














THE NERVOUS CHILD




PUBLISHED BY THE JOINT COMMITTEE OF
HENRY FROWDE, HODDER & STOUGHTON
17 WARWICK SQUARE, LONDON, E.C. 4




THE

NERVOUS CHILD


BY

HECTOR CHARLES CAMERON
M.A., M.D.(CANTAB.), F.R.C.P.(LOND.)
PHYSICIAN TO GUY'S HOSPITAL AND PHYSICIAN IN CHARGE OF
THE CHILDREN'S DEPARTMENT, GUY'S HOSPITAL


     "RESPECT the child. Be not too much his parent. Trespass not on
     his solitude."--EMERSON.


LONDON
HENRY FROWDE HODDER & STOUGHTON
OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C.
1920




_First Edition_ 1919
_Second Impression_ 1930




PRINTED IN GREAT BRITAIN
BY MORRISON & GIBB LTD., EDINBURGH




PREFACE


To-day on all sides we hear of the extreme importance of Preventive
Medicine and the great future which lies before us in this aspect of
our work. If so, it follows that the study of infancy and childhood
must rise into corresponding prominence. More and more a considerable
part of the Profession must busy itself in nurseries and in schools,
seeking to apply there the teachings of Psychology, Physiology,
Heredity, and Hygiene. To work of this kind, in some of its aspects,
this book may serve as an introduction. It deals with the influences
which mould the mentality of the child and shape his conduct. Extreme
susceptibility to these influences is the mark of the nervous child.

I have to thank the Editors of _The Practitioner_ and of _The Child_,
respectively, for permission to reprint the chapters which deal with
"Enuresis" and "The Nervous Child in Sickness." To Dr. F.H. Dodd I
should also like to offer thanks for helpful suggestions.

H.C.C.

_March_ 1919.




CONTENTS

CHAP.                                                  PAGE

   I. DOCTORS, MOTHERS, AND CHILDREN                      1

  II. OBSERVATIONS IN THE NURSERY                        16

 III. WANT OF APPETITE AND INDIGESTION                   50

  IV. WANT OF SLEEP                                      64

   V. SOME OTHER SIGNS OF NERVOUSNESS                    73

  VI. ENURESIS                                           89

 VII. TOYS, BOOKS, AND AMUSEMENTS                        96

VIII. NERVOUSNESS IN EARLY INFANCY                      104

  IX. MANAGEMENT IN LATER CHILDHOOD                     117

   X. NERVOUSNESS IN OLDER CHILDREN                     131

  XI. NERVOUSNESS AND PHYSIQUE                          145

 XII. THE NERVOUS CHILD IN SICKNESS                     160

XIII. NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS  169

 XIV. THE NERVOUS CHILD AND SCHOOL                      182

      INDEX                                             191




THE NERVOUS CHILD

CHAPTER I

DOCTORS, MOTHERS, AND CHILDREN


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.




CHAPTER II

OBSERVATIONS IN THE NURSERY


_(a)_ THE IMITATIVENESS OF THE CHILD

It is in the second and third years of the child's life that the
rapidity of the development of the mental processes is most apparent,
and it is with that age that we may begin a closer examination. At
first sight it might seem more reasonable to adopt a strictly
chronological order, and to start with the infant from the day of his
birth. Since, however, we can only interpret the mind of the child by
our knowledge of our own mental processes, the study of the older
child and of the later stages is in reality the simpler task. The
younger the infant, the greater the difficulties become, so that our
task is not so much to trace the development of a process from simple
and early forms to those which are later and more complex, as to
follow a track which is comparatively plain in later childhood, but
grows faint as the beginnings of life are approached.

