In more severe cases of stridulous laryngitis the complaint does not pass off so quickly. The catarrh is often not limited to the larynx, but also occupies the bronchi. The attacks then occur not only at night but also in the daytime, and in the intervals the breathing is more or less op pressed and " croupy," and the voice and cough hoarse. The clyspneea in these cases may be a very serious symptom, the child having the greatest difficulty in obtaining even a minimum supply of air. Indeed, in the worst cases during the access the face is livid, the hands and nails grow purple, the eyes become fixed, convulsive twitchings are noticed in the limbs, and an examination of the chest may detect signs of collapse at the bases of the lungs. In rare instances the patient dies suffocated unless relieved. The complaint is accompanied by moderate fever which persists between the attacks, and the complexion remains pale, with some lividity about the lips, until the free passage of air is again completely restored. An examination of the urine seldom detects albumen, but in the worst attacks, probably from renal congestion, albuminuria may be present.
A healthy-looking boy, aged four years and two months, was taken ill on March 1st with sneezing, coughing, and signs of tightness of the chest. The same night he was roused by a severe attack of dyspncea, his breath ing was oppressed and stridulous, and his cough loud and clanging. All the next day his voice was weak and hoarse, and his cough barking and hard.
When the child was seen on March 4th, his cough was hoarse and loud. The breathing was laboured, •46 ; the pulse, 140 ; the temperature, 101.4°. The skin was moist. The respiratory movements were very labo rious, the shoulders rising and falling, and the soft parts of the chest and the epigastrium sinking in deeply. The chest was resonant, and the breath sounds were loud and snoring. One-sixth of a grain of tartrate of anti mony was given every three hours•n a saline mixture.
On the night of the 5th the child had another severe attack of dysp ucea. He was accordingly put into a tent-bedstead and the air was kept moistened by the steam-kettle. The next day the cough was loose, and the voice, although hoarse, was much stronger. The dyspncea did not return, and the child was discharged convalescent on March 11th. The tempera ture remained over 100°, morning and evening, until March 9th.
In an ordinary case of moderate severity the cough loses its hard, bark ing character after a few days and becomes loose, the hoarseness of voice diminishes, and the child is soon convalescent. If, however, there' be general pulmonary catarrh, any neglect may easily aggravate the case into one of broncho-pneumonia, or in a weakly subject collapse of the lung may occur. In either case the child may die. Fatal cases of laryngitis stridulosa are in the large majority of cases so complicated, for few children die from the dyspncea alone.
In rare cases stridulous laryngitis, like laryngismus stridulus, may be ac companied by carpo-pedal contractions. A little girl, between four and five years old, was brought to me for contraction of the fingers, which had much alarmed her parents and made them fear that the child was "going to be paralysed." The patient was much emaciated from long-continued intes tinal catarrh, and had a pained expression of face. For a month she had had a cough, and at night was often roused by attacks of stridulous laryn gitis, in which respiration became noisy, and she seemed to have much dif ficulty in getting her breath. On examining her hands the fingers were found to be unusually straight-looking, the hands being bent only at the knuckles. The child could, however, squeeze well with both hands. It was stated that the fingers would often become quite stiff, with the thumbs turned rigidly into the palms of the hands. The girl was not rickety ; lungs were healthy ; and there was no enlargement of the abdominal organs or mesenteric glands. An iron mixture was prescribed, and the child was ordered some claret with her dinner. Under this treatment the symptoms soon subsided and the patient regained flesh and strength.
laryngitis must not be confounded with true membranous croup—a disease to which it often presents a striking resem blance. A distinction between these two affections is of the utmost prac tical importance ; for the operation of tracheotomy, which is especially in dicated in cases of membranous laryngitis, is rarely if ever necessary in the stridulous disorder, and if performed imports into the case an element of danger which would otherwise be wanting.
In laryngitis stridulosa the invasion is much more sudden, and the dyspncea at once attains its maximum intensity ; indeed, if the attack be repeated it seldom reaches the violence of its first access. The voice in false croup, although weakened and hoarse, is rarely suppressed, and the child, if persuaded to exert himself, can usually speak fairly loudly. Even young children, although silent and unwilling to cry when much hampered for breath, if disposed to do so, can often emit a considerable volume of sound. The cough, too, is loud and clanging, and rarely assumes the muffled, whispering character so distinctive of membranous laryngitis. Again, the stridor of the breathing is chiefly marked in inspiration, the expiration being much easier and comparatively noiseless, In false croup, also, there is no enlargement of the submaxillary glands, such as is apt to occur in cases of membranous laryngitis when there is any accompanying affection of the pharynx. An examination of the urine rarely discovers the presence of albumen.