LARYNGOSPASNI* The second form of convulsions whieh at the present day is ac knowledged as belonging to the spasmophile diathesis is laryngospasm (spasnius glottidis). It is true that this is only a symptom—like the earpopedal cramp in tetany—but it is almost always associated with the phenomenon of spasmophilia, and the cases which form an exceP tion to this rule run a somewhat different course and have a special interpretation. They will be referred to later.
Symptomatology.—Laryngospasm in its milder grades manifests itself merely by a strident, protracted, crowing inspiration. In severe eases, however, the spasmodic closure of the glottis is so complete that symptoms of asphyxia—anxious expression of countenance, cyanosis, short, clonic contractions in the facial muscles and those of the upper extremity, or even, unless the spasm is ONTIT0111C from time to time, by a forcible inspiration, severe general convulsions may result. Death may occur suddenly in a severe attaek of this kind, or the condition, after becoming quite alarming, passes off with a few longdrawn inspira tions, and the breathing gradually becomes normal again.
Whereas in a typical laryngospasm, be it mild or severe in degree, there is an unmistakable effort at inspiration, there are eases in which the spasm of the closers of the glottis extends to the diaphragm and the remaining muscles of inspiration. In this way the clinical picture which Kassowitz first described as "expiratory apnea" is produced. Attacks of this nature place the infant's life in the greatest jeopardy. In favorable cases they end like laryngospasm with a crowing inspira tion; or, if the spasm of the glottis has already relaxed, the attack passes off without any sound, and respiration is gradually restored.
According to my experience this expiratory apnoea is the most frequent cause of the C118C$ of sudden death occurring in apparently healthy children, in which the autopsy fails to give sufficient explanation.
The frequency of laryngospasmodic attacks is subject to the greatest variation. In one case the attacks may occur singly, while in others they may follow each other in rapid succession. Waking from sleep, weeping, crying, choking, anything in fact that interferes with the normal progress of respiration, and, finally, overfilling of the stomach by a copious meal, favor the occurrence both of lary-ngospasm and of expiratory apnea.
The duration of the disease is from a few days to many weeks or months.
The prognosis, aside from the possibility of death during the at tack, is absolutely favorable.
Relations to Spasmophilia.—When the relations existing be tween laryngospasm and the spasmophile diathesis were first discovered by Loos and Escherich, the former set up the following axiom: "No laryngospasm without symptoms of tetany." In this form the dictum of Loos was vigorously attacked by the opponents of the theoty, and it cannot be denied that it contains a certain measure of exaggeration; but in the great majority of cases, the number of which increases the more often and the more carefully examinations are made, spasm of the glottis is associated with the above-mentioned latent symptoms of the spasroophile condition.
This leaves a small remainder of patients in whom these symptoms cannot be demonstrated in spite of the most careful search. But these cases differ fundamentally by the character of their clinical COUNC from ordinary spasm of the glottis. Some of them belong to the organic diseases of the brain and exhibit, in addition to the laryngospasm, other bulbar and pseudobulbar symptoms (disturbances of degluti tion and of the movements of the tongue, constant protrusion of the tongue, and almost regularly profound idiocy); in other cases the laryngospastic attacks ending in apnea and convulsions are replaced, in the course of the subsequent months or years by typical epileptic attacks; while a very large proportion of the cases which we have had an opportunity to study rested on a foundation of hereditary syphilis. This faet, and the assoeiation of well-marked, hut non-progressive idiocy, show that the epilepsy must be regarded as syroptomatie.
It is worth while to observe that even in rare eases of meningitis there is also a respiratory disturbance similar to laryngospasm, a fact which is explained by the existence of eortical centres for co-ordinated movements of the larynx.
The eases of "bolding the breath" without genuine spasnp of the glottis. which occur after the age of infancy (so-called 'Paroxysms of rage) never present a single symptom of spasmophilia, but clo exhibit the signs of a neuropathic taint. (see page 354).
The third variety eonvulsions associated etiologically with the spasmophile diathesis is:—