At the age, then, of two or three the first quality of the child which
may arrest our attention is his extreme imitativeness. Not that the
imitation on his part is in any way conscious; but like a mirror he
reflects in every action and in every word all that he sees and hears
going on around him. We must recognise that in these early days his
words and actions are not an independent growth, with roots in his own
consciousness, but are often only the reflection of the words and
actions of others. How completely speech is imitative is shown by the
readiness with which a child contracts the local accent of his
birthplace. The London parents awake with horror to find their baby an
indubitable Cockney; the speech of the child bred beyond the Tweed
proclaims him a veritable Scot. Again, some people are apt to adopt a
somewhat peremptory tone in addressing little children. Often they do
not trouble to give to their voices that polite or deferential
inflection which they habitually use when speaking to older people.
Listen to a party of nurses in the Park addressing their charges. As
if they knew that their commands have small chance of being obeyed,
they shout them with incisive force. "Come along at once when I tell
you," they say. And the child faithfully reflects it all back, and is
heard ordering his little sister about like a drill sergeant, or
curtly bidding his grandmother change her seat to suit his pleasure.
If we are to have pretty phrases and tones of voice, mothers must see
to it that the child habitually hears no other. Again, mothers will
complain that their child is deaf, or, at any rate, that he has the
bad habit of responding to all remarks addressed to him by saying,
"What?" or, worse still, "Eh?" Often enough the reason that he does so
is not that the child is deaf, nor that he is particularly slow to
understand, but simply that he himself speaks so indistinctly that no
matter what he says to the grown-up people around him, they bend over
him and themselves utter the objectionable word.

We all hate the tell-tale child, and when a boy comes in from his walk
and has much to say of the wicked behaviour of his little sister on
the afternoon's outing, his mother is apt to see in this a most horrid
tendency towards tale-bearing and currying of favour. She does not
realise that day by day, when the children have come in from their
walk, she has asked nurse in their hearing if they have been good
children; and when, as often happens, they have not, the nurse has
duly recounted their shortcomings, with the laudable notion of putting
them to shame, and of emphasising to them the wickedness of their
backsliding--and this son of hers is no hypocrite, but speaks only, as
all children speak, in faithful reproduction of all that he hears.
Those grown-up persons who are in charge of the children must realise
that the child's vocabulary is their vocabulary, not his own. It is
unfortunate, but I think not unavoidable, that so often almost the
earliest words that the infant learns to speak are words of reproof,
or chiding, or repression. The baby scolds himself with gusto,
uttering reproof in the very tone of his elders: "No, no," "Naughty,"
or "Dirty," or "Baby shocked."

Speech, then, is imitative from the first, if we except the early baby
sounds with reduplication of consonants to which in course of time
definite meaning becomes attached, as "Ba-ba," "Ma-ma," "Na-na,"
"Ta-ta," and so forth. Action only becomes imitative at a somewhat
later stage. The first purposive movements of the child's limbs are
carried out in order to evoke tactile sensations. He delights to
stimulate and develop the sense of touch. At first he has no knowledge
of distance, and his reach exceeds his grasp. He will strain to touch
and hold distant objects. Gradually he learns the limitations of
space, and will pick up and hold an object in his hand with precision.
Often he conveys everything to his mouth, not because his teeth are
worrying him, or because he is hungry, as we hear sometimes alleged,
but because his mouth, lips, and tongue are more sensitive, because
more plentifully furnished with the nerves of tactile sensation. By
constant practice the sense of touch and the precision of the movement
of his hands are slowly developed, and not these alone, for the child
in acquiring these powers has developed also the centres in the brain
which control the voluntary movements. When the child can walk he
continues these grasping and touching exercises in a wider sphere. As
the child of fifteen or eighteen months moves about the room, no
object within his reach is passed by. He stretches out his hand to
touch and seize upon everything, and to experience the joy of
imparting motion to it. The impulse to develop tactile sensation and
precision in the movements of his hands compels him with irresistible
force. It is foolish to attempt to repress it. It is foolish, because
it is a necessary phase in his development, and moreover a passing
phase. No doubt it is annoying to his elders while it lasts, but the
only wise course is to try to thwart as little as we can his
legitimate desire to hold and grasp the objects, and even to assist
him in every way possible. But the mother must assist him only by
allowing free play to his attempts. To hand him the object is to
deprive the exercise of most of its value. Incidentally she may teach
him the virtue of putting things back in their proper places, an
accomplishment in which he will soon grow to take a proper pride. If
she attempts continually to turn him from his purpose, reproving him
and snatching things from him, she prolongs the grasping phase beyond
its usual limits. And she does a worse thing at the same time. Lest
the quicker hands of his nurse should intervene to snatch the prize
away before he has grasped it, he too learns to snatch, with a sudden
clumsy movement that overturns, or breaks, or spills. If left to
himself he will soon acquire the dexterity he desires. He may overturn
objects at first, or let them fall, but this he regards as failure,
which he soon overcomes. A child of twenty months, whose development
in this particular way has not been impeded by unwise repression, will
pick out the object on which he has set his heart, play with it,
finger it, and replace it, and he will do it deliberately and
carefully, with a clear desire to avoid mishap. Dr. Montessori, who
has developed into a system the art of teaching young children to
learn precision of movement and to develop the nerve centres which
control movement, tells in her book a story which well illustrates
this point.[1]

