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Assistant Physician and Physician-in-Charge of Department for Diseases of Children, Guy's Hospital, London; Author of "Diet and Disease in Infancy."

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-contol 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 realize 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 solemn-faced 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 13 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 over-anxious 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

restrain 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 recognize that prolonged infection makes a favourable soil for neuroses of all sorts. The frequency with which St. Vitus' 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' 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 over-emphasizing what is dangerous if over-emphasized, calls for a great deal of wisdom on the part both of the mother and her doctor.

23, Devonshire Place,


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