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 cla.s.ses 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 a.n.a.logy 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 appet.i.tes, 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 ALb.u.mINURIA

At an older age, in children from the fifth year onwards, a second type of physical defect a.s.sociated with p.r.o.nounced 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 a.s.sociated with slight alb.u.minuria. Its appearance is very capricious, but it is dependent to a great extent upon the a.s.sumption of the erect posture.

There has been much discussion as to its explanation. It has been argued that the lordosis itself produces the alb.u.minuria by mechanical compression of the renal vein, and it is said that alb.u.minuria can be produced, even in the p.r.o.ne 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 alb.u.minuria 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 a.s.sociation of alb.u.minuria 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.

_(b)_ Ma.s.sage and gymnastic exercises calculated to improve the muscular tone, while every effort is made to secure for the child as perfect hygiene in the environment as possible.

_(c)_ The stimulating effect of cold douches is often very evident in improving the vasomotor tone. These children, however, will not stand well the abstraction of heat from their thin and chilly little bodies, so that it is a good plan before the colder douche to immerse the child in a hot bath and to return again to the bath momentarily afterwards. With these precautions children will often enjoy a cold spray, the temperature of which may be constantly lowered as they become used to it. Prolonged hot bathing has a correspondingly prejudicial effect.

_(d)_ We must be on the watch to prevent the development of further postural deformities, such as scoliosis. If a child of strong muscular tone and good physique habitually adopts some posture, curled up, it may be, in some favourite easy-chair, there is little likelihood that its constant a.s.sumption will produce deformity. When the muscular system is lax and weak, on the other hand, deformity such as scoliosis is very readily caused. It is important, for example, to see that the child does not habitually incline to one side in reading or writing.

When there is little energy for free and energetic play the children are apt to become great bookworms. If there is shortsightedness, the dangers are correspondingly increased. A special chair may be made with a well-fitting back and the seat a little tilted upwards so as to throw the child's trunk on to the support of the back. Lastly, a desk, the height of which can be regulated at will, can be swung into the proper position. The child, sitting straight and square, with the weight supported by the foot-rest and back as well as by the seat of the chair, should be taught to write with an upright hand, avoiding the slope which leads to sitting sideways with the left shoulder lowered.

(e) Malt extract, cod liver oil, Parrish's food, and other tonics may be of undoubted service.

(3) RHEUMATISM AND Ch.o.r.eA

It is certain that there is a close a.s.sociation between rheumatism in childhood and the common nervous affection known as ch.o.r.ea. We are still ignorant of the precise nature of the infection which we know as rheumatism. There is much to suggest that in rheumatism we have to deal only with a further stage in those catarrhal infections to which so much infantile ill-health is to be attributed, and that endocarditis and arthritis, when they arise, signalise the entry of these catarrhal, non-pyogenic organisms into the blood stream, overcoming at last the barrier of lymphoid tissue which has hypertrophied to oppose their pa.s.sage. Certainly the connection of rheumatism with catarrhal infections of the mucous membranes and adenoid enlargements of all sorts is a close one. Whatever its nature, the rheumatic infection in childhood is more lasting and chronic than in adult life. Rheumatism in childhood is not manifested by acute and short-lived attacks of great severity so much as by a long-continued succession of symptoms of a subacute nature, a transient arthritis, perhaps, succeeding an attack of sore throat with torticollis, to be followed by carditis, to be followed again by another attack of tonsillitis. And so the cycle of symptoms revolves.

In most cases the child grows thin and weak; in most cases he becomes restless, irritable, and unhappy; often there is definite ch.o.r.ea. Of this cerebral irritability ch.o.r.ea is the expression. In adults, ch.o.r.ea is perhaps more obviously a.s.sociated with mental stress of all sorts and with states of excitement and agitation. In the case of little children it is often only the mother who really appreciates how radical an alteration the child's whole nature has undergone, and how great the element of nervous overstrain has been before the ch.o.r.ea has appeared.

