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The mind of the child is so unstable and yet so highly developed, that symptoms of nervous disturbance are more frequent and of greater intensity than in later life. Only rarely and in exceptional cases do certain symptoms, common in childhood, persist into adult life or appear there for the first time, and then usually in persons who, if they are not actually insane, are at least suffering from intense nervous strain. We have already mentioned the symptom of negativism and noted its occasional occurrence as an accompaniment of mental disorder in adult life, and its frequency among children who are irritable or irritated. Similarly, we may cite the digestive neuroses of adult life to explain the common refusal of food and the common nervous vomiting of the second year of life. Thus, for example, there exists in adult life a disturbance of the nervous system which is called "anorexia nervosa." A boy of nineteen was brought to the Out-patient Department of Guy's Hospital suffering from this complaint. He was little more than a skeleton, unable to stand, hardly able to sit, and weighing only four and a half stones. His mother, who came with him, stated that he had always been nervous, and that lately, after receiving a call to join the army as a recruit, his appetite, which had for some time been capricious, had completely disappeared. In spite of coaxing he resolutely refused all food, or took it only in the tiniest morsels, although at the same time it was thought that he sometimes took food "on the sly." A careful examination showed absolutely no sign of bodily disease. He was admitted to a ward for treatment by hypnotic suggestion, but before this could be begun he endeavoured to commit suicide by setting fire to his bed.

A girl of twenty-four years of age had become almost equally emaciated. Constant vomiting had persisted for many years and had defied many attempts at cure. It had even been proposed to perform the operation of gastro-enterostomy in the belief that some organic disease existed. In suitable surroundings and with the energetic support of a good nurse, who spent much time and care in restoring her balance of mind, the vomiting ceased, and she gained over two stones in weight. Work was found for her in some occupation connected with the War, and she left the Nursing Home to undertake this, bearing with her four pounds which she had abstracted from the purse of another patient.

Those who have not opportunities of observing how all-powerful is the effect of the mind upon the body, and especially perhaps upon the process of digestion, may find it hard to believe that these distressing symptoms and profound changes in the aspect and nutrition of the patients were due entirely to mental causes and were symptoms in accord with the attempted suicide or the theft of the money. In nervous little children we shall not often find such complex actions as suicide or theft, although they do occur, but combined with other evidence of nervousness we shall meet commonly enough with a persistent setting aside of appetite and refusal of food and with continuous and habitual vomiting, from nervous causes.

The experiments of Pawlow and others have explained the dependence of digestion upon mental states. They show that even before the food is taken into the mouth, while the meal is still in prospect, there has been instituted a series of changes in the wall of the stomach, which gives rise to the so-called psychic secretion of gastric juice. These changes are preceded by the sensation of appetite, which is evoked not by the presence of food in the stomach--for the food has not yet been swallowed--but by the anticipation of it, by the sight and smell of food, as well as by more complex suggestions, such as the time of day, the habitual hour, the approach of home, and so forth.

Emotional states of all sorts--grief, anger, anxiety, or excitement--put a stop to the process or interfere with its action, so that the sense of appetite is absent, and the taking of food is apt to be followed by discomfort or pain or vomiting. No doubt good digestion leads to a placid mind, but it is equally true that a placid mind is necessary for good digestion. Therefore we civilised people, living lives of mental stress and strain, try to increase the suggestive force of our surroundings and to provoke appetite by all devices calculated to stimulate the aesthetic sense. The dinner hour is fixed at a time when all work and, let us hope, all worry is at an end for the day. The dinner-table is made as pretty as possible, with flowers and sparkling glass. We are wise to dress for dinner, that with our working clothes we may put off our working thoughts.

In the treatment of adult dyspepsia we seldom succeed unless we can place the mind at rest. We may advise a visit to the dentist and a set of false teeth, or we may administer a variety of stomach tonics and sedatives, but if the mind remains filled with nameless fears and anxieties we shall not succeed.

In adult life the nervous person when subjected to excessive stress and strain is seldom free from dyspeptic symptoms of one sort or another, and what is true of adult life is even more true of childhood, when the emotions are more poignant and less controlled. Then tears flow more readily than in later life, and tears are not the only secretions which lie under the influence of strong emotion. Emotional states, which would stamp a grown man as a profound neurotic, are almost the rule in infancy and childhood, and may be marked by the same physical disturbances--flushing, sweating, or pallor, by the discharge of internal glandular secretions as well as by inhibition of appetite, by vomiting, gastric discomfort, or diarrhoea. Naturally enough, mothers and nurses are wont to demand a concrete cause for the constant crying of a little child, and teething, constipation, the painful passage of water, pain in the head, or colic and indigestion are suggested in turn, and powders, purges, or circumcision demanded. There can be no doubt that nervous unrest is capable of producing prolonged dyspepsia in infancy and childhood--a dyspepsia which, while it obstinately resists all attempts to overcome it by manipulation of the diet, is very readily amenable to treatment directed to quiet the nervous system.

