Читать книгу The Nervous Child - Hector Charles Cameron - Страница 5

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There is an old fairy story concerning a pea which a princess once slept upon—a little offending pea, a minute disturbance, a trifling departure from the normal which grew to the proportions of intolerable suffering because of the too sensitive and undisciplined nervous system of Her Royal Highness. The story, I think, does not tell us much else concerning the princess. It does not tell us, for instance, if she was an only child, the sole preoccupation of her parents and nurses, surrounded by the most anxious care, reared with some difficulty because of her extraordinary "delicacy," suffering from a variety of illnesses which somehow always seemed to puzzle the doctors, though some of the symptoms—the vomiting, for example, and the high temperature—were very severe and persistent. Nor does it tell us if later in life, but before the suffering from the pea arose, she had been taken to consult two famous doctors, one of whom had removed the vermiform appendix, while the other a little later had performed an operation for "adhesions." At any rate, the story with these later additions, which are at least in keeping with what we know of her history, would serve to indicate the importance which attaches to the early training of childhood. Among the children even of the well-to-do often enough the hygiene of the mind is overlooked, and faulty management produces restlessness, instability, and hyper-sensitiveness, which pass insensibly into neuropathy in adult life.

To prevent so distressing a result is our aim in the training of children. No doubt the matter concerns in the first place parents and nurses, school masters and mistresses, as well as medical men. Yet because of the certainty that physical disturbances of one sort or another will follow upon nervous unrest, it will seldom happen that medical advice will not be sought sooner or later; and if the physician is to intervene with success, he must be prepared with knowledge of many sorts. He must be prepared to make a thorough and complete physical examination, sufficient to exclude the presence of organic disease. If no organic disease is found, he must explore the whole environment of the child, and seek to determine whether the exciting cause is to be found in the reaction of the child to some form of faulty management.

For example, a child of two or three years of age may be brought to the doctor with the complaint that defæcation is painful, and that there has existed for some time a most distressing constipation which has resisted a large number of purgatives of increasing strength. Whenever the child is placed upon the stool, his crying at once begins, and no attempts to soothe or console him have been successful. It is not sufficient for the doctor in such a case to make an examination which convinces him that there is no fissure at the anus and no fistula or thrombosed pile, and to confine himself to saying that he can find nothing the matter. The crying and refusal to go to stool will continue after the visit as before, and the mother will be apt to conclude that her doctor, though she has the greatest confidence in him for the ailments of grown-up persons, is unskilled in, or at least not interested in, the diseases of little children. If, on the other hand, the doctor pursues his inquiries into the management of the child in the home, and if, for example, he finds that the crying and resistance is not confined to going to stool, but also takes place when the child is put to bed, and very often at meal-times as well, then it will be safe for him to conclude that all the symptoms are due to the same cause—a sort of "negativism" which is apt to appear in all children who are directed and urged too much, and whose parents are not careful to hide from them the anxiety and distress which their conduct occasions.

If this diagnosis is made, then a full and clear explanation should be given to the mother, or at any rate to such mothers—and fortunately they are in the majority—who are capable of appreciating the point of psychology involved, and of correcting the management of the child so as to overcome the negativism. To attempt treatment by prescribing drugs, or in any other way than by correcting the faulty management, is to court failure. As Charcot has said, in functional disorders it is not so much the prescription which matters as the prescriber.

But the task of the doctor is often one of even greater difficulty. Often enough there will be a combination of organic disturbance with functional trouble. For example, a girl of eighteen years old suffered from a pain in the left arm which has persisted on and off since the olecranon had been fractured when she was two years of age. She was the youngest of a large family, and had never been separated for a day from the care and apprehensions of her mother. The joint was stiff, and there was considerable deformity. The pain always increased when she was tired or unhappy. Again, a girl had some slight cystitis with frequent micturition, and this passed by slow degrees into a purely functional irritability of the bladder, which called for micturition at frequent intervals both by day and night. In such cases treatment must endeavour to control both factors—the local organic disturbance must if possible be removed, and the faults of management corrected.