Of the treatment of ch.o.r.ea there is no need to speak. It is purely symptomatic. Isolation, best perhaps away from home, as might be expected, gives the best results. If there are p.r.o.nounced rheumatic symptoms, the salicylates will be needed; if there is anaemia, a.r.s.enic and iron; if there is sleeplessness and great restlessness, bromides or chloral. Hypnotism is often almost instantly successful, but, apart from hypnosis, curative suggestions proceeding from the attendants form the princ.i.p.al means at our disposal.

(4) EXHAUSTION AND KATATONIA

A large number of children, in convalescence from infective disorders, when the nutrition of the body has fallen to a low ebb, show as evidence of cerebral exhaustion a group of symptoms which in a sense are the reverse of those which characterise cerebral irritation and ch.o.r.ea. The healthy child is a creature of free movement. The children we are now considering will sit for a long time motionless. The expression of their faces is fixed, immobile, and melancholy. If the arm or leg is raised it will be held thus outstretched without any attempt to restore it to a more natural position of rest for minutes at a time. The posture and expression remind us at once of the katatonia which is symptomatic of dementia praec.o.x and other stuporose and melancholiac conditions in adult life. Symptoms of this sort are especially common in children with intestinal and alimentary disturbances of great chronicity.

The symptom is so frequently met with that it is strange that it should have attracted so little attention as compared with the contrasting condition of ch.o.r.ea. And yet it is of more serious significance, more difficult to overcome, and with a greater danger that permanent symptoms of neurasthenia will result. In early childhood a careful dietetic regime, suitable hygienic surroundings, and a stimulating psychical atmosphere will often effect great improvement. As in ch.o.r.ea, however, relapses are frequent, and there are cases which for some unexplained reason are peculiarly resistant to all remedial influences.

(5) HYSTERIA

In hysteria, in contrast to the types previously described, the infective element may be completely absent. Except in some special features of minor importance the symptoms of hysteria do not differ from those of adults, and, as in adult age, the condition of hysteria may be present although the physical development may be perfect. We cannot here speak of any physical characteristics which are a.s.sociated with the nervous symptoms.

The third or fourth year represents the age limit, below which hysterical symptoms do not appear. Thereafter they may be occasionally met with, with increasing frequency. At first, in the earlier years of childhood, there is no preponderance in the female s.e.x. As p.u.b.erty approaches, girls suffer more than boys.

It may be said to be characteristic of hysteria in childhood that its symptoms are less complex and varied than in adult life. The naive imagination of the child is content with some single symptom, and is less apt to meet the physician half-way when he looks for the so-called stigmata. Similarly mono-symptomatic hysteria is characteristic of oases occurring in the uneducated or peasant cla.s.s.

In children, hysterical pain, hysterical contractures or palsies, mutism, and aphonia are the most usual symptoms. Hysterical deafness, blindness, and dysphagia are manifestations of great rarity in childhood.

CHAPTER XII

THE NERVOUS CHILD IN SICKNESS

In time of sickness the management of the nervous child becomes very difficult. Restlessness and opposition may reach such a pitch that it may be almost impossible to confine the patient to bed or to carry out the simplest treatment. Sometimes days may elapse before the sick-nurse who is installed to take the place of the child's usual attendant is able to approach the cot or do any service to the child without provoking a paroxysm of screaming. In such a case any systematic examination is often out of the question, with the result that the diagnosis may be delayed or rendered impossible. There is only one rea.s.suring feature of a situation, which arises only in nurseries in which the management of the children is at fault; the doctor has learned from experience that this p.r.o.nounced opposition of the child to himself, to the nurse, and even to the mother, is of itself a rea.s.suring sign, indicating, as a rule, that the condition is not one of grave danger or extreme severity. When the child is more seriously ill, opposition almost always disappears, and the child lies before us limp and pa.s.sive. Only with approaching recovery or convalescence does his spirit return and renewed opposition show itself.