Where a primary dyspepsia exists for any length of time, the growth and the nutrition of the child is clearly altered for the worse. The character of the stools, their consistency, smell, and colour, is apt to be changed because the bacterial context of the bowel has become abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, prolapse of the rectum, and infection with thread-worms are common complications. No doubt children with primary dyspepsia are often nervous and restless, and the elements of infection and of neurosis are frequently combined. Yet often we meet with cases in which the gastric or intestinal disturbance comes near to being a pure neurosis. The nutrition, then, seldom suffers to any very great extent, or to a degree in any way comparable to that which is characteristic of dyspepsia from other causes. Emaciation, wrinkling of the skin, dryness and falling out of the hair, decay of the teeth, are not as a rule part of the picture of nervous dyspepsia. The child may be slim and thin and nervous looking, but as a rule he is active enough, with a good colour and fair muscular tone, so that one has difficulty in believing the mother's statements, which are yet true enough, as to the trouble which is experienced in forcing him to eat, or as to the frequency of vomiting.

In early childhood the difficulty of the refusal of food often passes or diminishes when the child learns to feed himself with precision and certainty. To teach him to do so, it is not wise to devote all our attention to making him adept at this particular task. The fault is that the brain centres which control the movements of hands, mouth, and tongue have not been developed, because his activities in all directions have not been encouraged. It is much less trouble for a nurse to feed a little child than to teach him to feed himself, and if he is not given daily opportunities of practice he will certainly not learn this particular action. But the fault as a rule lies deeper. The child who cannot feed himself cannot be taught until fingers and brain have been developed in the thousand activities of his daily routine, by which he acquires general dexterity. A child who is still too young to feed himself is learning the dexterity which is necessary as a preliminary in every action of the day. If he can carry the tablecloth and the cups and saucers to the tea-table, imitating in everything the action of his nurse, it will be strange if he does not also imitate her in the central scene, the actual eating of the food. If, on the other hand, he is waited upon hand and foot, if he is restrained and confined, sitting too much passively, now in his perambulator, now in his high chair, now on his nurse's lap, his imitative faculties and his tactile dexterity alike remain undeveloped. The child who is slow in learning to feed himself shows his backward development in every movement of his body. One may note especially the stiff, "expressionless" hands, indicating a general neuro-muscular defect. I have seen many children of eighteen months or two years of age in whom the movements necessary for efficient mastication and swallowing had failed to develop satisfactorily. In some a pure sucking movement persisted, so that when, for example, a morsel of bread or rusk was put in the child's mouth, it would be held there for many minutes and submitted only to suction with cheeks and tongue. Attempts to swallow in such a case are so incoordinate that they give rise frequently to violent fits of choking, which distress the child and produce resistance and struggling, while at the same time they alarm the mother or nurse so much that further attempts to encourage the taking of solid food are hastily and for a long time abandoned. In this helpless condition the other factors which tend to develop what we have called negativism have full play. The want of imitation and the lack of dexterity is not the sole or perhaps the main cause of the child's refusal of food and of the apparent want of appetite, but it is the cause of the failure to learn to feed himself, which places him in a condition which is peculiarly favourable to the operation of other factors. If only we can teach the child to feed himself, the difficulties of the situation become much less formidable.

The first of the factors which encourage the persistent refusal of food is the extreme susceptibility of the child to suggestion. A particular article of diet may be refused on one occasion, perhaps in pique, because another more favoured dish was hoped for or expected, or perhaps because the taste is not yet familiar. Then if on this occasion a struggle for the mastery is waged, and a painful impression is made on the child's mind connecting this particular dish with struggling and tears, from that day forward the child may persistently refuse it on every occasion it is offered. Matters are made worse if the nurse, anticipating refusal, attempts to overcome the resistance by peremptory orders, or by excessive praise extolling the delicious flavour with such fervour that the child's suspicions are at once aroused. Previous experience has made him connect these excessive praises with articles which have aroused his distaste. If these fads and fancies on the part of the child are to be avoided, it is essential that we should do nothing to focus his attention on his refusal. It is better that his dinner should be curtailed on one occasion than that taste and appetite should be perverted perhaps for years. Every nurse or mother should cultivate an off-hand, detached manner of feeding the child, and should patiently continue to offer the food without uncalled-for comments or exhortations. Let her always remember the force of suggestion on the child's mind, and that a confident manner which never questions the child's acceptance will meet with acceptance, while a hesitating address, from fear of the impending refusal, will be apt to meet with refusal. Sometimes a still worse fault manifests itself, when nurse and mother speak before the child of the smallness of his appetite, and of his persistent refusal of this or that article of diet. The suggestion then acts still more powerfully on his mind. He is aware that the whole household is distressed by his peculiarity, and he grows to identify it with his own individuality, and to regard himself with some satisfaction as possessing this mark of distinction. If there is any difficulty of this sort it is often directly curative to reverse the suggestion and to speak before him of his improving appetite, and to say that he begins every day to eat better and better, even if to do so we have to break a good rule never to say to the child what is not strictly true. Or once or twice we may take his plate away before he has finished, saying positively that he has eaten so much that he must eat no more. If in spite of every care antipathies to certain articles of food appear and persist, we must be content to bide our time. When the child grows of an age to reason, we should seize every opportunity to make him feel that his persistent refusal is a little ridiculous and childish. Little by little the seed is sown, and will germinate till one day we shall note with surprise that he has taken of his own accord that which he has neglected for so long and with such obstinacy.

