A Case of So-called Laryngeal 
Y ertigo. 
BY 
I. ADLEE, M. T>., 
VISITING PHYSICIAN TO THB GERMAN HOSPITAL, 
XKW YORK. 
rkpeuitkb from 
mt 'Neto Yorfe pieWcal Journal 
for January SO, 1892. Reprinted from the New YorTc Medical Journal 
for January 30, 1892. 
A CASE OF 
SO-CALLED LARYNGEAL VERTIGO. 
I. ADLER, M. D., 
VISITING PHYSICIAN TO THE GEBMAN HOSPITAL, NEWYORK. 
That peculiar, though somewhat varying, group of 
symptoms which, following the lead of Charcot, is com- 
monly designated as laryngeal is still a subject of 
discussion as regards both its pathology and its fetiology. 
The well-authenticated cases thus far reported are compara- 
tively few in number. Scarcely more than two dozen cases 
have been reported since Charcot first called attention to 
the affection in 1879, and the authors differ widely in their 
interpretation of the clinical facts. Under these circum- 
stances every new case of so rare an affection becomes valu- 
able as possibly shedding some light on a point hitherto 
doubtful or obscure. From this point of view I venture to 
present the following case : 
Mr. J. E. H., aged about fifty-three, merchant. No heredi- 
tary taint of any kind. With the exception of several attacks 
of gonorrhoea, claims never to have had venereal disease. Mi- 
nute examination detects no evidence of syphilitic lesion. Does 
not use tobacco in any form. Is accustomed to take several 
glasses of wine or beer with his meals. He is a man of florid 
Copyright, 189 a, by D. Appleton and Company. 2 
A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
complexion and robust and healthy appearance. Pie professes 
never to have had any serious illness, but is subject to “ colds 
and coughs?’ From time to time during the last few years he 
has shown slight but sufficiently well marked symptoms of a 
gouty tendency and has had occasional attacks of muscular 
rheumatism. About three years ago he had an attack of acute 
bronchial catarrh with little or no febrile symptoms, accom- 
panied for several days by thin, foamy, and not very copious 
bloody expectoration. No pulmonary lesion could be detected, 
and the sputum then and since remained free from tubercle 
bacilli. The slight haemorrhage was referred to congestion of 
the bronchial mucosa. In November’"of 1890, in the course of 
a slight bronchial catarrh attended by rather violent paroxysms 
of cough, he claims during one of these coughing spells to have 
suddenly “ fainted.” Being hurriedly called in and arriving a 
few minutes after the attack, I found the patient apparently 
perfectly well and bright. Questions addressed to him and to 
the members of his family who had witnessed the attack 
elicited the following facts: The paroxysm of cough had been 
no worse than usual. He was in a sitting position when the 
cough seized him, and during the coughing he arose as if to 
expectorate, then suddenly fell to the floor, totally unconscious. 
He claims to have noticed no premonition of any kind. There 
was no giddiness; he was not conscious of any tickling or burn- 
ing or other sensation about tbe larynx. The bystanders were 
unable to state whether the face was pale or turgid or livid. 
There was no cry, no involuntary micturition, nor were any 
convulsive twitchings noticed. The unconsciousness lasted but 
a very few seconds. The patient raised himself without assist- 
ance from the floor, laughed at the alarm expressed by his 
family, felt no lassitude, sleepiness, or any discomfort whatso- 
ever. Careful examination showed some dry rales in the larger 
bronchial tubes, slight hypersemia of the pharynx and larynx, and 
an elongated uvula, otherwise no lesion of any kind. The bron- 
chial catarrh, accompanied by still rather violent paroxysms of 
cough, passed away in about a week, but no further seizure like 
the one described occurred. The treatment consisted in the 
administration of opiates and expectorants. A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
3 
I desire to note here a peculiarity in Mr. ll.’s manner of 
coughing which struck me whenever I had occasion to see him 
for one of his periodical attacks of coughing. It seems as if he 
had acquired a habit of “choking” over his cough whenever 
the paroxysm is even moderately severe. The chin is depressed 
so as almost to touch the sternum, head and shoulders stoop 
forward, the face becomes turgid and red, the superficial veins 
swell out, and the cough consists of a deep inspiration, succeeded 
by a number of short, spasmodic expiratory movements follow- 
ing each other in rapid succession, and differing only from per- 
tussis in lacking the long sibilant inspiration which commonly 
ends the paroxysm in the latter. 