It is a good physician who can appreciate and estimate accurately the temperament of his patient, and the need for this insight is nowhere greater than in dealing with the disorders of childhood. It can be acquired only by long practice and familiarity with children. In the hospital wards we shall learn much that is essential, but we shall not learn this. The child, who is so sensitive to his environment, shows but little that is characteristic when admitted to an institution. Only in the nursery can we learn to estimate the influences which proceed from parents and nurses of different characters and temperaments, and the reaction which is produced by them in the child.

The body of the child is moulded and shaped by the environment in which it grows. Pure air, a rational diet, free movement, give strength and symmetry to every part. Faults of hygiene debase the type, although the type is determined by heredity which in the individual is beyond our control. Mothers and nurses to-day are well aware of the need for a rational hygiene. Mother-craft is studied zealously and with success, and there is no lack of books to give sound guidance and to show the mean between the dangerous extremes of coddling and a too Spartan exposure. Yet sometimes it has seemed as if some mothers whose care for their children's physical health is most painstaking, who have nothing to learn on the question of diet, of exercise, of fresh air, or of baths, who measure and weigh and record with great minuteness, have had their attention so wholly occupied with the care of the body that they do not appreciate the simultaneous growth of the mind, or inquire after its welfare. Yet it is the astounding rapidity with which the mental processes develop that forms the distinguishing characteristic of the infancy of man. Were it not for this rapid growth of the cerebral functions, the rearing of children would be a matter almost as simple and uneventful as the rearing of live stock. For most animals faults of environment must be very pronounced to do harm by producing mental unrest and irritability. Thus, indeed, some wild animal separated from its fellows and kept in solitary captivity may sicken and waste, though maintained and fed with every care. Yet if the whole conditions of life for the animal are not profoundly altered, if the environment is natural or approximately natural, it is as a rule necessary to care only for its physical needs, and we need not fear that the results will be spoiled by the reaction of the mind upon the body. But with the child it is different; airy nurseries, big gardens, visits to the seaside, and every advantage that money can buy cannot achieve success if the child's mind is not at rest, if his sleep is broken, if food is habitually refused or vomited, or if to leave him alone in the nursery for a moment is to evoke a fit of passionate crying.

The grown-up person comes eventually to be able to control this tremendous organ, this brain, which is the predominant feature of his race. In the child its functions are always unstable and liable to be upset. Evidence of mental unrest or fatigue, which is only rarely met with in grown persons and which then betokens serious disturbance of the mind, is of comparatively common occurrence in little children. Habit spasm, bed-wetting, sleep-walking, night terrors, and convulsions are symptoms which are frequent enough in children, and there is no need to be unduly alarmed at their occurrence. In adult age they are found only among persons who must be considered as neuropathic. To make the point clear, I have chosen examples from the graver and more serious symptoms of nervous unrest. But it is equally true that minor symptoms which in adults are universally recognised to be dependent upon cerebral unrest or fatigue are of everyday occurrence in childhood. Broken and disturbed sleep, absence of appetite and persistent refusal of food, gastric pain and discomfort after meals, nervous vomiting, morbid flushing and blushing, headache, irritability and excessive emotional display, at whatever age they occur, are indications of a mind that is not at rest. In children, as in adults, they may be prominent although the physical surroundings of the patient may be all that could be desired and all that wealth can procure. It is an everyday experience that business worries and responsibilities in men, domestic anxieties or childlessness in women, have the power to ruin health, even in those who habitually or grossly break none of its laws. The unstable mind of the child is so sensitive that cerebral fatigue and irritability are produced by causes which seem to us extraordinarily trivial. In the little life which the child leads, a life in which the whole seems to us to be comprised in dressing and undressing, washing, walking, eating, sleeping, and playing, it is not easy to detect where the elements of nervous overstrain lie. Nor is it as a rule in these things that the mischief is to be found. It is in the personality of mother or nurse, in her conduct to the child, in her actions and words, in the tone of her voice when she addresses him, even in the thoughts which pass through her mind and which show themselves plainly to that marvellously acute intuition of his, which divines what she has not spoken, that we must seek for the disturbing element. The mental environment of the child is created by the mother or the nurse. That is her responsibility and her opportunity. The conduct of the child must be the criterion of her success. If things go wrong, if there is constant crying or ungovernable temper, if sleep and food are persistently refused, or if there is undue timidity and tearfulness, there is danger that seeds may be sown from which nervous disorders will spring in the future.