But the force which is acting most strongly in producing this refusal of food is the force of which we have spoken in a previous chapter--the force which results in negativism, the force which is in reality the habit of opposition, the love of power, and the desire to attract attention. Here again the refusal of food, if due to this cause, is never the sole manifestation of the fault. Just as the delay in learning to swallow and to chew properly and to feed himself is part of a general want of dexterity and capacity manifested in all his actions, so it will seldom happen that the child's anxiety to oppose is only seen at meal-times. Watch a nervous child in the nursery before the dinner hour. He is cross and restless and inclined to cry. The nurse hands him a doll, and he throws it away saying, "No, no doll." At the same moment he may catch sight of his ball, and it too is violently rejected, "No, no ball." Everything in turn is treated in the same way. Finally he falls upon his nurse, crying and beating her with his hands, saying, "No, no Nurse." If that long-suffering woman at that moment summons him to dinner, it will be strange indeed if his attitude is not "No, no dinner," and "No, no" to every mouthful offered him. How strong this love of opposition may be is illustrated by the case of a little boy who was brought to me for refusal of food. Three weeks before, he had been taken in a motor-car to his grandfather's to midday dinner on Sunday, when his absolute refusal of food had spoiled the day and had occupied the attention and the efforts of the whole party. Doubtless he had enjoyed himself, for three weeks later, when he caught sight of the car which was to bring him to me, and which he had not seen in the interval, he at once said, "Not eat my dinner." This child's father told me that the sight or sound of the preparation of a meal was enough to bring on a paroxysm of opposition. Now this force of opposition, as we have seen, only develops into a serious difficulty when the child's own will has been opposed too much, when authority has been too freely exercised, and when the child has been urged and entreated and reproved with too great frequency. His opposition grows with all counter-opposition. And he is not really naughty, only irritable and restless from the thwarting of his natural impulses, and unable to express his thoughts and desires. Negativism will not often confine itself to meal-times. It will show clearly in all the actions of the child, and to get him to eat well and freely we must so change our management of him that negativism disappears or at least diminishes. There is no other way. No entreaty, no force, no threats of force will ever succeed, but will only make him worse, and, since negativism is due to mental unrest, the struggles and crying will only perpetuate the cause. The one way to banish negativism and overcome the opposition is to cease to oppose, and to practise this aloofness not so much at meal-times, for somehow by patience the child must be got to take his food, but in all our conduct to him. Repression and reproof, and thwarting of the child's will, and coaxing and entreaty must cease. There is no fear that we shall thereby make the child unduly disobedient. We have already, in another chapter, decided that negativism is not strength of will on the part of the child which must be broken, but is the result of constant attempts to oppose his nature, and the consequent nervous unrest. If we cease to oppose, the symptoms will tend rapidly to disappear, the child will become busy and contented and happy in his play, and we shall hear no more of his refusal of food. If sometimes it recurs for a week or two, we shall know how to deal with it.

In children, as with us, periods of nervous unrest and unhappiness are apt to recur in a sort of cycle. This cyclical character of mental disturbance is often a marked feature. We see it in epilepsy and in what the French have called Folie Circulaire. We see it in the dipsomaniac, in the intermittency of his craving for drink and of his periodical outbursts, and we see it in ourselves in those periods of depression which recur so often, we know not why. Little children too sometimes get out on the wrong side of their beds, and never get right the whole long day. Their own experience of the vagaries of mental states should lead mothers to be indulgent to the children in their days of cloud and to be particularly careful not to goad them by well-intentioned efforts into bursts of naughtiness and passion, each one of which tends to perpetuate the condition and increase the nervous unrest. We know how closely dependent is the sensation of appetite upon emotional states, and we must do all in our power--and the task is sometimes one of real difficulty--to keep the child's mind sufficiently at rest to preserve the healthy desire for food unimpaired. If there is no sign of appetite, but every sign of restlessness and irritability, we must seek in the management of the child until we find the fault.

If food is taken mechanically and without appetite, if the preliminary changes in the stomach wall which are necessary for adequate digestion do not take place, but are inhibited by the mental unrest, the meal is apt to be followed by gastric pain and discomfort, or, more commonly with children, the stomach may promptly reject its contents. At the worst, nervous vomiting of this sort may follow almost every meal, although, again, it is curious to note how little, comparatively speaking, the nutrition of the child suffers. The vomiting too, as in adults, comes very near being a voluntary act, and mothers and nurses will often remark that they get the impression that it can be controlled at will. If once the diagnosis is made that the want of appetite or the vomiting is of nervous origin, the treatment of the condition is clear. Sedative drugs directed towards quieting the nervous excitability may be of service, but tonics, appetisers, laxatives, and drugs with a direct action on the stomach will have but little effect. Nor is there as a rule anything to be gained by modifying the diet or by excluding this or that article of food. The frequency of the vomiting is such that it is apt to have brought discredit one after the other upon almost every article of food which the child can take, with the result that many useful and necessary foods have been abandoned for long on the ground that they are the cause of the dyspepsia. A permanent cure will only be effected when the faults of environment have been overcome, when the cause of the nervous unrest has been removed, and when the child's mind is at peace.