[Footnote 1: _The Montessori Method_, pp. 84, 85.]

"The directress of the Casa del Bambini at Milan constructed under one
of the windows a long, narrow shelf, upon which she placed the little
tables containing the metal geometric forms used in the first lesson
in design. But the shelf was too narrow, and it often happened that
the children in selecting the pieces which they wished to use would
allow one of the little tables to fall to the floor, thus upsetting
with great noise all the metal pieces which it held. The directress
intended to have the shelf changed, but the carpenter was slow in
coming, and while waiting for him she discovered that the children had
learned to handle these materials so carefully that in spite of the
narrow and sloping shelf, the little tables no longer fell to the
ground. The children, by carefully directing their movements, had
overcome the defect in this piece of furniture."

By slow degrees the child learns to command his movements. If his
efforts are aided and not thwarted, before he is two years old he will
have become capable of conducting himself correctly, yet with perfect
freedom. The worst result of the continual repression which may be
constantly practised in the mistaken belief that the grasping phase is
a bad habit which persistent opposition will eradicate, is the nervous
unrest and irritation which it produces in the child. A passionate fit
of crying is too often the result of the thwarting of his nature, and
the same process repeated over and over again, day by day, almost hour
by hour, is apt to leave its mark in unsatisfied longing,
irritability, and unrest. Above all, the child requires liberty of
action.

We have here an admirable example of the effect of environment in
developing the child's powers. A caged animal is a creature deprived
of the stimulus of environment, and bereft therefore to a great extent
of the skill which we call instinct, by which it procures its food,
guarantees its safety from attack, constructs its home, cares for its
young, and procreates its species. If, metaphorically speaking, we
encircle the child with a cage, if we constantly intervene to
interpose something between him and the stimulus of his environment,
his characteristic powers are kept in abeyance or retarded, just as
the marvellous instinct of the wild animals becomes less efficient in
captivity.

The grasping phase is but a preliminary to more complex activities.
Just as in schooldays we were taught with much labour to make
pot-hooks and hangers efficiently before we were promoted to real
attempts at writing, so before the child can really perform tasks with
a definite meaning and purpose, he must learn to control the finer
movements of his hands. Once the grasping phase, the stage of
pot-hooks, is successfully past--and the end of the second year in a
well-managed child should see its close--the child sets himself with
enthusiasm to wider tasks. To him washing and dressing, fetching his
shoes and buttoning his gaiters, all the processes of his simple
little life, should be matters of the most enthralling interest, in
which he is eager to take his part and increasingly capable of doing
so. In the Montessori system there is provided an elaborate apparatus,
the didactic material, designed to cultivate tactile sensation and the
perception of sense stimuli. It will generally suffice to advise the
mother to make use of the ordinary apparatus of the nursery. The
imitativeness of the young child is so great that he will repeat in
almost every detail all the actions of his nurse as she carries out
the daily routine. At eighteen months of age, when the electric light
is turned on in his nursery, the child will at once go to the curtains
and make attempts to draw them. At the same age a little girl will
weigh her doll in her own weighing-machine, will take every precaution
that the nurse takes in her own case, and will even stoop down
anxiously to peer at the dial, just as she has seen her mother and
nurse do on the weekly weighing night. But at a very early age
children appreciate the difference between the real and the
make-believe. They desire above all things to do acts of real service.
At the age of two a child should know where every article for the
nursery table is kept. He will fetch the tablecloth and help to put it
in place, spoons and cups and saucers will be carried carefully to the
table, and when the meal is over he will want to help to clear it all
away. All this is to him a great delight, and the good nurse will
encourage it in the children, because she sees that in doing so they
gain quickness and dexterity and poise of body. The first purposive
movements of the child should be welcomed and encouraged. It is
foolish and wrong to repress them, as many nurses do, because the
child in his attempts gets in the way, and no doubt for a time delays
rather than expedites preparations. The child who is made to sit
immobile in his chair while everything is done for him is losing
precious hours of learning and of practice. It is useless, and to my
mind a little distasteful, to substitute for all this wonderful child
activity the artificial symbolism of the kindergarten school in which
children are taught to sing songs or go through certain semi-dramatic
activities which savour too much of a performance acquired by precise
instruction. If such accomplishments are desired, they may be added
to, but they must not replace, the more workaday activities of the
little child. The child whose impulses towards purposive action are
encouraged is generally a happy child, with a mind at rest. When those
impulses are restrained, mental unrest and irritability are apt to
appear, and toys and picture books and kindergarten games will not be
sufficient to restore his natural peace of mind.


