The diagnosis is made by the regular absence of inspiratory stridor and of galvanic overexcitability of the nervous system, and these attacks of convulsive rage cannot therefore be included among the phenomena of spasmophilia. There is also a difference in the age of the children. Whereas spasmophile convulsions occur chiefly between the ages of six and eighteen months, the above-described attacks of convulsive rage usually do not manifest themselves until the second or third year of life and almost always disappear at the latest when the child reaches the age of five. An attack can often be prevented by educational measures, by making it clear to the child that any attempt to hold its breath will be immediately followed by severe punishment; in this way one may often succeed in preventing the spasm by a blow or by merely threatening to strike. Once the attack has developed it can be shortened by dashing cold water on the face, by a light blow or some other cutaneous irritant; but even without interference of any kind no fear need be entertained for the child's life or any other injury, aside from the possibility of its hurting itself when it falls to the ground, and in this respect the attack differs essentially from spasmophile convulsions.
Disturbances of sleep occur in association with a great variety of diseases in childhood, as well as among adults, and indicate pain, fever or some other disturbance. In the absence of any physical basis we are justified in regarding the disturbance as a nervous phenomenon; in fact, objective investigation and observation of children whose sleep is habitually disturbed have shown that these children are nervous individuals and that the troubled sleep is merely a symptom of the constitutional anomaly.
The clinical manifestations are various. Some children, both infants and older children, instead of going to sleep at once after they have been sufficiently fed and put to bed, as normal children do, lie awake for hours, but when sleep finally comes on it is of normal depth and duration. Some children will not go to sleep unless they are allowed to suck a finger or a corner of the bedclothes; others must have the face completely covered with the bedclothes; and some cannot sleep unless they are sitting up or lying on their stomachs. These are mere habits for which the children's surroundings are frequently responsible, but the rapidity and obstinacy with which these habits become established nevertheless indicate the presence of some pathologic factor in the child's makeup. There are other cases in which the children go to sleep promptly, but do not sleep soundly and are easily aroused by a show of light, or even without any recognizable cause. Some children exhibit a variety of
motor phenomena, ,such as grinding the teeth, rolling about, flexion and extension of the arms and legs, and thc like, which indicate that they are not sleeping soundly. These movements continue without wakening the child and may be rhythmical and quite violent, presenting the character of stereotypias (jactatio capitis nocturna) [Swoboda, Zappert].
Many children as they drop off to sleep go through complicated actions which suggest dreams. They are apparently playing with some toy, or occupied with their school duties, point upward with the finger and indulge in other similar antics.
A good many children during the school age are given to so/mom /pi/ism; they get out of bed. go from the bedroom, for example, to the nursery, play with their books, and finally return to bed unless they are seen by some one and wakened. The child's behavior in the som nambulistic state is perfectly quiet, and it is quite unconscious, in contradistinction to its behavior during attacks of night terror, pavor noeturnus, which we shall now proceed to describe.
Pavor nocturnos, nig,let terror. is a special form of nervous disturbance which in the literature is usually described as an independent affection, although many authors have recognized, am! insisted upon its dependence on a nervous eonstitution.
Night terror occurs most frequently between the ages of three and six years, but may persist in older children up to the beginning of puberty. Both sexes are equally affected. The attacks usually occur one or several hours after the child has gone to sleep. It wakes up with a cry, sits up in bed, and manifests other signs of extreme terror, which often seem to be due to some terrible dream, judging from the words and fragments of sentences which the chili utters during, the attack. In a terrified manner it begs the nurse to keep off the dog or man that is frightening it, to hold on to it, not to let it drop, not to punish it, ete. Even after the light is turned up and the mother has taken the child up to comfort it, the terror still continues, and it takes from a quarter to half an hour before the child recognizes the situation and allows itself to be pacified, and goes to sleep again. Sometimes the attack recurs in a milder form once or rarely twice in the same night. As a rule, the child remembers nothing of the attack on awakening in the morning.
The intensity as well as the frequency of the attacks is extremely variable; sometimes attacks of (lay terror—paror diaraus—oceur in the daytime.