Nervous vomiting of this kind is not difficult to control, if those in charge of the children can be made to understand that the cause lies in the anxiety which they themselves show before the child, increasing his own apprehension or adding to his sense of power or importance. Once the child is convinced that his conduct excites no particular interest, the vomiting soon ceases. In more than one instance, vomiting which has persisted for many months has stopped at once after the matter has been fully explained to the parents. In the most inveterate case of this sort which has come under my notice, the child was regularly sick as soon as he caught sight of a white cloth being laid on the table for meals. Yet even this child never vomited when he was under the charge of a particular nurse who had to return more than once to the family, and on each occasion was successful in breaking the habit.

WANT OF SLEEP

So far, almost all that has been written--and there has been a great deal of unavoidable repetition--has been devoted to an attempt to determine the causes which lead the child to refuse food and the methods which we adopt to prevent or overcome the difficulty. Other neuroses may be studied in less detail, because they depend for their existence upon the same causes. For example, the habit of refusing sleep, which is as common and almost as distressing as the habit of refusing food, depends both upon a perversion of suggestion and upon the phenomenon that we have called negativism.

If struggling and crying has occurred upon a series of nights, the child comes to associate his bed not with sleep but with tears. If a mother values her peace of mind, if she would spare herself the discomfort of hearing her child sob himself nightly into uneasy sleep, she must be wary how this all-important event of going to bed is approached. With a nervous and restless child the preliminaries of preparing for bed must be managed carefully and tactfully. The hour before bedtime is almost universally the most interesting of the whole day for the child. Then the baby, with his best frock on, and books and toys, is the centre of interest in the drawing-room, till the clock strikes and the nurse appears at the door. Suddenly it is all over, and inexorable routine sends him off to bed. The good nurse will give the child a little time to recover from the shock of her arrival, and will not hurry him. She knows that his little mind is slow to act, and that he must be led gradually to face a new prospect. If she hurries him, catching him up in her arms from the midst of his unfinished pursuits, resistance and tears are almost sure to follow, and the difficult task of the day--the putting to bed--has made the worst possible start. When this has happened on one or two successive evenings, the habit of resistance to going to bed becomes fixed, and, like all bad habits, is difficult to break. A nurse who has a way with children will arouse his interest in a new pursuit, in which he can play the chief part, the putting away of his picture books and toys. If he is too small to carry his own chair or table to its allotted place in the room, at least he can show his learning by pointing out the spot. In the waving of good-byes he is expert and takes a legitimate pride, and upstairs he has learnt that there are new delights. He himself can turn on the taps in the bathroom, and he can set every article in the proper place ready for use. All children love their bath, and if interest and good temper has been so far preserved, without a break, it will be ill-fortune if even the drying process is not carried off without a hitch. Afterwards, for a little, nervous babies, whose brains still teem with all the excitements of the day, are best left to sit for a few moments by the nursery fire, while the nurse puts all the garments one by one to bed. Each as it goes to rest will be greeted by him with cheerful farewells; and so does the force of suggestion act, till the central figure himself plays his part in the scene, of which he feels himself the controller and director, and climbs to bed. But if there has been a hitch anywhere, if the bugbear of negativism has appeared, if he has been scolded or coaxed or repressed too much and there have been tears and struggles, then going to bed is a poor preparation for instant and quiet sleep.

With excitable, highly-strung children, the best laid plans and the most tactful nurse will not always succeed, and to place him in his cot is to provoke a storm of angry refusal and resistance. There are mothers who believe that the best way is then to turn out the light and leave the child to cry himself to sleep. This is a point on which no one can lay down rules which are applicable for all children. It may sometimes succeed, and the child may reason correctly and in the way we wish him to reason, deciding that the game is not worth the candle and so give it up. But with nervous, highly-strung children I doubt if this Spartan conduct is commonly successful. Often if the attempt is made, the troubled mother, listening to all these heart-breaking sobs, can bear it no longer, and goes back to the side of the cot to soothe and persuade him. Then certainly the longer she has restrained her natural inclination, the longer the child has sobbed himself into a pitiful little ball of perspiration and tears, the more difficult will be her task in quieting him, the stronger will be the impression formed on the child's mind, and the greater will be the suggestion which will act under the same circumstances to-morrow. Children who fall a prey to this uncontrolled crying, cry on because they cannot stop when they have begun. They do not then cry purposely or with a fixed intention, desiring to attain some object. They cry because their minds are not at rest, but are irritated and overwrought by the happenings of the day. We decided that it was useless to attempt by exhortations at meal-times to induce a nervous child to eat who habitually refuses food, and that we can only cure the condition by eliminating from his daily life the elements of repression and opposition which provoke the counter-opposition. And we must seek the same solution in this other difficulty of the refusal of sleep. It is useless to attempt to treat the symptom of refusal of sleep and to leave the cause of that symptom still constantly in action.