_(b)_ THE SUGGESTIBILITY OF THE CHILD

We may pass from considering the imitativeness of the child to study a
second and closely related quality, his suggestibility. His conception
of himself as a separate individual, of his ego, only gradually
emerges. It is profoundly modified by ideas derived from those around
him. Because of his lack of acquired experience, there is in the child
an extreme sensitiveness to impressions from outside. Take, for
example, a matter that is sometimes one of great difficulty, the
child's likes and dislikes for food. Many mothers make complaint that
there are innumerable articles of diet which the child will not take:
that he will not drink milk, or that he will not eat fat, or meat, or
vegetables, or milk puddings. There are people who believe that these
peculiarities of taste correspond with idiosyncrasies of digestion,
and that children instinctively turn from what would do them harm. I
do not believe that there is much truth in this contention. If we
watch an infant after weaning, at the time when his diet is gradually
being enlarged to include more solid food, with new and varied
flavours, we may see his attention arrested by the strange sensations.
With solid or crisp food there may be a good deal of hesitation and
fumbling before he sets himself to masticate and swallow. With the
unaccustomed flavour of gravy or fruit juice there may be seen on his
face a look of hesitation or surprise. In the stolid and placid child
these manifestations are as a rule but little marked, and pleasurable
sensations clearly predominate. With children of more nervous
temperament it is clear that sensations of taste are much more acute.
Even in earliest infancy, children have a way of proclaiming their
nervous inheritance by the repugnance which they show to even trifling
changes in the taste or composition of their food. We see the same
sensitiveness in their behaviour to medicines. The mixture which one
child will swallow without resentment, and almost eagerly, provokes
every expression of disgust from another, or is even vomited at once.
In piloting the child through this phase, during which he starts
nervously at all unaccustomed sensations and flavours, the attitude of
mother and nurse is of supreme importance. It is unwise to attempt
force; it is equally unwise, by excessive coaxing, cajoling, and
entreaty, to concentrate the child's attention on the matter. If
either is tried every meal is apt to become a signal for struggling
and tears. The phase, whether it is short or long continued, must be
accepted as in the natural order of things, and patience will see its
end. The management of this symptom,--refusal of food and an
apparently complete absence of desire for food,--which is almost the
commonest neurosis of childhood, will be dealt with later. Here it is
mentioned because I wish to emphasise that if too much is made of a
passing hesitation over any one article of food, if it becomes the
belief of the mother or nurse that a strong distaste is present, then
if she is not careful her attitude in offering it, because she is
apprehensive of refusal, will exert a powerful suggestion on the
child's mind. Still worse, it may cause words to be used in the
child's hearing referring to this peculiarity of his. By frequent
repetition it becomes fixed in his mind that this is part of his own
individuality. He sees himself--and takes great pleasure in the
thought--as a strange child, who by these peculiarities creates
considerable interest in the minds of the grown-up people around him.
When the suggestion takes root it becomes fixed, and as likely as not
it will persist for his lifetime. It may be habitually said of a child
that, unlike his brothers and sisters, he will never eat bananas, and
thereafter till the day of his death he may feel it almost a physical
impossibility to gulp down a morsel of the offending fruit. So, too,
there are people who can bolt their food with the best of us, who yet
declare themselves incapable of swallowing a pill.

