The child's bowels were attended to and he was given half a grain of chloral twice a day. The symptom then soon subsided.
In cases where there is great irritability of the nervous system cough or even swallowing may induce a paroxysm. Anything which frightens or irritates the patient may produce the same result. Thus in a young child who is subject to the attacks a fit of crying may bring on a seizure. Sometimes, again, the complaint is a relic of pertussis, the spasm remaining although the other symptoms of the disease have passed away.
Symptoms.—We may often notice in rickety babies an occasional crow or croak in their breathing which seems to cause them little or no incon venience. In some children this symptom may continue for weeks and then disappear without being followed by anything more serious. In others, after it has continued for some time the child is suddenly seized with a decided attack of laryngismus stridulus.
In a pronounced form of the seizure the child • becomes all at once quite stiff and lies with his head back, his face congested and livid, his eyes staring, and his expression haggard and frightened. After a few seconds the spasm relaxes, the breath is drawn. in with a crowing or hissing sound, and the attack is at an end. The child then looks pale and seems languid ; often he goes to sleep.
In the more severe cases the spasm is repeated several times at short intervals. Still, actual closure of the glottis is seldom prolonged beyond a few seconds. There is no pyrexia. At the end of an attack the child often vomits, and sometimes he has a good fit of crying.
The above is the simplest form of the complaint—that in which the spasm is limited to the muscles of the glottis. Even in these cases, how ever, signs of tonic spasms in voluntary muscles are often to be detected. The fingers are forcibly clenched upon the thumbs, and the toes are flexed under the feet. This tendency to carpo-pedal spasms may continue between the attacks and even for some little time after the seizures have ceased to appear. The number of the spasms and the frequency with which they are repeated vary considerably in different cases. Generally the attacks are not very frequent at first, and sometimes after occurring several times they cease to appear. But if the child be the subject of marked rickets he seldom escapes so easily. The seizures, having once
begun, sooner or later return. In the beginning they may be seen at comparatively rare intervals, and perhaps only after waking from sleep, or when the child is irritated or frightened ; but in bad cases they may recur so frequently that the patient is in constant peril. Dr. Roberton has referred to a case in which the spasms were not absent for more than ten minutes, day or night, for ten months. Sometimes they cease com pletely for a time; but return at the end of some weeks, or even months, when a sufficiently powerful exciting cause is again in operation.
As an illustration of the length of time during which these attacks often continue, I may instance a little rickety boy, aged twenty months, who was an in-patient under my care in the East London Children's Hos pital. Nine months before the child had had an attack of whooping-cough. After the cough had subsided the laryngeal spasms still continued, and were often repeated eight or nine times in the twenty-four hours. He had been treated as an out-patient three months before admission with much benefit, for the paroxysms had been greatly reduced in number, although they returned on the slightest provocation. If by any chance he coughed he always had an attack immediately. During the first few days after admission the child had three paroxysms daily. In these attacks, which came on quite suddenly, his lips turned blue, his breathing was excessively difficult, his inspirations were croupy, and his whole body was agitated, although there was no general convulsion. Then the spasm abruptly relaxed and he heaved a deep sigh. After the seizure he was always very pale, but the breathing was natural and there was no hoarse ness. The child had all the signs of well-marked rickets. He had only six teeth ; the joints were large; the fontanelle was open ; the ribs were very soft and the lower part of the thoracic wall receded deeply at each breath. The spleen was enlarged, reaching nearly to the level of the navel. There were no signs of swelling of the bronchial glands. The child's bowels were loose and his motions very offensive. There was no fever. In this patient the spasmodic attacks were cured almost immediately by bathing him three times a day in cold water.