If, in spite of our care to avoid unrest and irritation of the child's brain, sleep is refused, as may often happen, it is, as a rule, wise to cut short the crying if we can, before a vicious circle has been formed and the unrest has been intensified by the emotional storm. It is useless with little children to urge them to go to sleep or to coax. It is not usually wise to leave the child for a little and then to return. Each time the child is left, each time the mother or nurse returns, the crying bursts forth again with renewed force and vigour. It is at least one good plan with a little child to turn the light out, and, treating the whole incident in the most matter-of-fact way possible, lightly to stroke his head or pat his back rhythmically without speaking. With older children, if the crying is more purposeful and less emotional, the mother may busy herself for a little with some task in the room, ostentatiously neglecting the storm and making no reference to it. If she speaks to the child at all she should do so in a matter-of-fact way, referring lightly to other matters. If only she can convince him that his conduct is a matter of indifference to her, the victory is won. It is because the child knows so well that his mother does care that he so often has the upper hand. It is not difficult to distinguish between a true emotional storm and the tyrannous cry of a wilful child who demands his own way.

Light and broken sleep is a common accompaniment of a too excitable and overstimulated brain. The placid child, who eats well, plays quietly, and does not cry more than is usual, as a rule sleeps so soundly that no ordinary sounds, such as conversation carried on in quiet tones in his neighbourhood, have the power to waken him. When he wakes, he does so gradually, perhaps yawning and stretching himself. The nervous child may move at the slightest sound, or with a sudden start or cry is wide awake at once. A hard mattress should be chosen without a bolster, and with only a low pillow. Flannel pyjamas, which cannot be thrown off in the restless movements of the child, should be worn. The temperature of the room should be cool, and the air from the open window should circulate freely, while draughts may be kept from striking on the child by a screen. All the sensations of the nervous child are abnormally acute. Thus, for example, an itching eruption, or tight clothing, will produce an altogether disproportionate reaction, and may result in a frenzy of opposition. Especially such a child is sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool rooms and warm but light and porous clothing are essential. An electric torch, which can be flashed on the child for an instant, will assist the mother or nurse to make sure that the child has not thrown off all the bedclothing.

Sometimes want of sleep is accounted for by a real want of physical exercise. Town children especially are apt to suffer from their limited opportunities of running freely in the open. It is often considered enough that the child seated in his perambulator should take the air for three or four hours daily, while much of his time indoors as well is devoted to sitting. It is necessary for his proper development that he should have opportunities of daily exercise in the open. If for any reason this is not always practicable, a large room, as free as possible from furniture, should be chosen, with windows thrown wide open, in which the child may romp until he is tired.

It is rare for children of two or of three years of age, whose case we are now considering, to be troubled by bad dreams, nightmares, or night-terrors. If these should occur, obstructed breathing due to adenoid vegetations is sometimes at work as a contributory cause.

Finally, we should always remember that refusal of sleep is, for the most part, caused and kept up by harmful suggestions derived from mother and nurse, who allow the child to perceive their distress and agitation, who speak before the child of his habitual wakefulness, who unwittingly focus his attention on the difficulty. It is cured in the moment that the suggestion in the child's mind is reversed, in the moment when he comes to regard it as characteristic of himself not to make a fuss about going to bed, but to sleep with extraordinary readiness and soundness. Let every one join together to produce this effect. Let the suggestion act strongly on his mind that all these troubles of sleeplessness are diminishing, that night after night sees an improvement, and soon his reputation as a good sleeper will be established, and, as always with children, it will be rigidly adhered to.

In assisting to break the habit of sleeplessness, and in the process of altering the character of the suggestions which act on the child's mind, we can be of the greatest assistance to the mother by prescribing a suitable hypnotic. As to whether it is right in insomnia in childhood to prescribe depressant drugs is a question on which very various opinions are held. That it is wrong and probably ineffective to trust entirely to the drugs is certainly true, but as a temporary measure, to break the faulty suggestion and the bad habit, their use is both legitimate and successful. The dose required in children relatively to the adult is much smaller. In grown people, some specific distress of mind, whether real or imaginary, may suffice to resist very large doses of hypnotic. In children it is rare to find the same resistance, and comparatively small doses have a very constant effect. With deeper and more refreshing sleep, the conduct of the child during the day almost always changes for the better. A sound sleep, for a few nights in succession, will produce apparently quite a remarkable change in the whole disposition of the child. When good temper and interest take the place of fretfulness and restlessness, we may confidently expect that the symptom of sleeplessness will begin to abate. Sleeplessness by night and fretfulness by day form a vicious circle, and attempts must be made to break it at all points.

Chloral occupies the first place as a hypnotic for young children. In combination with bromide its effects are wonderfully constant and certain. Two grains of chloral hydrate and two grains of potassium bromide with ten minims of syrup of orange, given just before bedtime, will bring sound sleep to a child of a year old. At three years the dose may be twice as great, and three times at six years. It is seldom that other means are required. Aspirin for children seems relatively without effect. For children who are both sleepless and feverish, a grain of Dover's powder, and a grain of antipyrin, for each year of the child's age up to three, is very helpful. Lastly, if chloral and bromide cannot break the insomnia, and the condition of the child is becoming distressing, we can almost always succeed if we combine the prescription with an ordinary hot pack for twenty minutes.

