The Nervous Child by Hector Charles Cameron

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With nervous children we are apt to find sleep which is of little
depth and which constantly shows evidence of a too-active brain. The
body is tossed to and fro, words are muttered, and the respiration is
hurried and with a change in rhythm, because there is no depth of
anaesthesia. The body still responds to the impulses of the too-active
brain. From the nature of his dream--as shown by chance words
overheard--we may sometimes gather hints to help us to find where the
elements of unrest in his daily life lie. Sleep-walking is only a
further stage in this same disorder of sleep, in which the dream has
become so vivid that it is translated into motor action.

If a child begins to suffer from active sleeplessness we must not make
the mistake of urging him to sleep. He is no more capable than we are
ourselves of achieving sleep by an effort of will power. To urge him
to sleep is likely to cause him to keep awake because we direct his
attention to the difficulty and make him fear that sleep will not
come. If he understands that all that he needs is rest, he will
probably fall asleep without further trouble.

Day-dreams also may become abnormal, and tell of an unduly nervous
temperament. Any one who watches a little child at play will realise
the strength of his power of imagination. The story of Red Riding Hood
told by the nursery fire excites in the mind of the child an
unquestioning belief which is never granted in later life to the most
elaborate efforts of the theatre. All this imaginative force is
natural for the child. It becomes abnormal only when things seen and
acts performed in imagination are so vivid as to produce the
impression of actual occurrences, and when the child is so under the
sway of his day-dreams that he fails to realise the difference between
pretence and reality. Imagination which keeps in touch with reality by
means of books and dolls and toys is natural enough. Not so
imagination which leads to communion with unseen familiars or to acts
of violence due to the organisation of "conspiracies" or "robber
bands" amongst schoolboys.

If evidence of abnormal imagination appears, the child must be kept in
close touch with reality. We must give him interesting and rational
occupation, such as drawing, painting, the making of collections of
all sorts, gardening, manual work, and so forth. In older children we
must especially supervise the reading.

In many nervous children we find a faulty contact with environment, so
that instead of becoming interested in the thousand-and-one happenings
of everyday life and experiences, they become introspective and
self-conscious. As a result, sensations of all sorts, which are
commonly insufficient to arouse the conscious mind, attract attention
and, rising into consciousness, occupy the interest to the exclusion
of everything else. The conscious mind is not capable of being
occupied by more than one thing at a time. If attention is
concentrated upon external matters, bodily sensations, even extreme
pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells
us, hardly feels the scalping-knife as he shouts his death song. The
soldier in the excitement of battle is often bereft of all sense of
pain. On the other hand, the patient who is morbidly self-conscious
becomes oblivious of his surroundings while he suffers intensely from
sensations which are usually not appreciated at all. Self-conscious
children will complain much of breathlessness and a sense of
suffocation, of headache, of palpitation, of intolerable itching, of
the pressure of clothing, or of flushing and a sense of heat.
Excessive introspection influences their conduct in many ways. At
children's parties, for example, they will be found wandering about
unhappy, dazed and unable to feel the reality of the surroundings
which afford such joy to the others; or they may be anxious to join in
play, but finding themselves called upon to take their turn are apt to
stand helplessly inactive, or to burst into tears. At school, though
they may be really quick to learn, they will often be found oblivious
of all that has gone on around them, not from stupidity, but from
inability to dissociate their thoughts from themselves and to
concentrate attention upon the matter in hand. In such a case we must
aim at developing the child's interest to the exclusion of this morbid
introspection. Taking advantage of his individual aptitude, we must
strengthen his hold upon externals in every way possible, and we must
explain to him the nature of his failing and teach him that his
salvation lies in cultivating his capacity for paying attention to
things around him and developing an interest in suitable occupations.

