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 a.s.sisted. 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 repet.i.tion. 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 a.s.sociation 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, b.u.t.ter, 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 ot.i.tis 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 circ.u.mstance 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 pa.s.sionately 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 circ.u.mcision. 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.

There are certain points in the behaviour of a child with enuresis which seem to point to this conclusion.

_(a)_ In the first place, the trouble is seldom serious or very well developed in early childhood, and the reason for this, I take it, is that an occasional lapse in a child of perhaps two or three years of age is usually treated lightly and in the proper spirit of tolerance.

It is only with children a little older that nurses and parents become distressed and begin unwittingly by urging the child to present the suggestion to her mind, that the bed may or will be wetted. Hence the usual history is that control was partially acquired in the second year, but that, instead of later becoming complete, relapses began to be more frequent, and that since that time all that can be done seems only to make matters worse.

_(b)_ In the second place, the influence of suggestion is shown by the behaviour of the child when removed to a hospital for observation. It is the invariable experience that the enuresis then promptly stops. In hospital the att.i.tude of those around the child is entirely different.

She has the comfortable and consoling feeling that in wetting the bed she is doing exactly what is expected of her. There is even a feeling that otherwise she is showing herself to be something of a fraud, and that she has then been admitted to the hospital on false pretences.

Hence, perhaps for the first time in many years, the child is free from the obsession, and the bed is not wetted.

_(c)_ In the third place, it is easy to recognise in the history of many of the cases, the ill-effects of circ.u.mstances which add new force to the fear of failure or shake the confidence in the control which had been regained. Thus a boy, an only child, who had suffered from enuresis till his seventh year, had regained complete control till his eleventh year, when he went to school. In his dormitory at school was a boy who had enuresis, and who was being fined and punished by the schoolmaster. The enuresis at once reappeared and continued unchecked so long as he was at school. As might be expected, school life is very inimical to cure, unless the trouble can be kept from the knowledge of the other boys. Anything which directly increases the nervousness of the child--an illness, for example, with loss of weight and failure of nutrition, or some mental stress, such as the approach of an examination--is apt to accentuate the enuresis.

_(d)_ In the fourth place, the incontinence sometimes spreads to the daytime, and the child is wet both by day and night. Further, in bad cases it is not uncommon to find incontinence of faeces making its appearance also. These extensions of the fault only take place when the management continues to be very faulty, when the grown-up people around them are more than usually distressed and pessimistic, and have redoubled their expostulations and appeals.

Now these peculiarities of enuresis seem to me only explicable if we a.s.sume that the want of control is due to auto-suggestion, dependent at the beginning on the unwise att.i.tude adopted towards the fault by the nurses and parents, and later kept up by the sense of shame and the mental distress involved.

The forms of treatment which have been recommended from time to time are, as might be expected, very numerous.

_(a) Operative._--(i) Removal of tonsils and adenoids, (ii) Circ.u.mcision.

_(b) Manipulative._--(i) Injection of saline solution under the skin in the perineal and pubic regions, with object of lowering the excitability of the bladder by counter-irritation. (ii) Gradual distension of the bladder by hydrostatic pressure, (iii) Tilting the foot of the bed so as to throw the urine to the fundus of the bladder, in order to protect the sensitive trigone from irritation.

_(c) Educative._--(i) Curtailing the fluid drunk. (ii) Waking the child at intervals during the night by an alarm clock or otherwise.

(iii) Rewards and punishments.

_(d) Medicinal._--(i) Belladonna. (ii) Thyroid extract.

_(e) By Suggestion._--(i) By simple suggestion. (ii) By hypnotic suggestion.