Extreme nervousness in childhood carries with it a certain liability towards what is known as "delicacy of const.i.tution." The sensitiveness of the children is so great that they react with striking symptoms to disturbances so trivial that they would hardly incommode the child of more stable nervous const.i.tution. For example, a simple cold in the head, or a sore throat, may cause a convulsion or a condition of nervous irritability which may even arouse the suspicion that meningitis is present. Or, again, a little pharyngeal irritation which would ordinarily be incapable of disturbing sleep may be sufficient to keep the child wide awake all night with persistent and violent coughing. The little irritating papules of nettlerash from which many children suffer are commonly disregarded by busy, happy children during the day, and even at night hardly suffice to cause disturbance.

The nervous child, on the other hand, will scratch them again and again till they bleed, tearing at them with his nails, and making deep and painful sores.

The temperature is commonly unstable and readily elevated. Moreover, feverishness from whatever cause is often accompanied by an active delirium, which is apt to occasion unnecessary alarm. This symptom of delirium is always a manifestation of an excitable temperament. I remember being called to see a young woman who was thought to be suffering from acute mania. Examination showed that she was suffering from pneumonia in the early stages. It was only later that we discovered that she had always been of an unstable nervous temperament, and had been in an asylum some years before. Those of us who are fortunate in possessing a placid temperament and have developed a high degree of self-control are not likely to show delirium as a prominent symptom should we fall ill with fever; just as we should not struggle and scream too violently when we "come round"

from having gas at the dentist's. Looked at from this point of view, it is natural for all children to become delirious readily, and this tendency is peculiarly marked in those who are unduly nervous.

As a consequence of this extreme sensitiveness, the nervous child is likely to suffer more than others from a succession of comparatively trifling ailments and disturbances. The delicacy of the child has, in this sense, a real existence, and is not confined to the imagination of over-anxious and apprehensive parents. No doubt the nervous mother of an only child does worry unnecessarily, and is far too p.r.o.ne to feed her fears by the daily use of the thermometer or the weighing-machine; but her friends who are happy in the possession of numerous and placid children are not justified in laying the whole blame upon her too great solicitude. Children who are members of large families, whose nervous systems have been strengthened by contact with their brothers and sisters, are not habitually upset by trifles, and suffer even serious illnesses with symptoms of less severity. Nervous children, and only children, on the other hand, show the opposite extreme. Nevertheless, the mother of a nervous and delicate child--a child, that is to say, who, even if he is not permanently an invalid, nevertheless never seems quite well and lacks the robustness of other children--should realise clearly how much of this sensitiveness is due to the atmosphere of unrest and too great solicitude which surrounds him. It is a matter of universal experience that excess of care for only children has a depressing influence which affects their character, their physical const.i.tution, and their entire vitality. At all costs we must hide our own anxieties from the child, and we must treat his illnesses in as matter-of-fact a way as possible.

When illness comes, his daily routine should be interrupted as little as possible. In dealing with nervous children, it is often better to lay aside treatment altogether rather than to carry out a variety of therapeutic procedures which have the effect of concentrating the child's mind upon his symptoms. When we grown-up people are sick, we often find a great deal of comfort in submitting ourselves to some form of treatment. We have great faith, we say, in this remedy or in that. It is _our_ remedy, a _nostrum_. The physician knows well that the opportunities which are presented to him of intervening effectually to cut short the processes of disease by the use of specific cures are not very numerous, and that often enough the justification for his prescription is the soothing effect which it may exercise upon the mind of the patient, who, believing either in the physician or in his remedy, finds confidence and patience till recovery ensues. As a rule this form of consolation is denied to little children. They have no belief in the efficacy of the remedies which are applied with such vigour and persistence. Indeed, it is not the child, but his anxious mother, who finds comfort in the thought that everything possible has been done. Therefore, a prescription must be written and changed almost daily, the child's chest must be anointed with oil, and the air of the sick-room made heavy with some aromatic substance for inhalation, and all this when the disturbance is of itself unimportant, and owes its severity only to the undue sensitiveness of the child's nervous system.

