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 anæmia 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]