from other positive and negative proofs; the one is certainly at times preceded by, or associated with, the other, yet are they not identical; and until we become more acquainted with the fundamental conditions giving rise to irritation, we must be content with that term, which in our present ignorance on the point is as expressive as any other word that might be employed. To prove that irritation can produce spasm of the glottis, it has occurred when dissection has shewn tumours pressing upon filaments of the pneumogastric nerve, or the recurrent laryngeals, without any red blood, depositions of lymph, or other traces of inflammation in the air-passages.*

Sometimes in acknowledged instances of croup we are surprised at the sudden manner in which the child is carried off, and on inspection the new membrane, from its not entirely obstructing the ingress and egress of the air, does not satisfactorily account for the fatal termination; and the same might be said of acute laryngitis. In such instances there are good reasons for believing that the inflammation, by its irritative pro

in whom the disease is observed. It has been known as the prelude to hydrocephalus, and is often caused by dentition; and the cutting of the teeth and lancing of the gums have been found effectual reliefs. On setting in, the child will all at once have considerable difficulty in breathing; the chest is imperfectly expanded; between each inspiration a peculiar noise is made; the eyes look full and starting; the features livid; and often the voluntary muscles, especially those proper to the hands and feet, are spasmodically contracted,perties, produces spasmodic closure of the fissure, and so that the whole system seems under a convulsive thus the sudden termination in death may at once be influence, whilst the muscles common to the functions accounted for. During the time that I was assistant of respiration will for some moments continue in a pathologist to the Edinburgh Hospitals, one or two rigid fixity; at length, after an interval of several instances occurred which are now remembered as illusseconds, or, perhaps, a minute, the little sufferer istrative of this statement, particularly the case of a stout relieved by a full inspiration, and thus ends the paroxysm It differs from croup, because, as observed, it may

and robust man, who had been induced by some of bis credulous neighbours to take gin and pepper for a hoarseness, which had supervened on a common cold.

Dr. Merriman.

The

remarked, it is by far most frequently met with in the former, and thus there have been more extended opportunities for observation and general deductions. Spasm of the glottis in the up-grown is most common in females, and especially in hysterical young women. Dr. Joy says, "It occurs chiefly in children, but IN

SOME RARE INSTANCES IT HAS BEEN OBSERVED IN

ADULTS ALSO, CHIELFY IN NERVOUS WOMEN, AND OLD PERSONS." In nine cases out of ten, when becoming manifest in females, there is great mobility of the nervous system, and some disorder of the uterus or its appendages. It comes on paroxysmally, and presents sometimes accompanying features of the epileptic character. Cold, sudden emotions of the mind, obstructed catamenia, feelings which relate to the sexual functions, and similar excitants, may operate as proximate causes to its development. In such instances, percussion along the spinal processes will occasionally, in the lumbar or dorsal regions, be followed by tenderness, and upon enquiry, the patient will often be found subject to neuralgic pains in the different parts of the body, as under the left mamma or left ribs, at the epigastrium, hypogastrium, etc. She will also void large quantities of limpid urine, whilst the alvine evacuations are scanty and irregular. In males it is perhaps more frequently the result of irritation near to the larynx, than from distant impressions upon the nervous system. When it does occur without any obvious irritating cause in or near the throat, there are great reasons for believing that delicate hystericallyinclined young men, or boys at puberty, would be the most likely to have this curious, and to that sex uncommon, disorder.

On his first admission he came into the institution in the middle of the night, breathing with the greatest **-difficulty, and each inspiration being performed with aloud whistling noise. The warm bath and other "expedients were had recourse to, and in the course of ** two or three days he was dismissed the establishment. On the night of the day of his departure, the spasm of the throat suddenly returned, and be again sought entrance into the medical wards, which he but a few hours previously had left. The same line of treatment was employed, but not with like success. breathing continued difficult; there was engorgement of the countenance, and alarming attacks of dyspnoea, rendering the operation of tracheotomy desirable, after which expedient he survived not more than twentyfour hours. On dissection, lymph was found in the trachea, but very little in the larynx; the bronchi were red, and their membranous lining a good ideal injected. The inspection unequivocally demonstrated that the inflammatory action in the trachea had given rise to irritation, which produced spasmodic closure of the glottideal fissure. Another instance of a woman I well recollect, ou whom tracheotomy was performed, when it was anticipated there would be the results of inflammation in the larynx, which organ * I carefully laid open, and minutely examined, but could not discover a particle of lymph. If tumours, pressing upon filaments of the par vagum, or irritation in remoter parts of the nervous system, can give rise to spasm in the larynx, we can much more readily imagine inflammation in the trachea, or in the larynx itself, instituting spasm in this organ; and the pathological illustrations just cited are quite in accordance **--(certainly not inconsistent,) with rational theoretical inferences. With respect to its occurrence in children, "Wichmann, the Hanoverian physican, and Schmalz," says Dr. Joy, “have taken peculiar pains to point out the distinctions which exist between this disease and croup. The latter seems usually to depend on cold Gedamp air, and sudden atmospheric vicissitudes; its inflammatory nature is manifested as well in the character of its symptoms, as by the beneficial effects of antiphlogistic treatment, and the appearances on dissection. Spasm of the glottis, on the contrary, is excited by passions of the mind, and other sources of momentary irritation existing often in distant parts of the body; catarrhal symptoms form no essential part of the disease; it occurs chiefly in those who have a general disposition to convulsive affections; its attacks are intermittent, and are most susceptible of relief from agents acting on the nervous system; and it presents after death no traces of inflammation of the respiratory organs."* These observations relative to the disease in children have been offered, » because in them it has been more thoroughly investi-sidered, only particularly confined to infants, makes 'gated than in grown-up people; because, as previously

"Cyclop. of Pract, Med." Part IX., page 350.

When the glottideal fissure becomes spasmodically closed, the patient then of course suffers from all the evils of, or dies, from, asphyxia; the countenance becomes turgid and livid, the eyes prominent, and the whole frame convulsively affected. The preternatural vascularity in the encephaloid mass, the great congestion in the lungs, etc., together with the venoid condition of the blood, owing to imperfect aëration, readily impair the sensorial functions, and a state of unconsciousness at once supervenes, indicating the danger then present. The venous engorgement in the brain might be so considerable as to produce rupture of its vessels and consequent sanguineous effusion, after which the case might of course assume the ordinary characters of common apoplexy. The sense of constriction in the chest undoubtedly arises from pulmonary engorgement, as well as from the spasmodic fixity of the muscles proper to the function of respiration.

Dr. Lay, in his volume on "Laryngismus Stridulus,” which is but another name for the affection now con

some interesting remarks on the fundamental causes. He conceives it to be of cerebral origin, as from some