During April of this year Mr. H. had an attack of influenza, 
and following this, after the febrile stage had passed, a very vio- 
lent cough. At first there were all the symptoms of diffuse 
bronchial catarrh, sonorous rales over the entire chest, muco- 
purulent expectoration, etc. Later on the rMes gradually van- 
ished, the expectoration diminished, and finally at the end of 
about ten days ceased altogether, but the cough remained more 
violent than ever, and assumed a more spasmodic character. 
The peculiar habit referred to above was still more marked. 
The cough came in paroxysms, during both day and night, seri- 
ously interfering with his sleep. It commenced with tickling in 
the region of the throat and larynx, became at once very vio- 
lent, accompanied by turgidity of head and neck, lasting from 
some seconds to several minutes, and ended usually with the 
expectoration of a small lump of glassy mucus, sometimes, how- 
ever, without any expectoration. This state of things continued 
for about a week, sinapisms, opiates, expectorants, and inhala- 
tions being administered without any apparent effect on the par- 
oxysms of coughing. One evening during a violent coughing 
spell, which occurred while Mr. H. was standing upright, he 
suddenly dropped to the floor utterly unconscious. 1 was called 
in at once and arrived a few minutes after the seizure. There 
had been no premonitory signs. The cough commenced with 
the usual tickling in the upper air-passages, but did not appar- 
ently differ from any of the preceding paroxysms. There had 
been no giddiness. The patient did not feel that anything un- 4 
A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
usual was going to happen. He simply dropped to the floor, 
almost immediately to arise again, feeling perfectly well, but 
not aware of any unusual occurrence. 
The physical condition now was the following: Very mod- 
erate granular pharyngitis, elongated uvula, slight hypersemia 
of the.larynx, heai’t and lungs in normal condition, pulse full 
and regular—between 60 and 80 beats per minute. The pupils 
of equal size and reacting normally. Ophthalmoscopic exami- 
nation negative. Ho appreciable symptoms on the part of the 
nervous centers. The knee-jerk somewhat subnormal, but still 
sufficiently well marked. The urine, which was examined fre- 
quently and carefully, at no time showed albumin, casts, or 
sugar. The quantity of phosphates and urates was slightly in 
excess of the normal. Ho other abnormity could ever be de- 
tected. Opiates had been given before; they were now admin- 
istered in larger doses. Ho attack during the next two days; 
then another one of exactly the same character as before, with 
merely this difference: that, happening to recline on the sofa, he 
did not fall to the ground, but simply lost consciousness. As 
opiates had been of no service, they were now replaced by large 
doses of the bromides of sodium and ammonium, and a com- 
petent laryngologist made daily applications of a spray to the 
pharynx and larynx. The attacks of sudden loss of conscious- 
ness following cough now appeared daily, soon several times 
during twenty-four hours, by night as well as by day. During 
one of these attacks about this time Mr. H. slightly bit his 
tongue. The seizures evidently becoming more frequent and 
more severe, the local treatment, after about ten days of spray- 
ing, was discontinued. By the desire of the patient and his 
friends, the advice of a very well known neurologist was ob- 
tained. On recommendation of the latter, iodide of sodium was 
added to the bromides, and both gradually increased up to ten 
grammes pro die, also gradually increasing doses of the red 
iodide of mercury, blisters to the back of the neck and laryn- 
geal region, and large doses of cerium oxalate. This treatment 
was continued for about three weeks. Under the influence of 
the bromides the pharynx and larynx became quite anaesthetic, 
and the patient stupid and somnolent. There were marked A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
5 
symptoms of iodism. The seizures, however, steadily increased 
both in violence and frequency. He had now as many as four 
or five in twenty-four hours. In one of these attacks, which came 
upon him while descending from one floor to another, he fell 
dow.u stairs and was badly bruised. In another he dropped while 
standing with a friend in the street and severely hurt his face. 
It is to be noted that, while no seizure ever took place with- 
out preceding cough, by no means every violent paroxysm of 
cough was followed by loss of consciousness. The daily cough- 
ing spells were quite numerous—sometimes several dozen in 
twenty-four horn’s-—but, as far as I have been able to ascertain, 
he never had more than five seizures attended by loss of con- 
sciousness in one day. Nor were always the most violent fits of 
coughing followed by these peculiar attacks. Not infrequently 
a very violent paroxysm would .pass without further conse- 
quences, while a comparatively rather mild cough would send 
the patient into unconsciousness. It is stated, too, that in several 
instances, when the state of unconsciousness had been of some- 
what longer duration than usual, slight convulsive twitchings of 
the eyes and arms were noticed just before consciousness re- 
turned. 