There are many women who, without any deep thought on the matter, have the inborn knack of managing children, who seem to understand them, and have a feeling for them. With them, we say, the children are always good, and they are good because the element of nervous overstrain has not arisen. There are other women, often very fond of children, who are conspicuously lacking in this power. Contact with one of these well-meaning persons, even for a few days, will demoralise a whole nursery. Tempers grow wild and unruly, sleep disappears, fretfulness and irritability take its place. Yet of most mothers it is probably true that they are neither strikingly proficient nor utterly deficient in the power of managing children. If they lack the gift that comes naturally to some women, they learn from experience and grow instinctively to feel when they have made a false step with the child. Although by dearly bought experience they learn wisdom in the management of their children, they nevertheless may not study the subject with the same care which they devote to matters of diet and hygiene. It is the mother whose education and understanding best fits her for this task. In this country a separate nursery and a separate nursery life for the children is found in nearly all households among the well-to-do, and the care for the physical needs of the children is largely taken off the mothers' shoulders by nurses and nursemaids. That this arrangement is advantageous on the whole cannot be doubted. In America and on the Continent, where the children often mingle all day in the general life of the household, and occupy the ordinary living rooms, experience shows that nerve strain and its attendant evils are more common than with us. Nevertheless, the arrangement of a separate nursery has its disadvantages. Nurses are sometimes not sufficiently educated to have much appreciation of the mental processes of the child. If the children are restless and nervous they are content to attribute this to naughtiness or to constipation, or to some other physical ailment. Their time is usually so fully occupied that they cannot be expected to be very zealous in reading books on the management of children. Nevertheless, in practical matters of detail a good nurse will learn rapidly from a mother who has given some attention to the subject, and who is able to give explicit instructions upon definite points.

It is right that mothers should appreciate the important part which the environment plays in all the mental processes of children, and in their physical condition as well; that they should understand that good temper and happiness mean a proper environment, and that constant crying and fretfulness, broken sleep, refusal of food, vomiting, undue thinness, and extreme timidity often indicate that something in this direction is at fault.

Nevertheless, we must be careful not to overstate our case. We must remember how great is the diversity of temperament in children—a diversity which is produced purely by hereditary factors. The task of all mothers is by no means of equal difficulty. There are children in whom quite gross faults in training produce but little permanent damage; there are others of so sensitive a nervous organisation that their environment requires the most delicate adjustment, and when matters have gone wrong, it may be very difficult to restore health of mind and body. When a peculiarly nervous temperament is inherited, wisdom in the management of the child is essential, and may sometimes achieve the happiest results. Heredity is so powerful a factor in the development of the nervous organisation of the child that, realising its importance, we should be sparing in our criticism of the results which the mothers who consult us achieve in the training of their children. A sensitive, nervous organisation is often the mark of intellectual possibilities above the average, and the children who are cast outside the ordinary mould, who are the most wayward, the most intractable, who react to trifling faults of management with the most striking symptoms of disturbance, are often those with the greatest potentialities for achievement and for good. It is natural for the mother of placid, contented, and perhaps rather unenterprising children, looking on as a detached outsider, seeing nothing of the teeming activities of the quick, restless little brain, and the persistent, though faulty reasoning—it is natural for her to blame another's work, and to flatter herself that her own routine would have avoided all these troublesome complications. The mother of the nervous child may often rightly take comfort in the thought that her child is worth the extra trouble and the extra care which he demands, because he is sent into the world with mechanism which, just because it is more powerful than the common run, is more difficult to master and takes longer to control and to apply for useful ends.