SOME OTHER SIGNS OF NERVOUSNESS

HABIT SPASM

Two of the three qualities which we have mentioned as characteristic of the child's mind are concerned in the causation of habit spasm. In the early stages the movement is sometimes due to imitation, but the susceptibility of the child to suggestion plays the chief part in determining its persistence. It is an interesting speculation how far tricks of gesture, attitude, or gait are inherited and how far they are acquired by imitation. A child by some characteristic gesture may strikingly call to mind a parent who died in his infancy. A whole family may show a peculiarity of gait which is at once recognisable. It is told of the son of a famous man, who shared with his father the distinctive family gait, that when a boy his ears were once boxed by an old gentleman who chanced to observe him hurrying to overtake his parent, and who resented what he took to be an act of impertinent caricature. In the reproduction by the child of the habitual actions of his parents, heredity is largely concerned, but imitation too plays its part. In habit spasm the force of imitation is clearly seen. A child who has developed a habit spasm of one sort or another will readily serve as a model to other children. The malady will sometimes spread through a school almost with the force of a contagious disorder. A child affected in this way may prove an unwelcome guest. The little visitor with a trick of contorting his mouth and grimacing is apt to leave his small host an expert in faithfully reproducing the action. A cough that is genuine enough in one member of the family may produce a crop of counterfeits in brothers and sisters.

The force of suggestion acting upon the child's mind can clearly be traced. Once his attention is focused upon the particular movement by unwise emphasis on the part of the parents, he loses the power to control its occurrence. This trio of common neuroses--refusal of food, refusal of sleep, and habitual involuntary movement--grows only in an atmosphere of unrest and apprehension. Parents and nurses anxiously watch their development. They are distressed beyond measure to note their steady growth in spite of every attempt which they make to control or forbid them. And of all this unrest and unhappiness the child is acutely conscious. The whole household may become obsessed with the misfortune which has befallen it, and the mother, losing all sense of proportion, feels that she cannot regain her peace of mind until it has been overcome. The child is in need of mental and moral support from those around him, and all that he finds is an openly expressed apprehension and sense of impotence. Even grown-up people, when their nerves are on edge, are apt to be obsessed by uncontrollable impulses or by vague and nameless apprehensions, and surely all have learnt the support they gain from contact and conversation with some one strong and sane, who treats their worries in such a matter-of-fact way that immediately they lose their power and become of no account. The child with habit spasm cannot control these movements. The more he is reproved or entreated, the less able does he find himself to hold them in check. He does not wish them to continue. He has lost control of what he once controlled, and the realisation of this is not pleasant, and may be alarming to him. Yet when unconsciously he looks to his mother for support, he finds in her open dismay that which serves only to increase his uneasiness. She must subdue her own feelings and give the child strength. If she treats the whole thing in a matter-of-fact way, as a temporary disturbance which is of no importance in itself, and only has meaning because it implies that the brain has been over-stimulated, she will no longer exercise a prejudicial effect on the child. If the bad habit is taken as a matter of course, if too much is not made of it, if the child is encouraged to think that nobody cares much about it at all, then recovery will soon take place. It goes without saying that habit spasms and tics of all sorts are made worse by excessive emotional display and by nervous fatigue. On the other hand, if the child becomes absorbed in some interesting occupation, the movements will disappear for the time being.

AIR SWALLOWING, THIGH RUBBING, THUMB SUCKING

At a somewhat earlier age than that in which habit spasms become common, and before bed wetting appears as a formidable difficulty, we meet with another group of habitual actions which yet retain their voluntary character. Among such habitual actions are thumb sucking, thigh rubbing, and air swallowing. If the child is old enough to express himself on the subject, he will explain that these actions are performed because of the satisfaction derived from them, because it is "comfy" and "nice." Even if the child is too small to speak, the expression is that of beatitude and content. These actions are not confined to nervous children, and their occasional practice need not be taken to imply that there is any strong element of nervous overstrain. It is only when the action is repeated with great frequency and persistence, and when signs of irritation ensue if gratification is not obtained, that we are justified in classing it among the symptoms of mental unrest.

The second of these actions, thigh rubbing, is found for the most part in little girls, and inasmuch as it consists of a stimulation of the sexual organs sometimes causes much distress to the parents. It is in reality a habit of small importance unless exercised with very great frequency. It is, of course, not associated in the child's mind with any sexual ideas, and is of precisely the same significance as the other two actions of the same class. Children who can speak will refer to it openly without any sense of shame. As a rule the action is performed in a half-dream state, that condition between sleeping and waking which is found when the child is lying in the morning in her cot or in her perambulator after the midday nap. The child's attention should not be focused on the symptom. She should lie on a hard mattress, and when she wakes in the morning she should either leave her cot at once or she should be roused into complete wakefulness by encouraging her to play with her toys. Little children should be taught to sleep with their hands folded and placed beside the cheek. If the movement occurs on going to sleep, it is best left alone and completely neglected. As a rule each child has his or her own favourite action of this class, and they are seldom combined in the same child. If thigh rubbing is very constant and obstinate and does not yield to the measures suggested, it may even sometimes be a successful manoeuvre to substitute the thumb-sucking habit in the expectation that this less distressing habit may eject the other more objectionable action. As a rule, however, a wise neglect and careful watching during the drowsy condition that follows sleep in a warm bed will succeed in stopping the practice of thigh rubbing before the end of the second or third year. Apparatus designed to restrain movement of the child's legs or blistering the opposed surfaces of the thighs are both of no effect. They have indeed the positive disadvantage that they focus the child's attention on the practice. The habit ceases only when the child has forgotten all about it, and these devices serve only to keep it in remembrance. The same may be said of any system of punishments. Further, we cannot always have the child under observation, and at some time or other opportunity will be found for gratification. Of older children, in whom self-control and a sense of honour can be cultivated, I am not here speaking.