Fainting fits are not uncommon amongst nervous children from about
the sixth year onwards, and are apt to give rise to an unwarranted
suspicion of epilepsy. In other cases fears have been aroused that the
heart may be diseased. In children who faint habitually the nervous
control of the circulation is deficient. We notice that when they are
tired by play, or when they are suffering from the reaction that
follows excitement of any sort, the face is apt to become pale, and
dark lines may appear under the eyes. Yet there may be no true anaemia
present: it is only that the skin is poorly supplied with blood for
the moment. After a little rest in bed, or under the influence of a
new excitement, the colour returns, and the tired look vanishes. If
children of this type are made to stand motionless for any length of
time, and if at the same time there is nothing to attract their
interest or attention--a combination of circumstances which unhappily
is sometimes to be found during early morning prayers at school--the
want of tone in the blood vessels may leave the brain so anaemic that
fainting follows. The first fainting attack is a considerable
misfortune, because the fear of a recurrence is a potent cause of a
repetition. Standing upright with the body at rest and the mind
vacant, the circulation stagnates, the boy's mind is attracted by the
suggestion, he fears that he will faint as he has done before, and he
faints. Schoolmasters are well aware that if one or two boys faint in
chapel and are carried out, the trouble may grow to the proportion of
a veritable epidemic. It is important that this habit of fainting
should be combated not only by general means to improve the tone of
the body and circulation, but also by taking care that the child
understands the nature of the fainting fit, and the part which
association of ideas plays in producing it. Disease of the heart
seldom gives rise to fainting.

The same vasomotor instability which shows itself in the tendency to
syncopal attacks is apparent in many other ways. Sudden sensations of
heat and of flushing, equally sudden attacks of pallor, coldness of
the extremities, abundant perspiration,--raising in the mind of the
anxious mother the fear of consumption,--and excessive diuresis are
common accompaniments. A further group of symptoms is provided by the
extreme sensibility of the digestive apparatus. Dyspepsia,
hyperaesthesia of the intestinal tract, viscero-motor atonies and
spasms, and anomalies of the secretions, whether specific like that of
the gastric juice or indifferent like that of the nasal, pharyngeal,
gastric, and intestinal mucus, are all of common occurrence. Whenever
the nervous child is subjected to any exhausting experience, any
excitement, pleasurable or the reverse, or any undue exertion, whether
mental or physical, one may note the subsequent gastro-intestinal
derangement, including even a coating of the tongue. The slightest
deviation from the usual diet, the most trivial fatigue, a chill of
the body, even a change in the temperature of the food may set loose
the most extreme reactions in the gastro-intestinal tract--motor,
sensory, or secretory. It is not an accident that so often the mucous
diarrhoea, which may have afflicted an excitable child in London for
many months, and which a visit to the seaside, with all its healthy
activities, may seem to have completely cured, relapses within a day
or two of the return to the restricted environment and uninteresting
routine of life in London. The child who was happy and busy and at
peace with himself, at play in the open air, resents the sudden
cessation of all this, and the nervous unrest returns. To attempt
treatment by dietetic restrictions alone is to deal only with a
symptom. The gastro-intestinal reactions are so violent that the
parents are generally voluble on the subject of the many foods which
cannot be taken and the few which are not suspect. To prescribe rigid
tables of diet is to add to the alarm of the mother, and to sustain
her in the belief that the child is in daily danger of being poisoned
by a variety of common articles of diet. Only by lowering the
excitability of the nervous system, by occupying the mind and giving
strength to the child's powers of control can we effectively combat
the hyperaesthesia. If necessary the personnel of the management of
the child will have to be altered. There may be no other way to
achieve certain and rapid improvement in a condition which is causing
grave danger to the child and very genuine distress and suffering to
the parents. A violent reaction to intoxications of all sorts is a
further stigma of nervous instability. Sudden and even inexplicable
rises of temperature are frequent complaints, and the constitutional
effects of even trivial local infections are apt to be
disproportionately great.

Fatigue is easily induced and is exhibited in all varieties of
activity--mental, physical, or visceral. Mental work may produce
fatigue with extreme readiness even although the quality of the work
may remain of a high standard. To Darwin and to Zola work for more
than three hours daily was an impossibility, and yet their work done
under these restrictions excites all men's admiration. The palpitation
and breathlessness which follows upon trivial exertion, such as
climbing a flight of stairs, is a good example of visceral fatigue.

