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 reassuring 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 pronounced opposition of
the child to himself, to the nurse, and even to the mother, is of
itself a reassuring 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 passive. 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 constitution." 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 constitution. 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 prone 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 constitution, 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 reassure 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 passionate 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. Appetite, 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 passed 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.