The above-mentioned symptoms have very- different diagnostic values; the presence of one alone proves absolutely nothing. It must be remembered also that many of them may have an organic cause— as for example, increase in the reflexes; abnormal increase of the blood pressure (inflammation of the kidneys); inequality of the pupils (en largement of the bronchial and mediastinal glands stimulating the dilator fibres in the sympathetic nerve); tremor and the like. Others, such as stammering, may represent an independent disease; others again, such as Rosenbach's symptom, tremor of the hands, among others, are extremely elusive, they are indications of uneasiness and excitement rather than signs of the neuropatlaie constitution and for that reason observed only at the first examination, after which the child ceases to be afraid of the doctor. It should also be stated that the facial phenomenon (Frankl-Hochwart and others), which is often included among the symptoms of neurasthenia is, in our opinion, to be regarded not as a general nervous symptom but as a characteristic sign of latent spasmophilia (Thiemich) (compare page 317).
The paroxysmal somatic manifestations of infantile neurasthenia are many and various. Often they show themselves only under special circumstances, such as the presence of some acute general disease, because the normal power of inhibition is absent and certain symptoms on that account assume alarming dimensions and exhibit an abnormal degree of severity. These are seen in diseases of the respiratory organs which are accompanied by cough. Where a child with sound nerves would merely have an ordinary cough, a nervous child will develop convulsive cough of alarming severity, with cyanosis, choking and vomiting. There is no doubt that cases of this kind are often mistaken for whooping-cough, even by physicians. Vomiting is a neuropathic symptom, produced in many children by any kind of excitement—for instance, when they are awakened in the morning to go to school, or during the walk to school, or as soon as they have entered the class room. Constipation also occurs in children as in adult " hypochondriacs," although diarrluma, or even incontinence of feces, is more frequent as the result of worry or excitement. These, however, are graver forms of the disease. Loss of appetite is a frequent symptom.
Diurnal and nocturnal enuresis and pollakiuria, which are usually due to a general neuropathic constitution, have been sufficiently dis cussed in the chapter on Hysteria (see page 373). In this connection mention should also be made of the inability to urinate in the presence of other persons—even near relatives, which is observed in many children.
Palpitation and arrhythymia are also symptoms of neurasthenia. The neuropathic sYmptoms referable to the nervous system, such as vertigo on looking clown front a great height or riding backwards in a carriage, or under other similar circumstances, sudden syncope fron1 fright, fatigue and like causes, occupy an intermediate position between the somatic and the purely psychic phenomena. Mention must also
be made of nerrous headache, which is one of the most frequent somatic symptoms in neuropathic children. As a rule it does not appear until the child is old enough to go to school, and of all the neuropathie symp toms is probably the one that is the most frequently attributable to the stress of school work. Forced attention, not the result of spon taneous interest in the subject under discussion, a restless anxiety as to how the lessons will turn out, or positive fear when the lesson has not been properly prepared or understood; in short, the whole array of school worries, which adults often smile at 80 inconsiderately, may produce headache. Other things that contribute to the headache are the enforced immobility for several hours and the vitiated and over heated air which accumulates in an ill-ventilated class-room by the end of the hour, particularly as these children are usually pale and flabby and habitually stiffer from cold hands and feet, or, in other words, from improper distribution of the blood. Hence we arc often told, and we have no reason to disbelieve the statement, that the headache readily disap pears during the holidays and returns a week or two after school begins.
The headache may be present in the morning, but usually does not develop until after several hours of lessons, sometimes earlier some times later, disappearing gradually during the noonday meal or per sisting until the child goes to bed. It does not, as a rule, appear to be very severe; the child rarely wants to lie down unless accustomed to do so by the anxious mother. It is usually described as a dull headache, chiefly frontal; the variety described as affecting the entire skull like an ill-fitting helmet (casque neurasthenique, Charcot) seems to be rare in children. The scalp is often sensitive, sometimes so much so that combing the hair causes intense pain and is given up on that, account. Although this "school headache" which we have just described is usually neurasthenic, there are also many; cases in which it proves to be an hysterical imitation. Thus as a school inspector I would find that in some classes of girls a third or more of the children, usually between the ages of 10 to 14, when questioned, would answer that they had headache; whereas, in another class of -10 to 50 girls of the same age, only a few complained of headache. The oftener the question is asked during the year in the same class, the greater will be found the number of children complaining of headache. When large numbers of these children are treated by suggestion, giving them daily a few drops of bitter tincture, or compound tincture of cinchona, or a short douche to the forehead, a rapid and permanent cure is effected in a great many eases (Herrmann). Such eases are hysterical, whereas the same treat ment is without effect in neurasthenic children.