The very name of illness should be banished from such nurseries.

Everything should be done to rea.s.sure the child and to make light of his symptoms, and we can keep the most scrupulous watch over his health without allowing him to perceive at all that our eye is on him.

With older children the evil results of suggestions, unconsciously conveyed to them by the apprehension of their parents, become very obvious. The visit of the doctor, to whom in the child's hearing all the symptoms are related, is often followed by an aggravation which is apt to be attributed to his well-meant prescription. The harm done by examinations, which are specially calculated to appeal to the child's imagination, as, for instance, an X-ray examination, is often clearly apparent. I remember a schoolboy of thirteen who was sent to me because he had constantly complained of severe abdominal pain. He was a nervous child with a habit spasm, the son of a highly neurotic father and an overanxious mother. An X-ray examination was made, but showed nothing amiss. The child's interest and preoccupation in the examination was painfully obvious. That night his restraint broke down altogether, and he screamed with pain, declaring that it had become insupportable. Younger children, less imaginative but equally perverse, noticing how anxiously their mothers view their symptoms, will often make complaint merely to attract attention and to excite expressions of pity or condolence. Sometimes they will enforce their will by an appeal to their symptoms. I have had a little patient of no more than thirteen months of age who suffered severely and for a long time from eczema, and who in this way used his affliction to ensure that he got his own way. If he was not given what he wanted immediately he would fall to scratching, with an expression upon his face which could not be mistaken. To him, poor child, the grown-up people around seemed possessed of but one desire--to stop his scratching; and he had learnt that if he showed himself determined to scratch they would give way on every other point.

The ill-effects of departing too readily from ordinary nursery routine on account of a little illness, and of adopting straightway a variety of measures of treatment, is well shown in cases of asthma in children. The asthmatic child is almost always of a highly nervous temperament, and often pa.s.sionate and ungovernable. Often the most effective treatment of an attack, which usually comes on some hours after going to bed, is to make little of it, to talk naturally and calmly to the child, to turn on the light, and to allow him, if he will, to busy himself with toys or books. To be seized with panic, to send post-haste for the doctor, to carry the patient to the open window, to burn strong-smelling vapours, and so forth, not only is apt to prolong the nervous spasm on this occasion, but makes it likely that a strong impression will be left in his mind which by auto-suggestion will provoke another attack shortly. With nervous children a seeming neglect is the best treatment of all trivial disorders. Meanwhile we can redouble our efforts to remedy defects in management, and to obtain an environment which will gradually lower the heightened nervous irritability.

When the illness is of a more serious nature, as has been said, the restlessness as a rule promptly disappears. In each case it must be decided whether it is best for the child to be nursed by his mother and his own nurse, or by a sick-nurse. In the latter event the ordinary nurse and the mother should absent themselves from the sick-room as much as possible. Often the firm routine of the hospital nurse is all that is wanted to obtain rest. Less often, the child will be quiet with his own nurse, and quite unmanageable with a stranger.

There is, however, another side to the question. The relation of neurosis in childhood to infection of the body is complex. I have said that with the nervous child a trivial infection may produce symptoms disproportionately severe. Persistent and serious infection, however, is capable of producing nervous symptoms even in children who were not before nervous, and we must recognise that prolonged infection makes a favourable soil for neuroses of all sorts. The frequency with which St. Vitus's dance accompanies rheumatism in childhood forms a good example of this tendency. The child who, from time to time, complains of the transient joint pains which are called "growing pains," and who is found by the doctor to be suffering from subacute rheumatism, is commonly restless, fretful, and nervous. Appet.i.te, memory, and the power of sustained attention become impaired. Often there is excessive emotional display, with, perhaps, unexplained bursts of weeping. The child is readily frightened, and when sooner or later the restless, jerky movements of St. Vitus's dance appear, the usual explanation is that some shock has been experienced, that the child has seen a street accident, has been alarmed by a big dog jumping on her, or by a man who followed her--shocks which would have been incapable of causing disturbance, and which would have pa.s.sed almost unappreciated had not the soil been prepared by the persistent rheumatic infection.