Among adult neuropaths we recognise the harm which may be done by
unwise speeches on the part of relatives, or still more on the part of
doctors. A chance word from a doctor or nurse off their guard for the
moment will implant in the minds of many such a person the unyielding
conviction that he or she is suffering from some gastric complaint,
from some cardiac affection, or from some constriction of the bowel.
It may take the united force of many doctors to uproot this
pathological doubt which was implanted so easily and so carelessly.
The medical student is notoriously prone to recognise in himself the
symptoms of ailments which he hears discussed. Little children, too,
are apt to suffer in the same way. How much illness could be avoided
if mothers would cease to erect some single manifestation of
insufficient nervous control into a local disorder which becomes an
object of anxiety to the child and to the whole household.

Undue liability to fatigue, irritability, instability, lack of
control over the emotions, extreme suggestibility, prompt and
exaggerated reactions to toxins of all sorts, excessive vasomotor
reactions and anomalies of secretion, weakness of the
gastro-intestinal apparatus--these, and many other symptoms, are of
everyday occurrence in the nervous child. To discuss them more fully
would be to pass too far from our nursery studies into a consideration
of psychological medicine.

CHAPTER XI

NERVOUSNESS AND PHYSIQUE

It has already been said that symptoms of nervousness are often
accompanied by faults in the physical development of the child. The
defects may assume so many forms as to make any attempt at description
very difficult. Nevertheless, certain types of physical defect present
themselves with sufficient frequency, in combination with neurosis, to
merit a detailed description. For example, we recognise a type of
nervous child which is marked by a persistence into later childhood of
certain infantile characteristics of the build and shape of body.
Further, we meet with a group characterised by a special want of tone
in the skeletal muscles, by lordosis, by postural albuminuria, and by
abdominal and intestinal disturbances of various sorts. We recognise
also the rheumatic type of child with a tendency to chorea, and in
contrast to this a type with listlessness, immobility, and katatonia.
Lastly, in a few children, in boys as well as in girls, we may meet
with cases of hysteria.[3]

[Footnote 3: If we accept as hysterical all symptoms which are
produced by suggestion and which can be removed by suggestion, we may
correctly speak of a physiological hysteria of childhood, which
includes a very large number of the symptoms discussed. The term is
used here in its older more limited sense.]

(1) A GROUP WITH PERSISTENCE OF CERTAIN INFANTILE CHARACTERISTICS

During the first year or eighteen months of life, the rounded
infantile shape of body persists. The limbs are short and thick, the
cheeks full and rounded, the thorax and pelvis are small, the abdomen
relatively large and full. The great adipose deposit in the
subcutaneous tissue serves as a depot in which water is stored in
large amounts. In the healthy child of normal development by the end
of the second year a great change has taken place. The shape of the
body has become more like that of an adult in miniature. The limbs
have grown longer and slimmer. The thorax and pelvis have developed so
as to produce relatively a diminution in the size of the abdomen. The
body fat is still considerable, but no longer completely obliterates
the bony prominences of the skeleton. Delay in this change, in this
putting aside of the infantile habit of body, is commonly associated
with a corresponding backwardness in the mental development. Such
children walk late, talk late, learn late to feed themselves, to bite,
and to chew effectively. Watery and fat, they carry with them into
later childhood the infantile susceptibility to catarrhal infections
of the lung, bowel, skin, etc., and they are apt to suffer, in
consequence, from a succession of pyrexial attacks. Nasal catarrh,
bronchitis, otitis media, enteritis, eczema, urticaria papulata, are
apt to follow each other in turn, giving rise in many cases to a
persistent enlargement of the corresponding lymphatic glands. The
effect upon the different tissues of the body of these repeated
infections is very various. We are probably not wrong in attributing
the failure to develop and the persistently infantile appearance to a
prejudicial effect upon the various ductless glands in the body. The
condition is associated with an excessive retention of fluid in the
body, secondary in all probability to alterations in the concentration
and distribution of the saline constituents of the body. A rapid
excretion of salts may be followed by a correspondingly speedy
dehydration of the body, a retention of salts by a sudden increase of
weight. The parathyroid glands are probably closely concerned in
regulating the retention and excretion of salts, and especially of
calcium, a circumstance which becomes of significance when we remember
how frequently rickety changes, tetany, and other convulsive seizures
form part of the clinical picture which we are now considering. While
it is difficult to determine the effect of repeated infections upon
the functions of the endocrine glands, we have clear evidence of the
deleterious influence upon almost all the tissues of the body, the
functioning of which it is more easy to estimate. For example, the
cells of the skin and of the mucous membranes which happen to be
visible to the eye show clear evidence of diminished vitality and
increased vulnerability. Physiological stimuli, incapable of producing
any visible reaction in healthy children, habitually determine widely
spread and persistent inflammatory reactions. For example, the
licking movements of the tongue at the corners of the mouth produce
the little unhealthy fissures which the French call _perleche_. The
physiological stimulus of the erupting tooth is capable of causing a
painful irritation of the gum, so that the child is said to suffer
from teething, accompanied, it may be, and the association is
significant, by "teething convulsions." The irritation of the urine
produces rawness and excoriation of the skin of the prepuce, contact
with intestinal contents not in themselves very abnormal, an
intractable dermatitis of the buttocks or a persistent diarrhoea and
enteral catarrh. Improvement in the general health, the result of the
cessation for the time being of the recurrent infections, perhaps
consequent upon improved hygienic conditions, always determines the
rapid disappearance of all these accompaniments of the general
diminution of tissue vitality.