It is through the mother, and by means of her alone, that the doctor can influence the conduct of the child. Without her co-operation, or if she fails to appreciate the whole situation, with the best will in the world, we are powerless to help. Fortunately with the majority of educated mothers there is no difficulty. Their powers of observation in all matters concerning their children are usually very great. It is their interpretation of what they have observed that is often faulty. Thus, in the example given above, the mother observes correctly that defæcation is inhibited, and produces crying and resistance. It is her interpretation that the cause is to be found in pain that is at fault. Again, a mother may bring her infant for tongue-tie. She has observed correctly that the child is unable to sustain the suction necessary for efficient lactation, and has hit upon this fanciful and traditional explanation. The doctor, who knows that the tongue takes no part in the act of sucking, will probably be able to demonstrate that the failure to suck is due to nasal obstruction, and that the child is forced to let go the nipple because respiration is impeded. The opportunities for close observation of the child which mothers enjoy are so great that we shall not often be justified in disregarding their statements. But if we are able to give the true explanation of the symptoms, it will seldom happen that the mother will fail to be convinced, because the explanation, if true, will fit accurately with all that has been observed. Thus the mother of the child in whom defæcation is inhibited by negativism may have made further observations. For example, she may have noted that the so-called constipation causes fretfulness, that it is almost always benefited by a visit to the country or seaside, or that it has become much worse since a new nurse, who is much distressed by it, has taken over the management of the child. To this mother the explanation must be extended to fit these observations, of the accuracy of which there need be no doubt. Fretfulness and negativism with all children whose management is at fault come in waves and cycles. The child, naughty and almost unmanageable one week, may behave as a model of propriety the next. The negativism and refusal to go to stool are the outcome of the nervous unrest, not its cause. Again, the nervous child, like the adult neuropath, very often improves for the time being with every change of scene and surroundings. It is the ennui and monotony of daily existence, in contact with the same restricted circle, that becomes insupportable and brings into prominence the lack of moral discipline, the fretfulness, and spirit of opposition. Lastly, the conduct of the nervous child is determined to a great extent by suggestions derived from the grown-up people around him. Refusal of food, refusal of sleep, refusal to go to stool, as we shall see later, only become frequent or habitual when the child's conduct visibly distresses the nurse or mother, and when the child fully appreciates the stir which he is creating. The mother will readily understand that in such a case, where constipation varies in degree according as different persons take charge of the child, the explanation offered is that which alone fits with the observed facts. A full and free discussion between mother and doctor, repeated it may be more than once, may be necessary before the truth is arrived at, and a line of action decided upon. Only so can the doctor, remote as he is from the environment of the child, intervene to mould its nature and shape its conduct.

If the doctor is to fit himself to give advice of this sort, he must be a close observer of little children. He must not consider it beneath his dignity to study nursery life and nursery ways. There he will find the very beginnings of things, the growing point, as it were, of all neuropathy. A man of fifty, who in many other ways showed evidence of a highly nervous temperament, had especially one well-marked phobia, the fear of falling downstairs. It had never been absent all his life, and he had grown used to making the descent of the stairs clinging firmly to the stair-rail. Family tradition assigned this infirmity to a fall downstairs in early childhood. But all children fall downstairs and are none the worse. The persistence of the fear was due, I make no doubt, to the attitude of the parents or nurse, who made much of the accident, impressed the occasion strongly on the child's memory, and surrounded him thereafter with precautions which sapped his confidence and fanned his fears.

In what follows we will consider first the subject of nursery management, searching in it for the origin of the common disorders of conduct both of childhood and of later life. I have grouped these nursery observations under the heads of four characteristic features of the child's psychology—his Imitativeness, his Suggestibility, his Love of Power, and his acute though limited Reasoning Faculties. I feel that some such brief examination is necessary if we are to understand correctly the ætiology of some of the most troublesome disorders of childhood, such as enuresis, anorexia, dyspepsia, or constipation, disorders in which the nervous element is perhaps to-day not sufficiently emphasised. Finally, we can evolve a kind of nursery psycho-therapeutics—a subject which is not only of fascinating interest in itself, but which repays consideration by the success which it brings to our efforts to cure and control.