Another example of the force of suggestion, whether unconscious or
openly exercised by speech, is given us in the matter of sleep. Among
adults the act of going to bed serves as a powerful suggestion to
induce sleep. Seldom do we seek rest so tired physically that we drop
off to sleep from the irresistible force of sheer exhaustion. Yet as
soon as the healthy man whose mind is at peace, whose nerves are not
on edge, finds himself in bed, his eyes close almost with the force of
a hypnotic suggestion, and he drops off to sleep. With some of us the
suggestion is only powerful in our own bed, that on which it has acted
on unnumbered nights. We cannot, as we say, sleep in a strange bed. It
is suggestion, not direct will power, that acts. No one can absolutely
will himself to sleep. In insomnia it is the attempt to replace the
unconscious auto-suggestion by a conscious voluntary effort of will
that causes the difficulty. A thousand times in the night we resolve
that now we _will_ sleep. If we could but cease to make these
fruitless efforts, sleep might come of itself and the suggestion or
habit be re-established.

In little children the suggestion of sleep, provoked by being placed
in bed, sometimes acts very irregularly. Often it may succeed for a
week or two, and then some untoward happening breaks the habit, and
night after night, for a long time, sleep is refused. The wakeful
child put to bed, resents the process, and cries and sobs miserably,
to the infinite distress of his mother. It then becomes just as likely
that the child will connect his bed in his mind, not with rest and
sleep, but with sobbing and crying on his part, and mingled entreaties
and scoldings from his nurse or mother. An important part in this
perversion of the suggestion is played by the attitude of the person
who puts the child to bed. Often the nurse is uniformly successful,
while the mother, who is perhaps more distressed by the sobbing of the
child, as consistently fails, because she has been unable to hide her
apprehension from him, and has conveyed to his mind a sense of his own
power.

Just in the same way, grown-up people, filled with anxiety because of
the helplessness of the young child, unable to divest their minds of
the fears of the hundred and one accidents that may befall, or that
within their own experience have befallen, a little child at one time
or another, unconsciously make unwise suggestions which fill his mind
with apprehension and terror. They do not like their children to show
fear of animals. Nor would they if it were not that their own
apprehension that the child may be hurt communicates itself to him.
The child is not of himself afraid to fall, it is they who suffer the
anxiety and show it by treating the fall as a disaster. The child is
not of himself afraid to be left alone in a room. It is they who sap
his confidence in himself, because they do not venture to leave him
out of their sight, from a nameless dread of what may happen. A little
girl cut her finger and ran to her nurse, pleased and interested:
"See," she said, seeing it bleed, "fingers all jammy." Only when the
nurse grasped her with unwise expressions of horror did she break into
cries of fear. A town-bred nurse, who is afraid of cows, will make
every country walk an ordeal of fear for the children.

Every mother must be made to realise the ease with which these
unconscious suggestions act upon the mind of the little child, and
should school herself to be strong to make her child strong, and to
see to it that all this suggestive force is utilised for good and not
for evil.

It is upon this susceptibility to suggestion that a great part of his
early education reposes. No one who is incapable of profiting by this
natural disposition of the child can be successful in her management
of him. Turn where you will in his daily life the influence of this
force of suggestion is clearly apparent. The child does without
questioning that which he is confidently expected to do. Thus he will
eat what is given him, and sleep soundly when he is put to bed if only
the appropriate suggestion and not the contrary is made to him. Again
we have seen that a perversion of suggestion of this sort is a common
source of constipation in early childhood. If the child's attention is
directed towards the difficulty, if he is urged or ordered or appealed
to to perform his part, if failure is looked upon as a serious
misfortune, the bowels may remain obstinately unmoved. In children as
in adults a too great concentration of attention inhibits the action
of the bowels, and constipation, in many persons, is due to the
attempt to substitute will power for the force of habitual suggestion.
No matter what other treatment we adopt, the mother must be careful to
hide from the child that his failure is distressing to her. A cheerful
optimism which teaches him to regard himself as one who is
conspicuously regular in his habits, and who has a reputation in this
respect to live up to is sure to succeed. To talk before him of his
habitual constipation, and to worry over the difficulty, is as surely
to fail. In the same way unwise suggestion can interfere with the
passing of water at regular and suitable intervals. There are children
who constantly desire to pass water on any occasion, which is
conspicuously inappropriate, because their attention has been
concentrated on the sensations in the bladder. Often enough when at
great inconvenience opportunity has been found, the desire has passed
away, and all the trouble has proved needless. It is not too much to
say that every occupation and every action of the day can be made
delightful or hateful to the child, according to the suggestion with
which it is presented and introduced. Dressing and undressing, eating
and drinking, bathing, washing, the putting away of toys, even going
to bed, can be made matters of enthralling interest or delight, or a
subject for tears and opposition, according to the bias which is given
to the child's mind by the words, attitude, and actions of nurses and
mothers.