The muscular system and the bones are commonly also involved, so that
rickety changes are often found in these infantile and watery
children. In early childhood the processes of calcification and
decalcification proceed side by side and with great rapidity, and in
health there is always a balance on the side of the constructive
process. In the children whom we are now considering, saturated as
they are, from time to time, with the toxins resulting from repeated
infection, ossification may be so interfered with as to cause
softening and bending, with the evolution of a state of rickets.
Between bone and muscle, too, we find a close relationship. We do not
find powerful muscles with softened bone, nor flabby muscle with
rigid and well-formed bone.

In the nervous system, the conditions are somewhat different. In skin,
in bone, and in muscle new cell elements are constantly being formed,
and the life of the individual cell is relatively short. In the
nervous system, on the other hand, the individual cells are long
lived. Their life-history may even be coterminous with that of the
individual, and if destroyed they are not replaced. Nevertheless, they
do not escape undamaged in the general disturbance. In a deprivation
of calcium we have, in all probability, the explanation of the
increased irritability of peripheral nerves and of the tendency to
convulsive seizures of all sorts which is a common accompaniment of
the condition. Convulsions, laryngismus stridulus, tetany, or
carpopedal spasm are all frequently met with. In crying, the children
hold their breath to the point of producing extreme cyanosis, ending,
as the spasm relaxes, with a crowing inspiration, which resembles and
yet differs in tone from both the whoop of whooping-cough and the
crowing inspiration of croup.

Apart, however, from this tendency to convulsive seizures the nervous
system of these children is abnormal. As a rule they are excitable,
and develop late the power to control their emotions. Lagging behind
in physical development and in the capacity to interest themselves in
the pursuits of normal children, their emotional state remains that of
a much younger child. In the infant classes at schools they are
recognised as dullards, learning slowly, speaking badly, and lacking
co-ordination in all muscular movements.

The clinical picture so depicted is encountered with extreme frequency
among the children of the poor in our large cities. To find a name for
the condition is no easy matter. To call it "rickets" is to place an
undue emphasis upon the bony changes which, though common, are by no
means invariable. Elsewhere I have suggested the name status
catarrhalis, on an analogy with the name status lymphaticus, which in
the post-mortem room is used to describe the secondary overgrowth of
lymphatic tissue which is found in these catarrhal children. In the
present connection it is of interest to us to note how commonly the
nervous system is involved in the general picture and the frequency
both of convulsive disorders and of neuropathy.