Air swallowing is less common than thigh rubbing, but belongs to the same group of actions and takes place in the same drowsy condition. The child will rapidly gulp down air which distends the stomach, and is then regurgitated with a loud sound. Thumb sucking seldom distresses the mother to the same extent, and the proper attitude of tolerance is adopted towards it. If much is made of it, it is astonishing how persistent the habit may become, surviving all attempts to forbid it, to break it by rewards or punishments, or to render it distasteful by the application of a variety of ill-tasting substances smeared on the offending digit.

PICA AND DIRT EATING

Certain other bad habits will become ingrained if attention is called to them, because of that curious spirit of opposition which characterises little children, and because of their susceptibility to suggestion. Some children will constantly pluck out hairs and eat them, or will devour particles of fluff drawn from the blankets. Others will seize every opportunity to eat unpleasant things, such as earth, sand, mud, or dirt of any sort. All tricks of this sort are best neglected and treated by attracting the child's attention to other things. In adult life they are associated with serious mental disturbance, in early childhood they are of little account, or at most suggest a certain nervousness which may be due to nervous irritation from faults of management which we must strive to correct.

CONSTIPATION

As has been already mentioned, much of the common constipation of the nursery is due to neurosis. The excessive concentration of the nurse's thoughts on this daily question communicates itself to the child. The difficulty is emphasised, and an attempt is made to substitute will power for forces of suggestion which are at once inhibited by concentration of the mind upon the process. Here also, just as in the refusal of food, a further stage of "negativism," that is, of active resistance with crying and struggling, is reached, so that complaint may be made by the mother that defaecation is painful. The same negativism may be shown in micturition, and mothers will give distressing accounts of the suffering of the child during the passing of water.

BREATH-HOLDING AND LARYNGISMUS STRIDULUS

In some children, in the first two years of life, we find a definite and measurable increase in the irritability and conductivity of the peripheral nerves. The strength of current necessary to produce by direct stimulation of the nerve a minimal twitch of the corresponding muscle may be many times less than the normal. Of this heightened irritability of the nervous system, to which the name "spasmophilia" has been given in America and on the Continent, the most striking symptom is a liability alike to tetany or carpo-pedal spasm, to generalised convulsions, and to laryngismus stridulus. In addition, in most cases it is generally possible to demonstrate the presence of Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a visible twitch of the facial musculature, especially of the orbicularis palpebrarum or of the orbicularis oris, in response to a gentle tap administered over the facial nerve in front of the ear. Trousseau's sign is the production of tetany by applying firm and prolonged pressure to the brachial nerve in the upper arm. The aetiology of spasmophilia is still a matter for dispute, but the evidence which we possess is in favour of the view that we have here to deal with a disturbance of calcium metabolism. The calcium content both of the blood and of the central nervous system has been shown to be much lowered. It is in keeping with this that clinically we note how frequently spasmophilia and rickets occur in the same child. In some families the condition recurs through many generations.

For our present purpose--the examination of some common neuroses of nursery life--it would be out of place to enter into a detailed consideration of this disorder of spasmophilia as a whole. The symptom of laryngismus stridulus--the so-called breath-holding--alone need concern us, and that for a special reason. The spasm of the glottis is produced under the influence of any strong emotion--in anger, for example, or in fear, in excitement or in crying for any reason. To control or prevent it we must direct attention not only to the condition of spasmophilia, but also to the management of the children who are always excitable and emotional. In these children every burst of crying, however produced, whether by a fall, by a fright, by the entrance of a stranger, or by a visit to a doctor, is apt to be ushered in by a long period of apnoea, due to spasm of the glottis and of the diaphragm. The first few expirations are not followed by any inspiration. For several seconds the silence may be complete, while the child steadily becomes more and more cyanosed, or the body may be shaken by incomplete expiratory movements and strangled cries which are suppressed because the chest is already in a position of almost complete expiration. In the worst cases, when the apnoea lasts a very long time, there may be convulsive twitching of the muscles of the face, or the attack may even terminate in general convulsions. Very 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.

MIGRAINE AND CYCLIC VOMITING

The aetiology of cyclic or periodic vomiting in childhood is not yet completely understood. We do not know how far it is dependent upon disturbance of the liver, and it is still disputed whether the acidosis which accompanies it is the cause or the result of the profuse vomiting. Into these difficult questions we need not at the moment enter. It is enough in the present connection to recognise that the great majority of children who suffer from cyclic vomiting are sensitive, excitable, and nervous, and that every one is agreed that the nervous system is intimately concerned in its causation.