The management of the nervous child whose physical health remains comparatively good is difficult enough, but these difficulties are increased many times when the physical health seriously fails. To steer a steady course which shall avoid neglecting what is dangerous if neglected, and overemphasising what is dangerous if over-emphasised, calls for a great deal of wisdom on the part both of the mother and her doctor.

CHAPTER XIII

NERVOUS CHILDREN AND EDUCATION ON s.e.xUAL MATTERS

In this chapter I approach with diffidence a subject which is rightly enough occupying a great deal of attention at the present time: the instruction of our children in the nature, meaning, and purpose of s.e.xual processes. It is a subject filled with difficulties. Every parent would wish to avoid offending the sense of modesty which is the possession of every well-trained child, and finds it difficult to escape the feeling that discussion on such matters may do more harm than good. There is certainly some risk at the present time that, putting reticence on one side, we may be carried too far in the opposite direction. The evils which result from keeping children in ignorance are well appreciated. We have yet to determine the effect upon them of the very frank and free exposure of the subject which is recommended by many modern writers. Nevertheless, it must be granted that it is not right to allow the boy or girl to approach adolescence without some knowledge of s.e.x and the processes of reproduction. If nothing is said on such subjects, which in the nature of things are bound to excite a lively interest and curiosity in the minds of older children, evil results are apt to follow. Because parents have never mentioned these subjects to their child, they must not conclude that he is ignorant of all knowledge concerning them. It is not unlikely that the question has often occupied his thoughts, and that his speculations have led him to conclusions which are, on the whole, true, although perhaps incorrect in matters of detail. Most children, unable to ask their mother or father direct questions upon matters which they feel instinctively are taboo, have pieced together, from their reading and observation, a faulty theory of s.e.xual life. The pursuit of such knowledge, in secret, is not a healthy occupation for the child. His parents' silence has given him the feeling that the unexplored land is forbidden ground. In satisfying his curiosity he is most certainly fulfilling an uncontrollable impulse, but he has been forced to be secretive, and to look upon the information he has acquired as a guilty secret. So far even the best of children will go upon, the dangerous path. If training has been good, and if the child has responded well to it, he will go no further. Though he can hardly be expected to refrain from constructing theories and from testing them in the light of any chance information which may come his way, he will instinctively feel that the subject is one best left alone. He will not talk of it with other boys--not even with those who are older than himself and whose superior knowledge in all other matters he is accustomed to respect. We need not be surprised, however, that the majority of children do not attain to this high standard of conduct, and that the interest and excitement of exploring the unknown and the forbidden proves too great. Children will consult with each other about such matters, and knowledge of evil may spread rapidly from the older to the younger. In some schools, as is well known, there may grow up with deplorable facility an unhealthy interest in s.e.xual matters. On the surface of school life all may seem fair enough, but beneath, hidden from all recognised authority, lies much that is unspeakable. If the boy has not been taught to have clean thoughts upon matters which are essentially clean, if he has not learned to know evil that he may avoid it, he may not escape great harm. The fault in us which kept him in ignorance will recoil upon our own heads. He will maintain the barrier which was erected in the first place by our own unhappy reticence, and we may find it a hard task to penetrate behind it and prevent his constant return to secret thoughts and imaginings or secret habits and practices. Certain physiological processes come to have for him an unclean flavour which is yet perniciously attractive. He knows little of the real meaning of s.e.xual processes or of the great purpose for which they are designed. It is only that an unhealthy interest becomes attached to all subjects which are scrupulously avoided in general conversation. In secret he develops a wrong att.i.tude to all these matters.