A more complicated form of the complaint is that in which the spasm is not limited to the glottis, but involves also the diaphragm and other respiratory muscles. These cases assume much more the characters of general convulsions, for there is often more or less tonic spasta of the limbs, and consciousness may even be interfered with. Thus the child lies backwards with dusky face, half-opened eyelids, and upturned eyes ; breathing is laboured and inspiration difficult and crowing ; the diaphragm acts irregularly ; and there are often convulsive contractions of the mus cles, causing profound recession of the lower ribs and soft parts of the chest. Sometimes for a few seconds the glottis is completely closed ; the face then becomes lead-coloured, and the limbs are agitated by convulsive movements. According to Rilliet and Barthez, the pulse is Email, frequent, and irregular, and the heart's action also irregular and tumultuous. If the child be markedly rickety a general eclamptic attack may supervene, or there may be tonic contractions of all the voluntary muscles, the body becoming stiff, the limbs contracted, and the fingers and toes forcibly flexed.
In new-born infants, on account of the feebleness of the child—for it is in weakly or prematurely born infants only, as far as I have noticed, that laryngismus occurs so soon after birth—the symptoms are quieter. In the cases I have seen crowing-breathing was absent. The lips were no ticed to turn blue and the face to become livid ; the baby stretched him self out stiffly and remained for a few seconds perfectly motionless, with flexed fingers and toes. There was complete immobility of the respiratory muscles, and he seemed as if dead. Then he drew a deep sigh and the attack was over. In these cases the spasm appears to be seated in the dia phragm and external muscles of respiration, leaving the glottis unaffected ; for no symptom is noticed of narrowing of the rima. Obstruction to breathing seems to be complete. The seizure is short arid rarely lasts longer than five or at the most ten seconds.
In an uncomplicated case of laryngismus stridulus, i.e., in a case where the complaint consists of pure muscular spasm, there is no fever. Some times, however, laryngismus complicates an attack of pneumonia. The temperature is then high. These cases are very serious and usually end fatally.
Even in an uncomplicated case death may ensue. If this happen during a paroxysm, the face assumes an expression of the utmost terror ; the eyes are widely open and suffused, the pupils are dilated, and the eyeballs seem to project ; the complexion grows more and more dusky, sweat breaks out on the forehead, and the pulse grows feeble and small. Inspiratory efforts are at first violent, then cease ; the heart stops, and the child falls back dead. Death may be preceded by general convulsions. This is the result of asphyxia from too long-continued spasm of the inspiratory mus cles. According to Dr. J. Solis Cohen, incarceration of the epiglottis is
apt to occur in the more violent paroxysms, and may produce death by suffocation. The epiglottis is drawn forcibly down by the spasmodic action of the ary-epiglottidean muscles, and its free edge is caught between the posterior face of the larynx and the wall of the pharynx, so as to cover the glottis like a lid and completely occlude it. In such cases it can be felt by the finger passed deeply into the child's throat. Sometimes death takes place still more suddenly, and the end then resembles an attack of fatal syncope. The dusky face assumes a ghastly pallid hue, the muscles gen erally relax, and the patient is found to be dead.
In other instances, where the seizures have been violent and persistent, especially if they have been complicated by general convulsions, the child may die more slowly. In most of these cases extensive collapse takes place in the lungs. The spasmodic symptoms subside but the child's face continues dusky. His lips are blue, his nostrils work, he lies very quietly breathing with rapid, shallow inspirations which expand the chest very im perfectly ; he gets more and more livid, and after some hours dies quietly or in a final convulsion.
Sudden death from asphyxia may take place early, even it is said in the first attack. The slower death from collapse of the lung is seldom seen except in severe cases where the child is exhausted by repeated and violent paroxysms, or where the complaint has been complicated by general con vulsions. In rickety children who are left untreated for that disease the spasms continue as long as the faulty nutrition to which the disorder is due remains unremeelied. The seizures may therefore go on for months, or even years, when the parents are ignorant or careless, and the child is injudiciously reared. In ordinary cases the patient is treated early and soon recovers. Children after the second year rarely suffer from the com plaint. I have, however, met with it once in a rickety little girl of four and a half years old.
Diagnosis.—In new-born babies laryngismus, especially if it be of that variety which is manifested by spasm of the diaphragm and intercostal muscles without closure of the glottis, may be mistaken for infantile teta nus. We may distinguish the two diseases by remarking that in laryngis mus the temperature is normal, and that between the attacks the muscles are perfectly relaxed. This complete relaxation of the muscles is the most trustworthy distinguishing mark, for the temperature in very young chil dren may be raised by many trifling and temporary conditions. Some times, however, there may be a more serious complication that gives rise to pyrexia. Thus I once saw an infant of two weeks old who suffered from these attacks, and in whom there was pyrexia dependent upon pericarditis with copious effusion into the sac of the heart.