I do not think that any single one of these various forms of treatment outlined under the first four heads has any effect other than to aid the suggestion of cure which we proffer in adopting it. Removal of tonsils and adenoid vegetations might conceivably cure an enuresis which is nocturnal, it cannot account for an incontinence which spreads to the day. We might believe that to distend the bladder by hydrostatic pressure was a cure for incontinence of urine, and that it acted by removing the local cause,--the smallness and contraction of the bladder,--were it not that the loss of control is so apt to spread to the r.e.c.t.u.m as well. There is no evidence that the urine is peculiarly irritating. Indeed, such evidence as we have goes to show that, as in some other neuroses, the urine in enuresis is unduly copious, and of very low specific gravity. Incidentally, we have in this polyuria a further argument against the view recently advanced that a small and contracted irritable bladder is the cause of enuresis. We do, of course, meet with cases of irritable bladder often enough, but the complaint is then not of incontinence, but always of the discomfort of having to rise so frequently for micturition.

To deprive the child of fluid, to wake her many times at night, to tilt the foot of the bed, are devices which may help in the hands of some one who is confident of his ability to cure the condition and can communicate the confidence to the child. Carried out hopelessly and pessimistically by a tired and exasperated mother, they are well calculated to strengthen the hold which the obsession has on the child, so that often we meet with a mother who rightly enough maintains that the more she wakes the child, the oftener the bed is wet, till she wonders where it all comes from.

The treatment of enuresis to be successful must be conducted through and by means of the grown-up persons who have the control of the children. To stop the development of enuresis in early infancy we must intervene to prevent the concentration of the child's mind on the difficulty. During the time when control is ordinarily developed, in the second and third year, judicious management of the child is essential. The emphasis should be laid upon successes, not upon failures. For every child his reputation will sway in the balance for a time. He must be helped and encouraged to self-confidence, not rendered diffident or self-conscious.

If the case is well established before it comes under our notice, the mother, the nurse, the schoolmaster, or whoever is responsible for the child's management, must understand clearly the nature of the trouble.

The suggestion acting on the child's mind must be altered, and self-confidence restored. The child must learn to see that the thing is not so desperately tragic. He should be told that the trouble always gets well, and that it only goes on now because he is worried about it and keeps thinking of it. If the whole environment of the child is bad, so that such a change of suggestion is not possible, and if enuresis is but one of many symptoms of mental or moral instability, it may be necessary to remove the child and place him under the influence of some one else. Sometimes the prescription of a rubber urinal, which the child can slip on at night, is directly curative. A public school boy, who was about to be sent away from school for this failing, fortified by the possession of this apparatus, wrote six months later to say that he knew now that it must be all worry that caused the trouble, because with the urinal in position he had not once had the incontinence.

In inveterate cases hypnotic suggestion is always, I think, successful. It is obvious, however, that in many cases there are objections to its use. Often enuresis is evidence that the child's home environment has been at fault, and that his mental and moral development has been r.e.t.a.r.ded. It is the management which must be modified or the home, if necessary, changed. Hypnotic suggestion will make this one symptom disappear promptly enough, but it will rather perpetuate than combat the cause--that undue susceptibility to suggestion, which is characteristic alike of the little child and of many older neuropathic persons.

CHAPTER VII

TOYS, BOOKS, AND AMUs.e.m.e.nTS

Any one who has an opportunity of watching little children must have observed that they are happiest and most contented when playing alone.

The education of the little child is carried on by means of games and toys. Handling the various objects which we give him, imparting movement to them, transferring them from hand to hand and from one situation to another, he learns dexterity and precision of movement, and in the process hand and brain grow in power. When at play, his whole energies should be absorbed to the exclusion of everything else.

He will often be oblivious to everything that is going on around him, intent only on the purpose of the moment. In order to permit this fervour of self-education it is necessary that the child should be accustomed to playing alone, and it is well, if only for convenience'

sake, that he should be accustomed to playing in a room by himself.

Something is wrong if the child cannot be left for a few moments without breaking into tears or displaying bad temper. Engrossed in his own tasks, he should be content to leave his nurse to move in and out of the room without protest. If this fault has appeared and the child cannot be left alone, our whole educational system is undermined, and play will be profitless and over-exciting, because it demands the constant partic.i.p.ation of grown-up people. As a preliminary to all improvement in the management of a nervous child, we must see to it that he becomes accustomed to being alone. We must so arrange his nursery that he can do no damage to himself. Scissors and matches must not be left lying about, and a fireguard must be fixed in position so that it cannot be disturbed. Then, disregarding his protests, the nurse must leave him to himself, at first only for a moment or two, re-entering the room in a matter-of-fact way without speaking to him, and again leaving it. Soon he will learn that a temporary separation does not mean that we have abandoned him for all time. Then the period of absence can be gradually lengthened till all difficulty disappears.

