A system of practical medicine. By American authors. Vol. 3

by Unknown

The disease occurs both in children and in adults. There is, however, in its etiology, course, and terminations quite a marked difference, as observed before and after puberty. We shall therefore consider, first, spasm of the glottis in children; second, in adults.

Spasm in Children.

SYNONYMS.—Laryngismus stridulus, False croup, etc.

ETIOLOGY.—Predisposing Causes.—The disease occurs most frequently in children from a few months to two or three years old. It is occasionally met with in those still older and up to puberty. It seems to be more often encountered in patients of a strumous habit than in those of a healthy constitution. Rickety children are especially liable to the affection: the German pathologists especially insist upon this factor. Patients of a nervous temperament predisposed to general spasms are especially predisposed to this affection in the larynx. It is a general law that muscles weakened either by disease or by fatigue or by deficient nutrition are especially irritable. In them mechanical as well as other forms of stimuli produce local contraction with great readiness. These contractions are, it is true, rather the expression of the condition of the muscles than of the nerves. The muscular condition must, however, be regarded as a predisposing cause of the spasm. In the same way, perhaps—namely, by the inherited tendency to lower forms of vitality, weakened muscular power—we may account for the fact that family history of similar conditions, such as false croup in other members or in the parents, should be considered as among the evidences of predisposing tendencies to spasm of the glottis.

Sex has in this affection, as well as in most laryngeal diseases of children, a predisposing influence. Mackenzie has collected in all, from different sources, 8248 cases. Of these, 5378 were boys and 2870 girls—a proportion of nearly 2 boys to 1 girl. In adults the reverse holds good, females being much more frequently seized than males. It is certain that season has something to do with the development of the disease, but this influence should be regarded rather as a producing than a predisposing cause.

Dentition, worms, weaning, or anything which produces an irritation of the alimentary canal may also, by exciting the reflex irritability of the nervous system, become predisposing causes of laryngismus. The influence of dentition has, however, been probably over-estimated.

The exciting causes of spasm of the glottis are not well defined. In a few cases we are able to definitely fix upon something as the occasion of the attack. It is possible that there may be some central lesion, and this may be well defined. This is rare, however. It is nevertheless true that the onset is generally preceded by some derangement of the general health. There has been for a day, or perhaps only for an hour or two, a slight cold, a little hyperæmia of the respiratory mucous surfaces, or disturbances of the digestive tract, or the child has been unusually fatigued or excited from play or study. The secretions have in other cases been deranged. No one of these causes has perhaps been of sufficient gravity to attract the attention of the mother or nurse. The indisposition, if it has been noticed at all, has been regarded as only one of the many ephemeral troubles that so often occur in infancy, and no anxiety has been felt. Of all these possible causes, the one most frequently invoked after the attack is a cold, slight, it is true, but nevertheless, in the light of the subsequent history, evidently a mild form of inflammation of the laryngeal mucous membranes.

SYMPTOMS.—Spasm of the glottis usually takes place at night. It is true that some authorities deny that this is the case. Stefen says "that it is quite as likely to occur during the day as night." In a great majority of instances, however, it will be found that the attack occurs after the child has been asleep. During the day there has been perhaps a slight disturbance of the general health, a little inclination to cough, or there has been a catarrh of the fauces or bronchial mucous surfaces; nothing, however, of a serious character has been observed. At midnight or later the little one awakes with a crowing or whistling inspiration. It starts up in bed, and evidently experiences great difficulty in breathing; this difficulty is manifestly in inspiration; expiration is easy and free. The eyes are prominent, the lips blue, the surface often bathed in perspiration; pulse frequent, small, at times irregular; there is, if the child be old enough to reason in the matter, great alarm; there is often cough, and this cough is characteristic: it is a hoarse, metallic, barking, peculiar cough, described as croupy. If the spasm is limited to the larynx, the other muscles not being affected, the patient clutches at whatever it can reach, and often seizes the throat as though there was something there to tear away. The general surface becomes cyanotic and all the symptoms of asphyxia are present. The voice, though not generally extinct, is altered; it becomes hoarse, or husky, as it is called; in a few minutes the severity of the attack is passed, and the little sufferer sinks exhausted into a sleep more or less disturbed. A second attack may occur the same night, or there may be nothing more to alarm the attendants till the next night. The second attack, if it occurs, as it generally does, on the succeeding night, is less severe than the first; the third still more mild; and this generally ends the case for the time being. During the intervals—that is, during the day—the patient in a majority of cases is up, and seems to be but slightly affected by the seizure of the night before. There will perhaps be a slight cough, with some loss of appetite and indisposition to engage in play. This is the most usual type of the disease. In a few cases there is more marked derangement of the general health. The spasms are more severe; the cramp is not confined to the laryngeal muscles, but involves other parts, such as the muscles of the chest and the extremities. During the intervals of the attack there is perhaps a little fever, the digestive tract is disordered, the cough may be marked during the day, there may be an increase in the secretions of the respiratory surfaces. Attacks may recur during the day and for several days; the cough may retain its croupy character, and the voice may continue to be hoarse.

COURSE AND DURATION.—Spasm of the larynx is usually a transient phenomenon, lasting only from a few seconds in the milder cases to several minutes in the more severe forms of the disease. The attacks are intermittent. The seizures are relieved by intervals of comparative relaxation of the muscles of the parts. Even in the intervals there is, however, a degree of contraction of the constrictors, so that the relief is not absolute. Two or three days elapse before the attack may be said to have entirely ceased. In the severer forms the consequences of the spasm may continue even for a still longer time. There are usually no sequelæ. When the patient has recovered there is nothing left of the disease, though there is often a predisposition to a recurrence; the same causes that produced the first attack, or even slighter causes, may produce a second. These causes are generally persistent; the seizures are therefore usually repeated.