Here we approach very near to the heart of the subject. Stripped of
all that is not essential we see the problem of the management of
children reduced to the interplay between the adult mind and the mind
of the receptive suggestible child. That which is thought of and
feared for the child, that he rapidly becomes. Placid, comfortable
people who do not worry about their children find their children
sensible and easy to manage. Parents who take a pride in the daring
and naughty pranks of their children unconsciously convey the
suggestion to their minds that such conduct is characteristic of them.
Nervous and apprehensive parents who are distressed when the child
refuses to eat or to sleep, and who worry all day long over possible
sources of danger to him, are forced to watch their child acquire a
reputation for nervousness, which, as always, is passively accepted
and consistently acted up to. Differences in type, determined by
hereditary factors, no doubt, exist and are often strongly marked. Yet
it is not untrue to say that variations in children, dependent upon
heredity, show chiefly in the relative susceptibility or
insusceptibility of the child to the influences of environment and
management. It is no easy task to distinguish between the nervous
child and the child of the nervous mother, between the child who
inherits an unusually sensitive nervous system and the child who is
nervous only because he breathes constantly an atmosphere charged with
doubt and anxiety.


(_c_) THE CHILD'S LOVE OF POWER

Let us study briefly a third quality of the child which, for want of a
better name, I have called after the ruling passion of mankind, his
love of power. Perhaps it would be better to call it his love of being
in the centre of the picture. It is his constant desire to make his
environment revolve around him and to attract all attention to
himself. Somewhat later in life this desire to attract attention, at
all costs, is well seen in the type of girl popularly regarded as
hysterical. The impulse is then a morbid and debased impulse; in the
child it is natural and, within limits, praiseworthy. A girl of this
sort, who feels that she is not likely to attract attention because of
any special gifts of beauty or intellect which she may possess,
becomes conscious that she can always arouse interest by the severity
of her bodily sufferings. The suggestion acts upon her unstable mind,
and forthwith she becomes paralysed, or a cripple, or dumb, presenting
a mimicry or travesty of some bodily ailment with which she is more or
less familiar. "Hysterical" girls will even apply caustic to the skin
in order to produce some strange eruption which, while it sorely
puzzles us doctors, will excite widespread interest and commiseration.
Now little children will seldom carry their desire to attract
attention so far as to work upon the feelings of their parents by
simulating disease. They have not the necessary knowledge to play the
part, and even if they make the attempt, complaining of this or that
symptom which they notice has aroused the interest of their elders,
the simulation is not likely to be so successful as to deceive even a
superficial observer. But within the limits of their own powers,
children are past masters in attracting attention. The little child is
unable to take part in any sustained conversation; most of his
talking, indeed, is done when he is alone, and is addressed to no one
in particular. But he knows well that by a given action he can produce
a given reaction in his mother and nurse. A great part of what is said
to him--too great a part by far--comes under the category of reproof
or repression. He is forbidden to do this or that, coaxed, cajoled,
threatened long before he is old enough to understand the meaning of
the words spoken, although he knows the tone in which they are uttered
and loves to produce it at will. How he enjoys it all! Watch him draw
near the fire, the one place that is forbidden him. He does not mean
to do himself harm. He knows that it is hot and would hurt him, but
for the time being he is out of the picture and he is intent on
producing the expected response, the reproof tone from his mother
which he knows so well. He approaches it warily, often anticipating
his mother's part and vigorously scolding himself. He desires nothing
more than that his mother should repeat the reproof, forbidding him a
dozen times. The mind of all little children tends easily to work in a
groove. It delights in repetition and it evoking not the unexpected
but the expected. If his sport is stopped by his mother losing
patience and removing him bodily from the danger zone, his sense of
impotence finds vent in passionate crying. But if his mother takes no
notice, the sport soon loses its savour. He is conscious that somehow
or other it has fallen flat, and he flits off to other employment.