A close association between cyclic vomiting in children and that form of periodic headache known as migraine has often been observed. It is sometimes found that one or both parents of a child with cyclic vomiting suffer habitually from migraine. In a few instances the one condition has been observed to be gradually replaced by the other, the child with cyclic vomiting becoming in adult life a sufferer from migraine. There is indeed much which is common to the two conditions. The periodic nature of the seizure, often following a time when the general health and vigour appear to have been at their optimum, the extreme prostration, and the comparatively sudden recovery are found in both. In the cyclic vomiting of children, it is true, little complaint is made of headache, the visual aura is absent, and the vomiting is invariably the most prominent symptom.

Cyclic vomiting seldom occurs before the fourth year. It is characterised by sudden profuse and persistent vomiting and by very great prostration. All food, it may be even water, is promptly rejected. The vomited matter is generally stained with bile; occasionally the violence of the vomiting causes haematemesis. In many cases the temperature is raised; sometimes it may be as high as 103? F. The duration of an attack varies. In most cases it does not last longer than forty-eight hours. On the other hand, attacks lasting as long as a week are by no means unknown. Within a short time of the onset the urine may be found to contain acetone bodies, the breath may smell distinctly of acetone, and the child may become torpid and drowsy or agitated and restless. At times there may be exaggerated and deepened respiratory movements--the so-called air hunger. In many cases, however, otherwise characteristic, these more severe manifestations are absent or but little apparent. Recovery is usually rapid and complete. The child asks for food, which is retained. A fatal ending is very rare, though not unknown. The frequency of attacks is very various. Sometimes months or even years may elapse between successive seizures; in other cases a fortnightly or monthly rhythm establishes itself.

It is clear that both the frequency and the severity of the attacks are much influenced by the general state of the child's health. Like migraine, cyclic vomiting appears to be a symptom of nervous exhaustion. It affects, for the most part, children who are intellectually alert, impressionable, and forward for their age, and who, when well, throw themselves into work or play with a great expenditure of nervous energy. Often their physical development is unsatisfactory, and we must set ourselves to correct this as the first step in prevention. It is highly important that children suffering in this way should have free opportunities for exercise in the open country, and that all the excretory organs--the skin, kidneys, and bowels--should be acting freely and efficiently. The child should live a life of ordered routine. Sleep should be sound and sufficient in amount. The diet must not exceed the strict physiological needs. Many of these children appear to have a lowered tolerance for fats of all sorts, and it may be necessary to limit strictly the consumption of milk, cream, butter, and so forth. A daily administration of a small dose of alkali by the mouth is credited with preventing attacks. In the present connection, however, we shall not do wrong to emphasise the part played by the nervous system in the production of the attacks. In all cases of cyclic vomiting it should be our endeavour to recognise and remove the elements in the daily life of the child which are proving too exhausting.

In nervous children we sometimes meet with inexplicable rises of temperature. The pyrexia may have the same periodic character as that just noted in cases of cyclic vomiting. At intervals of three, four, or five weeks there may be a rise of temperature to 103? F., or even higher, which may last for two or three days before subsiding. In other cases the chart shows a slight persistent rise over many weeks or months. That in nervous children the temperature may be very considerably elevated without our being able to detect much that is amiss does not of course make it any the less necessary to be careful to exclude organic disease. Pyelitis, tuberculosis, and latent otitis media occur with nervous children as with others and must not be overlooked. If, however, organic disease can be excluded, and if the pyrexia is the only circumstance which prevents the decision that the child is well and should be treated as well, then the thermometer may be overruled and the pyrexia neglected.

ENURESIS

I have dealt in previous chapters with certain common disorders of conduct in childhood, which show clearly their origin in the apprehensions of the grown-up people who have charge of the children, and in the unwise suggestions which they convey to them. The same forces are at work in the production of enuresis, or bed wetting, although the matter is here often complicated by the development later on of a sense of shame and unhappiness in the child. There comes a time when the child passionately desires to regain control and is miserable about her failure, until the concentration of her thoughts on the subject becomes a veritable obsession. Every night she goes to bed with this only in her mind. Every night she falls asleep, miserably aware that she will wake to find the bed wetted. The suggestion impressed in the first place on the mind of the tiny child by injudicious management has become fixed by the growing sense of shame and the complete loss of self-confidence.

It is usually taught that a great variety of causes is concerned in producing enuresis. It is said to be due to a partial asphyxia during sleep from adenoid vegetation. It is said to be caused by phimosis, and to be cured by circumcision. It is said that the urine is often too acid and so irritating that the bladder refuses to retain it for the usual length of time. It is said that enuresis may be due to a deficiency of the thyroid secretion, and that it can be cured by thyroid extract. Such a number of rival causes may make us hesitate to accept the claims of any one of them. Certainly I have not been able to satisfy myself that any one of these conditions exercises any influence at all or is commonly present in cases of enuresis. I think that if we examine a large number of cases of bed wetting in children we can come to no other conclusion than that the cause of the trouble is due to just such a pervasion of suggestion as we have been considering above.

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