It appears from the literature on the subject that the frequency of felony, as well as that of laryngospasm, varies greatly in different countries and cities. While in some localities the eases are so frequent at certain times of the year, as to be absolutely "epidemic," they are said to be rare at all times of the year in others. Whether these statements correspond to the facts, or are merely due to errors on the part of the various officials, is beyond our ken; but for the present we feel at liberty to entertain considerable doubt.
Most authors state that spasmophile diseases are inueli more fre quent in the poorer layers of society, and this observation has in fact been utilized as the basis of far-fetched conclusions in regard to the pathogenesis (respiratory diseases, Kassowitz). Personally, I have so often had oceaaion to observe the manifestations of the spastnophile diathesis in children living under favorable conditions as regards resi dence and care, that I am inclined to doubt these statements, and by no means regard the tetanoid diseases as eharacteristic of the proletariat.
Spasmophilia possesses in a high degree the characteristics of heredity. Direct inheritance and a family tendency to the disease are extremely characteristic. Of this fact, which was known to Selig Pott, and others, I have become more and more convinced as my experience has increased, and I believe it, is one of the most impor tant and best established data that we have in regard to the disease. From the clinical material of the Breslau Kinderklinik I now have more than a dozen observations relating to families in whom the mother had laryngospasm or eclanipsia in her ehildhood and still shows a well marked faeial phenomenon as a residuary latent symptom; while sev eral of her children presented this or that manifestation of the same disease in their early childhood and on careful examination are found to have latent symptoms. There is no doubt that one or several in a series of children may escape altogether, just as we occasionally en counter in a family of children predisposed to obesity- or eatarrhal dis eases one member that is lean or exhibits no abnormalities whatever; on the other hand, it is much more common to find that three or four children of the same parents ,possihly because of the influence of ana logous alimentary diseases) develop convulsions or laryngospasm one after the other in the second or third year of life, and eventually suc cumb to these diseases.
I was once consulted by a woman who was expecting her seventh child, after losing the other six from convulsions. On questioning the woman. who 1111 S quite intelligent, I learned that all these children had been normal at birth, and had continued to develop normally until the time of dentition, when they died of epileptic convulsions without the presence of any febrile infectious diseases or any severe gastro enteric symptoms. It is, fortunately. rare to find so many cases of the severest forms in the same family; but a tendency to the milder forms, and those which remain permanently latent and are cliseovered only by repeated careful examination, can be demonstrated in many families.
It should be added that in a few case.s we found that the disease was inherited from the father's side.
The fact that the mothers of eclamptic children quite often present the facial phenomenon attracted the attention of Kassowitz when he went over the polyclinic material, and he utilized this fact in :supporting his theory of the respiratory etiology on the ground that the vitiated air in the houses of the poor acts injuriously both on the mother and on the child. But the fact that the same thing is observed under the best
hygienic conditions, and among mothers who work in the open air, refutes this assumption.
Whether spasmophile families arc to be regarded as neuropathic in the ordinary sense of the term, must remain undecided until more systematic investigations are made. According to my experience, while there is no lack of nervous or other pronouncedly neurasthenic parents or other relatives in these families, they do not by any means constitute the majority. I therefore believe I am justified in stating that spastuophilia is an independent disease and not merely a symptom of a general neuropathie diathesis. Epilepsy in the parents or brothers and sisters of eclamptic patients is absolutely- exceptional.
Tbe age at which eelarnpsia and laryngospasm begin is from about the fourth month of life to the end of the second year; in the ease of tetany, to the end of the third year. The greatest frequency is observed in the second and third semesters of the infant's life. This applies both to the occurrence of the first manifest phenomena and to their disap pearance. There is no doubt whatever that both the occurrence and the disappearance of the symptoms are dependent on the time of the year as well as on the age, as has already heen stated. This peculiarity' is particularly noticeable in relapses, which are not rare. The course in these cases is usually about as follows: A child, say in January, when it is nine months old, develops eclampsia and goes through a number of attacks during the spring months. During the summer the attacks cease and the child loses its overexcitability. In the following winter, the beginning of the predisposing season, the spasmophilia returns, and quite often the child has one or two convulsive seizures, although the attacks are rarely massed. In a small proportion of children this is again repeated during the third, or even the fourth winter and spring, although the child has by this time attained an age at which the disease is rare and primary attacks are quite exceptional, or have indeed scarcely ever been observed. I have not observed recurrences during the succeed ing year in tetany and laryngospasm as frequently as in eclampsia.
In contrast to these cases, which belong almost exclusively to early infancy, we have those cases of eclampsia and manifest tetany, rarely of laryngospasm, which occur in the third to the sixth or eighth year of life and do not represent relapses. In the case of tetany the diagnosis is clear enough; but when eelampsia develops in a healthy child that has IleVeF exhibited symptoms of spasmophilia, the recognition of the disease may be mueh more difficult, and the differential diagnosis, especially of this form of "late eclampsia" from epilepsy, may be of very great importance.
Persistence of the latent diathesis for years or even decades is much more common than recurrence of one of the above manifestations of the disease. The readiest method of determining persistence of the latent diathesis is by examining the patient for the presence of the facial phenomenon, which, according to Thiemich's observations and explanations, even in older children, must not be regarded as a neuro pathie stigma, but as a specific latent symptom of tetany spasmophilia.
The obviou.s indication to confirm this view by testing the elec trical irritability in older children has never been satisfied, because no one has undertaken the laborious task of collecting alsolutely correct normal values for later childhood.