Mothers will complain that children seem to take a perverse pleasure
in evoking reproof, appeals, entreaties, and exhortations. A small boy
of four who had several times repeated the particular sin to which his
attention had been directed by the frequency of his mother's warnings
and entreaties, finding that on this occasion she had decided to take
no notice, approached her with a troubled face: "Are you not angry?"
he said; "are you not disappointed?" In reality the naughty child is
often only the child who has become master of his mother's or his
nurse's responses, and can produce at will the effect he desires. The
idea that the child possesses a strong will, which can and must be
broken by persistent opposition, is based upon this tendency of the
child. It is an entire misconception of the situation: Strength of
will and fixity of purpose are among the last powers which the human
mind develops. In little children they are conspicuously absent. What
appears to us as a fixed and persistent desire to perform a definite
action in spite of all we can say or do, is often no more than the
desire to produce the familiar tones of reproof, to traverse again the
familiar ground, to attract attention and to find himself again the
centre of the picture. If no one pays any attention and no one
reproves, he soon gives up the attempt. If too much is made of any one
action of the child, a strong impression is made on his mind and he
cannot choose but return to it again and again.

This little drama of the fireplace may teach us a great deal in the
management of children. The wise mother and nurse will find a hundred
devices to catch the child's attention and lure him away from the
danger zone without the incident making any impression on his mind at
all, and will not call attention to it by repeated reproofs or
warnings which will certainly lead him straight back to the spot.

In matters of greater moment the same impulse to oppose the will of
those around him is seen. In considering the point of the child's
susceptibility to suggestion, we have mentioned the refusal of sleep
and the refusal of food. In both it is possible to detect the
influence of this pronounced force of opposition. As the child lies
sobbing or screaming in bed, every new approach to him, every fresh
attempt at pacification, renews the force of his opposition in a
crescendo of sound. But it is in his refusal of food that the child is
apt to find his chief opportunity. Meal-times degenerate into a
struggle. There at least he can show his complete mastery of the
situation. No one can swallow his food for him, and he knows it. He
can clench his teeth and shake his head and obstinately refuse every
morsel offered. He can hold food in his mouth for half an hour at a
time and remain deaf to all the appeals of his helpless nurse. If she
tries force, he quells the attempt by a storm of crying. If she
declines upon entreaty and coaxing, he will not be persuaded. It is
the little scene of the fireplace over again. The attempts at force or
the attempts at persuasion, by making much of it, have concentrated
the attention of the child upon the difficulty, and have taught him
his own power to dominate the situation.