Once his attention is removed from the grown-up people who mean so much to him, his natural impulse to explore and experiment with his playthings will show itself. Those toys are best which are neither elaborate nor expensive. For a little child a small box containing a miscellaneous collection of wooden or metal objects, none of them small enough to be in danger of being swallowed, forms the material for which his soul craves. Everything else in the room may be out of his reach. A dozen times he will empty the box and then replace each object in turn. He will arrange them in every possible combination, and then sweep the whole away to start afresh.

At eighteen months of age observation and imitative capacity will have made more complex pursuits possible. As a rule the objects which are most prized and which have most educative value are those which lend themselves best to the actions with which alone the child is familiar. Hence the supreme importance of the doll and the doll's perambulator. The doll will be treated exactly as the child is treated by the nurse. It will be washed, and dressed, and weighed, and put to bed in faithful reproduction of what the child has daily experienced.

Dusting, and sweeping, and laying the table will be exactly copied. If a child has no opportunity of being familiar with horses, if he has not seen them fed, and watered, and groomed, and harnessed, he may not find any great satisfaction in a toy horse, or pay much attention to it, no matter how costly or realistic it may be.

In the third year more precise tasks, such as stringing beads, drawing, and painting, will play their part, while at the same time the increased imaginative powers will give attraction to toy soldiers or a toy tea-service. Playing at shop, robbers, and rafts are developments of still later growth. In the child's games we recognise the instinct of imitation--playing with dolls, sweeping and dusting, playing at shop or visitors; the instinct of constructiveness--making mud pies and sand castles, drawing or whittling a stick; and the instinct of experiment--letting objects fall, rattling, hammering, taking to pieces. All this activity must be encouraged, never unduly repressed or destroyed. But whatever form it takes, the bulk of the play must be carried on without the intervention of grown-up persons, or it will lose its educative value and prove too exacting. If grown-up people attempt to take part, the child will lose interest in the play and turn his attention to them.

Children differ very much in their att.i.tude towards books. One child quite early in the second year will be happy poring over picture books, while another will seldom glance at the contents and finds pleasure only in turning over the pages, opening and shutting them, and carrying them from place to place. Such differences are natural enough and foreshadow perhaps the permanent characteristics that divide men and women, and produce in later life men of thought and men of action, women who are Marthas and women who are Marys.

Nevertheless, we should bear in mind that there is danger in a training that is too one sided, and that books and toys have both their part to play in developing the powers of the child. All the activities of the child should be used in as varied a way as possible.

The eye is but one doorway to knowledge and understanding, the ear is another, the hand a third.

From pictures an imaginative child will derive very strong impressions, and mothers should be careful in their choice. It is foolish to confuse the growth of aesthetic perceptions by presenting children with books which depict children as grotesquely ugly beings with goggle eyes and heads like rubber b.a.l.l.s. Children love animals and endow them with all their own reasoning attributes, and in stories of the home life of rabbits, and bears, and squirrels they take a pure delight. Books of the "Struwwelpeter" type are less to be recommended. The faults which they are intended to eradicate become peculiarly attractive from much familiarity. A little boy of two and a half who resolutely refused all food for some days was in the end detected to be playing the part of that Augustus, once so chubby and fat, who reduced himself to a skeleton, saying, "Take the nasty soup away; I don't want any soup to-day." Tales of naughty children who meet with a distressing fate may either frighten the child unduly, or else produce in a child of inquiring mind the desire to brave his fate and put the matter to the test. Pictures should not be terrifying or horrible. Ogres devouring children are out of place as subjects for pictures and may cause night-terrors.