occasionally the spasm is actually fatal.  In all fatal cases which have come to my notice the child at the moment of death had been alone in the room.  I have met with no fatal case where the baby could be picked up and assisted.  As a rule, therefore, the cause and mode of death must be conjectural, but when an infant is found dead in its cot unexpectedly, it would seem likely that it has waked from sleep with a sudden start, become excited, and, about to cry, has been seized by the fatal spasm.  In two instances reported to me a cat had been found in the room with the dead child, and it was suggested that the animal had lain upon the child’s face.  Both these children, however, were vigorous and capable of powerful movements of resistance.  I think it more likely that the cat may have awakened them in fright, and that the emotional excitement, giving rise to the spasm, was the cause of the suffocation.  That the apnoea in these extremely rare instances should end fatally produces a difficult position for the doctor.  It need hardly be said that the seizures are alarming to the parents.  For the sake of great accuracy in the statement of our prognosis are we to add a hundred times to the mother’s alarm by stating the possibility of death?  In each case we must use our own judgment.  I believe that in a child over a year old the risk is almost negligible.

Fortunately in all save the rarest possible instances the apnoea yields and a deep inspiratory movement follows.  As the air rushes past the glottis, which is still partially closed, a sound recalling the whoop of pertussis is heard.  Often this recurs throughout all the burst of crying which follows, and each inspiration is accompanied by a shrill stridulous sound.  With the re-establishment of respiration the cyanosis rapidly fades, to be succeeded in some cases by pallor and perspiration.

It need hardly be said that we should do all in our power to prevent these alarming and distressing attacks.  Each seizure predisposes to a repetition.  In some children we notice that months and even years after an attack of whooping-cough, a slight bronchial catarrh may be sufficient to bring back the characteristic cough.  In laryngismus in the same way we may suppose that the reflex path is made easy and the resistance lowered by constant use.  Fortunately the spasms are not usually difficult to control.  Calcium bromide, in doses of from two to four grains, according to age, three times daily, is generally successful with or without the addition of chloral hydrate in small doses.  At the same time we must endeavour in every way possible to keep the child calm, by paying close attention to nursery management.  The child with spasmophilia is as a rule excitable and easily upset, and although calcium bromide is a drug which offers powerful aid it is not able to achieve its effect unless we are able at the same time to guarantee a reasonable immunity from emotional upsets.  It is for this reason that I have included some description of laryngismus, although its origin is undoubtedly very different from that of the other disorders of conduct which we have examined.