As the patient was evidently getting worse, all this treat- 
ment was now stopped; no medicine whatever was adminis- 
tered, and when, after about six days, the local effect of the 
iodide and bromide had completely disappeared, another very 
careful general and local examination was made. The result of 
the general examination proved entirely negative. Locally the 
same appearances were found as above stated. The larynx was 
carefully examined with a probe, in order to determine the 
presence of any hypersesthetic spot as the origin of the convul- 
sive coughs. No such spot was found. As no tangible point 
of attack could be made out in the larynx, as medicinal treat- 
ment had plainly and completely failed, and bearing in mind 
the experiences of Gleitsmann, who had cured a similar case by 
removing adenoid vegetations at the base of the tongue, and of 
Charcot, who effected a cure by cauterizing a granular pharyn- 
gitis, I determined to clip the uvula. This was done at once. 
The patient went home and had no attack for twenty hours; 6 
A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
then two very slight ones in rapid succession, and none since 
then. The cough continued for some five or six days, having 
completely lost its spasmodic character, and then disappeared 
altogether. 
The preceding history has.been given at great length 
because it seems to offer several points of interest. We 
have here a man without organic lesion and of fairly good 
health, who, after a moderate attack of bronchitis, becomes 
subject to spasmodic cough, attended by frequent seizures 
of complete loss of consciousness. There is no aura pre- 
ceding the seizure, no cry, no involuntary micturition, no 
hebetude or confusion of mind on regaining consciousness. 
Unfortunately, it so chanced that I was never able to ob- 
serve an attack in person. Tt is therefore impossible to say 
what was the behavior of pulse and heart during a seizure. 
The members of Mr. H.’s family, who witnessed quite a 
number of these sudden losses of consciousness, were in- 
variably startled and alarmed to such a degree as to render 
them unfit for the purposes of closer observation. It was 
impossible even to make out with any degree of certainty 
whether the patient was red or pale in the face. Altogether 
the witnesses tend more toward the belief that the face was 
red and turgid. The patient himself describes his sensa- 
tions during a violent paroxysm of cough as “choking,” as 
“ wishing to cough, and not being able to cough out ”—a 
sensation evidently very similar to that described by the 
patient of Russell* It seems reasonable to assume from 
all this that the spasmodic cough was frequently followed 
by spasm of the glottis. That for this latter the elongated 
uvula was principally responsible would seem to follow from 
the failure of all other treatment and the prompt relief from 
all symptoms after the clipping. In what manner the uvula 
produced the spasm can not be positively ascertained. I 
* Birmingham Medical Review, vol. xvi, August, 1884, A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
7 
am inclined to assume that it was by direct irritation of the 
rima glottidis. The patient’s peculiar attitude while cough- 
ing would tend to raise the larynx sufficiently to permit 
this, while the fact of these spasms occurring frequently at a 
time when the pharynx and superior portions of the larynx 
were well under the influence of bromide anaesthesia would 
seem to preclude any other mode of mechanical irritation. 
It is not impossible that the attack of influenza which pre- 
ceded these spasmodic seizures may have induced a more 
than ordinary irritability of the nervous system, and that 
this may explain why former attacks of cough were never, 
with but a single exception, followed by similar complica- 
tions. 
Leaving out of consideration those cases in which simi- 
lar attacks have occurred in the course of locomotor ataxia, 
as so-called laryngeal crises, and where well-marked ana- 
tomical lesions have been found in the track of the pneumo- 
gastric and recurrent,* we find widely differing opinions as 
to the nature of this singular neurosis. Charcot fis inclined 
to accept this group of symptoms as a disease sui generis and 
analogous to Meniere’s disease, the afferent nerve in this in- 
stance being the superior laryngeal. Gray| and Massei* 
consider these attacks to be essentially epileptic. Others 
again, such as Mcßride, || Russell,A and Gleits- 
mann, J explain the loss of consciousness and attendant 
* Jean, Gazette hebdom., 18*76, No. 2*7. Fereol, Oaz. hebdorn., 
1869, No. *7. 
fLe Progres med., 1879, 17. Revue des sciences med., x, p. 135. 
\ Arner. Jour, of Neurol, and Psych., November, 1882. 
# Giornale internaz. delle scienze med., Anno vi. Abstracted in In- 
ternal. Ctrlbl. f. Laryngologie u. Rhinologie, 1885, p. 21 
| Edinb. Med. Jour., March, 1884. 
