The ætiology 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 hæmatemesis. 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.
Unexplained Pyrexia
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.
CHAPTER VI
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.