The nervous symptoms of both sorts are to be allayed only by improving
the general hygiene of the child and raising its resistance against
infection. A sufficiency of fresh air and of sunlight, and a
management which encourages independence of action in the child, are
both necessary. The diet is of the first importance. It should be
sufficient, and no more than sufficient, to cover the physiological
needs of the child for food. The majority of these children have
enormous appetites, and excess of food, and especially of carbohydrate
food, plays some part in the production of the disturbance. We must
guard against overfeeding, against want of air and want of exercise,
and against those errors of management described in previous chapters,
which produce the maximum of disturbance in this type of child.

(2) A GROUP WITH MUSCULAR ATROPHY, LORDOSIS, AND POSTURAL ALBUMINURIA

At an older age, in children from the fifth year onwards, a second
type of physical defect associated with pronounced nervous disturbance
presents itself with some frequency. The body is thin and badly
nourished, and the muscular system especially poorly developed and
very lax in tone. The most striking feature is the extreme lordosis,
accompanied usually by a secondary and compensatory curve in the
cervico-dorsal region, so that the shoulders are rounded, with the
head poked forward. Viewed from in front the abdomen is seen to be
prominent, overhanging the symphysis pubis, while the shoulders have
receded far backwards. The scapulae have been dragged apart, as though
by the weight of the dependent arms, with eversion of their vertebral
borders and lowering of the points of the shoulders. The position
which they adopt is that into which the body falls when it ceases to
be braced by strong muscular support. The muscular system is here so
weakly developed and so toneless that the posture is determined by the
bony structure and its ligamentous attachments.

The lordosis resembles the similar deformity which develops in cases
of primary myopathy, when the spinal muscles have undergone complete
atrophy. As in myopathy the movements are very uncertain. The
children are apt to fall heavily when the centre of gravity is
suddenly displaced, because their upright posture is maintained by
balancing the trunk upon the support of the pelvis. The frequency and
severity of the falls which these children suffer is a common
complaint of the mother. The faulty posture is often associated with
slight albuminuria. Its appearance is very capricious, but it is
dependent to a great extent upon the assumption of the erect posture.
There has been much discussion as to its explanation. It has been
argued that the lordosis itself produces the albuminuria by mechanical
compression of the renal vein, and it is said that albuminuria can be
produced, even in the prone position, by placing the child in a
plaster jacket applied so as to maintain the position of lordosis.
Other observers, however, have not obtained this result. It seems most
likely that the albuminuria is due to defective tone in the vasomotor
musculature, comparable in every way to the defective tone in the
muscles of the skeleton. We have often further evidence of vasomotor
weakness. Fainting attacks are so common as to be the rule rather than
the exception. Again, mothers are likely to complain of the child's
pallor and of dark lines under the eyes, especially after exertion or
in the reaction which follows excitement of any sort. As a rule a
blood count will not show any very striking evidence of true anaemia.
The pallor is of vasomotor origin, determined by faults in the
distribution of the blood from vasomotor weakness and not by deficient
blood formation. Circulatory and vasomotor disturbance probably also
accounts for the dyspeptic pains and vomiting which commonly accompany
any emotional excitement, or follow any unusual exertion or fatiguing
experience. Constipation is a common, and mucous diarrhoea an
occasional, symptom. The abdomen is often pigmented. The hands and
feet are usually cold and cyanosed.

The extreme nervousness of the children is the point upon which most
stress may be laid in the present connection. The association of
albuminuria with neurosis in childhood has been noticed by many
observers. The gastric and intestinal symptoms are especially
characteristic. If the condition of the children is not materially
improved, and if the symptoms, both of the physical defect and of the
nervous disturbance, are not cut short, we may predict that in adult
age their lives will be made miserable by a variety of abdominal
symptoms dependent both on the vasomotor disturbance and upon the
accompanying neurosis. Now that surgery forms so large a part of our
therapeutic proceedings, they may not reach middle life without being
submitted to one or more surgical operations. With good management
both on the physical side and on the moral or psychological side they
can be made into strong and useful members of society.

The treatment of these cases may be summed up as follows:

_(a)_ We must search for any source of infection, a source which is
often to be found in the condition of the tonsils. Enucleation may
then be indicated as the first step in treatment.

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