A Loc..cit. 
() Transactions of the Amer. Laryng. Assoc., 1886, p. 84. 
| Med. Monatsschr., i, p. 510. 8 
A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
symptoms by disturbances of circulation in the brain, basing- 
their views on the well-known experiments of E. F. Weber. * 
It is not my intention to enter into a detailed discussion 
and criticism of these conflicting- opinions, nor to give an 
exhaustive review of the cases thus far recorded. All this 
has been done most fully and ably by Thermes,f Knight, 
and others. In the case of Mr. 11., the complete loss of 
consciousness and the absence of all vertigo and even giddi- 
ness, as well as of nausea and vomiting, seem to preclude 
all analogy to Meniere’s disease. There seems no necessity 
of ranging our case under the head of reflex epilepsy. No 
spot or nerve could be found by the irritation of which it 
was possible to produce an attack. Nearly all cases of 
well-authenticated reflex epilepsy present well-marked con- 
vulsive seizures with all the classical symptoms preceding 
and following the convulsions. Interesting in this respect 
are the cases of Schneider.^ 
The oft-quoted case of in which a large 
fibroid of the left vocal cord apparently caused true convul- 
sive attacks of epilepsy, can not be considered here, as the 
patient had had epileptic attacks fifteen years before which 
were at that time referred to a cicatrix on the right hand 
and disappeared after the excision of the scar. Evidently 
this wTas a case of well-marked “epileptic disposition.” 
It seems as if all the symptoms in our case could be 
satisfactorily accounted for by the experiments and theory 
* Ueber ein Verfahren, den Kreislauf des Blutes und die Function 
des Herzens willkiirlich zu unterbrechen. Muller’s Archiv, 1851, 
p. 88. 
f Deux observations de vertige larynge dans la coqueluche chez les 
vieillards. Jour, de rn'ed. de Paris, 1887, p. 936. 
\ Einige Falle von geheilter Reflexepilepsie der Nase. Perl. Min. 
Woch., 1889, No. 43. 
# Ueber ein grosses Fibroid des Kehlkopfes als Ursache der Epi- 
lepsie. Perl. Min. If'Wo, 1876, p. 563, A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
9 
of Weber. Forced expiratory movements with a spasmod- 
ically closed glottis caused increased intrathoracic pressure. 
Ultimately not only the heart itself to a certain extent, but 
principally the venae cavce are compressed, the flow of blood 
to the heart is diminished and then ceases, a condition of 
arterial ischaemia and venous hypenemia ensues in the 
brain. The pulse becomes weaker and finally disappears 
altogether, and the heart’s action comes to a standstill un- 
less, before this climax is reached, the glottis is reopened 
and normal respiration is resumed. That this mechanism 
can and does produce complete loss of consciousness with 
total amnesia, and even convulsive twitchings, within a frac- 
tion of a minute is established by Weber’s experiments on 
himself. All the conditions given by Weber were present 
in the case of our patient—the spasm of the glottis with vio- 
lent, rapid expiratory movements, the turgid face and neck, 
etc. Had it been possible to obtain a satisfactory record 
of the pulse and heart, or even of the pulse alone, during 
one of the seizures, the question could have been settled 
beyond peradventure. As it is, the case appears in all 
essential respects analogous to Thermes’s second case, where 
the pulse and heart during the spell of unconsciousness were 
found so characteristically in accord with Weber’s results. 
Being still completely ignorant of the true anatomical 
lesion underlying epilepsy, and the experiments of Kuss- 
m aid and Tenner and others making it at least probable 
that disturbances of cerebral circulation play an important 
role in the pathology of epilepsy, there can be no objection, 
if one was so inclined, to call the peculiar seizure of laryn- 
geal vertigo epileptoid—epileptoid attacks, however, result- 
ing not from a hypothetic irritation of a peripheral nerve, 
but from great and sudden disturbance of cerebral circu- 
lation. 
Finally, it is perhaps worthy of note that in the present 10 
A CASE OF SO-CALLED LARYNGEAL VERTIGO. 
case again, as in so many before recorded, there is a his- 
tory of gout and rheumatism. That in all hitherto recorded 
cases, with but one exception (the second case of Knight), 
the patients are males, of whom the large majority had 
passed their fortieth year when they became subject to 
these attacks, are facts that must be taken into account in 
the future study of this affection. REASONS WHY 
Physicians should Snhscriie 
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