The Nervous Child

by Hector Charles Cameron

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 defæcation 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 ætiology 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 apnœa, 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 apnœa 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 apnœa 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 apnœa 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