SOME OTHER SIGNS OF NERVOUSNESS
HABIT SPASM
Next to refusal of food and refusal of sleep perhaps the most frequent
manifestation of nervous unrest is provided by the group of symptoms
which we may call, with a certain latitude of expression, Habit
Spasms. By a habit spasm is meant the constant repetition of an action
which was originally designed to produce some one definite result, but
which has become involuntary, habitual, and separated from its
original meaning. The nervous cough forms a good example of a habit
spasm. A cough may lose its purpose and persist only as a bad habit,
especially in moments of nervousness, as in talking to strangers, in
entering a room, or at the moment of saying "How do you do" or
"Good-bye." Twitching the mouth, swallowing, elongating the upper lip,
biting the lips, wrinkling the forehead so strongly that the whole
scalp may be put into movement, and blepharospasm are all common
tricks of little children which may become habitual and uncontrolled.
In worse cases there may be constant jerking movements of the head,
nodding movements, or even bowing salaam-like movements. In mild
cases we may note hardly more than a restless movement of mouth or
forehead, or constant plucking or writhing of the fingers whenever the
child's attention is aroused, when he is spoken to, or when he himself
speaks. In nervous children these movements, which should properly be
confined to moments of real emotional stress, become habitual, and are
displayed apart from the excitement of particular emotions. Whatever
their intensity, habitual and involuntary movements of this nature
should not be overlooked, and should be regarded as evidence of mental
unrest. They do not commonly appear during the first or second years
of the child's life. They are more frequent after the age of five, but
they may begin to be marked as early as the third year. With refusal
of food and refusal of sleep they form the three common neuroses of
early childhood.
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 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 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 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.