A variety of physical causes have been suggested for the occurrence of the attacks, such as worms, digestive disturbances, overloading of the stomach, constipation and the like. Rey called attention to the presence of adenoid vegetations in many cases. He believes that the interference with respiration and the consequent accumulation of carbon dioxide causes intoxication of the brain ani a nervous discharge in the form of an attack. These possible CIIIISC6 must of course receive attention in the treatment of this class of patients; it is to be remembered, how ever, that they are absent in a great many cases of night terror and, conversely, that they are present in many children without producing anv attacks. The increased susceptibility to carbon dioxide accumula tion, which is mentioned by Rey, is after all but a sign of an abnormally irritable nervous system.
Neither somnambulism nor night terror has anything to do with • e pilepsy.
In connection with this nocturnal disturbance it should be cursorily mentioned that some children are very difficult to wake, even after a long night's rest. In the morning they are drunk with sleep, irritable when they are called, and continue to be half awake while they are dressing and eating their breakfast. It takes these children a long time to wake up completely. In psychopathic institutions, particularly, it is often noticed that the more nervous children do not accomplish as much during the first hour as they do later in the day.
Heredity play's an essential part in the etiology of neurasthenia. It is, however, usually- associated with injurious environment and im proper training. An irregular mode of life, restlessness and dissensions at home, being allowed to take part in the amusements of adults, usually at the expense of sleep, and the reading of books that excite the imagina tion, ete., greatly undermine the child's nervous constitution. The mental strain of school work, particularly in children who are naturally nervous and not very highly gifted intellectually, and who are made to begin school too early and forced in their studies, is also a potent factor of evil.
A severe somatic disease, as well as frequently recurring milder illnesses (as, for example, in children with a tendency to exudative diseases) may give rise to neurasthenic conditions; but it is a mistake in our opinion, to say- that every child of school-going age that looks a little pale is aneemic, and to accept that as sufficient explanation for existing nervous symptoms.
Finally, the bad effects on the child's nervous system of indulging regularly in alcoholic beverages, must be alluded to, although this very modern theme requires no further elaboration.
The diagnosis of neurasthenia is not difficult in most cases, but the child must always be subjected to a searching examination for the existence of any organic disease that may be either the cause, or merely a concomitant of the neuropathic symptoms, whiek are the most promi nent features of the clinical picture. Many cerebral affections, such as
tumors, epilepsy and chorea, for a long time give rise only- to general neuropathic symptoms, until finally the grave characteristic signs of the organic disease make their appearance.
The prognosis of infantile neurasthenia depends partly on tile severity of the inherited disability and partly on the environment, whether favorable or unfavorable to the child's development. Under favorable conditions complete recovery is possible.
In many cases the most important part of the treatment is the removal of the most prominent symptoms, which may be aeeomplished by the usual methods employed with a certain measure of discretion. The conscientious physician, however, will never lose sight of the causa tive disease and will therefore scrupulously avoid polypragmasia and a mere pretense at treatment for the sake of doing something. The egotism and the tendency to hypochondriacal self-analysis, which are charac teristic of neurasthenic children—astonishing examples of this tendency are often seen in children of a tender age—are in danger of being enhanced by constant medical treatment, both directly ancl indirectly, and by thc constant attention such children receive from their parents. Indeed, hysteria may be directly produced by such a policy. Besides, drugs at this age usually have but little effect and may be. dispensed with alto gether. This is especially true of the great multitude of nutrients, tonics, Mematonics and other remedies which are shamelessly advertised and placed on the market by our modern industrial institutions.
in almost every instance the symptoms can be made to disappear by correcting faulty environment, by restricting well-meant but ill advised educational methods, and by regulating the child's mode of life, providing it is in the physician's power to do so.
As an example, we may mention the symptom of anorexia. Every physician is familiar with the type of nervous child that never asks for anything to eat and for whom every meal, especially the principal meal of the day, is a source of terror lest the anxious, neuropathic father may force it to eat by threatening a flogging. Every physician knows also that he can accomplish more by forbidding every form of coercion than with any medicine or diet-list that he might order, and the children of this type, when they are away for their summer holidays or on a visit to relatives in the country, learn to eat without any trouble. It is equally irrational to put a neuropathic child on a forced diet that is quite beyond its appetite, unless it is at the same time placed in a sana torium where it will be separated from fussy parents who unconsciously create an arnosphere of excitement and unrest—a plan which must always be borne in mind as a last resort.