It is right that parents should realise that the disturbing and
irritating element in the child's environment is nearly always
provided by the intrusion of the adult mind and its contact with the
child's. Some supervision and some intrusion, therefore, is of course
absolutely necessary, but the best-regulated nursery is that in which
it is least evident. Something is definitely wrong if a child of two
years will not play for half an hour at a time happily and busily in a
room by himself. It is an even better test if the child will play
amicably by himself with nurse or mother in the room, without the two
parties crossing swords on a single occasion, without reproof or
repression on the one side or undue attempts to attract attention on
the other. If the child is entirely dependent upon the participation
of grown-up persons in his pursuits, then not only do those pursuits
lose much of their educative force, but they become a positive source
of danger because of the constant interplay of personality with
personality. The child who, seated on the ground, will play with his
toys by himself, rises with a brain that is stimulated but not
exhausted. Only very rarely do we find that solitary play, or play
between children, is too exciting. In older children of very quick
intelligence and nervous temperament we occasionally find that the
pace which they themselves set is too exciting or exhausting. I recall
a little boy of seven, an only child of particularly wise and
thoughtful parents, who was brought to me with the complaint that he
exhausted himself utterly both in body and mind by the intense nervous
energy which he threw into his pursuits. For instance, he had been
interested in the maps illustrating the various fronts in the European
War, with which the walls of his father's study were hung, and
although left entirely by himself he had become intensely excited and
exhausted by the eagerness with which he had spent a whole morning,
with a wealth of imaginative force, in drawing a map of the garden of
his house and converting it into the likeness of a war map, filled
with imaginary Army Corps. Such excessive expenditure of nervous force
is unusual even in older children, and as in this case is found
usually only when there is a pronounced nervous inheritance. In little
children in the nursery, solitary play or play between themselves
seldom produces nervous exhaustion. It is quite otherwise when the
child is dependent to a too great extent upon the participation of
adults. It is almost impossible for the mother and nurse not to take
the leading part in the exchange of ideas, and no matter what may be
their good intentions, the pace set is apt to be too great.
Environment, without the intrusion of the adult mind, is best able to
adjust the necessary stimulus and produce development without
exhaustion. Play with grown-up persons, the reading aloud of story
books, the showing of pictures, and so forth, undoubtedly have their
own importance, but they should be confined within strict limits and
to a definite hour in the daily routine. There is sometimes too great
a tendency for parents to make playthings of their little children.
Save at stated times, they must curb their desire to join in their
games, to gather them in their arms, to hold them on their knee, while
they stimulate their minds by a constant succession of new
impressions. With an only child, whose existence is the single
preoccupation of the nurse and mother, and, often enough, of the
father as well, it is difficult to avoid this fault. Yet, if wisdom is
not learnt, the damage to the child may be distressingly serious. He
rapidly grows incapable of supporting life without this excessive
stimulation. Without the constant society and attention of a grown
person, he feels himself lost. He cannot be left alone, and yet cannot
enjoy the society he craves. He grows more and more restless,
dominating the whole situation more and more, constantly plucking at
his nurse's skirts, perversely refusing every new sensation that is
offered him to still his restlessness for a moment. The result of all
this stimulation is mental irritability and exhaustion, which in turn
is often the direct cause of refusal of food, dyspepsia, wakefulness,
and excessive crying.

The devices by which children will attract to themselves the
attention of their elders, and which, if successful, are repeated with
an almost insane persistence, take on the most varied forms. Sometimes
the child persistently makes use of an expression, or asks questions,
which produce a pleasant stir of shocked surprise and renewed reproofs
and expostulations. One little boy shouted the word "stomachs" with
unwearied persistence for many weeks together. A little girl dismayed
her parents and continued in spite of all they could do to prevent her
to ask every one if they were about to pass water.

Disorders of conduct of this sort are not really difficult to control.
Suitable punishment will succeed, provided also that the child is
deprived of the sense of satisfaction which he has in the interest
which his conduct excites. His behaviour is only of importance because
it indicates certain faults in his environment and a certain element
of nervous unrest and overstrain.

The young child demands from his environment that it should give him
two things--security and liberty. He must have security from shocks to
his nervous system. It is true that from the greater shocks the
children of the well-to-do are as a rule carefully guarded. No one
threatens or ill-uses them. They are not terrified by drunken brawls
or scenes of passion. They are not made fearful by the superstitions
of ignorant people. Nevertheless, by the summation of stimuli little
emotions constantly repeated can have effects no less grave upon
their nervous system. From this constantly acting irritation the child
needs security. In the second place, he requires liberty to develop
his own initiative, which should be stimulated and sustained and
directed. Without liberty and without security conduct cannot fail to
become abnormal.


(_d_) THE REASONING POWER OF THE CHILD

Before we proceed to a closer examination of the various symptoms of
nervous unrest in detail, we may very briefly consider the scope and
power of the child's understanding. As a rule I am sure that it is
grossly underestimated. The mental processes of the child are far
ahead of his power of speech. The capacity for understanding speech is
well advanced, and an appeal to reason is often successful while the
child is still powerless to express his own thoughts in words. Because
he cannot so express himself there is a tendency to underestimate the
acuteness of his reasoning, to talk down to him, and to imagine that
he can be imposed upon by any fiction which seems likely to suit the
purpose of the moment. A child of eighteen months is not too young to
be talked to in a quiet, straightforward, sensible way. Only if he is
treated as a reasonable being can we expect his reasoning faculties to
develop. Children dislike intensely the unexplained intervention of
force. If a pair of scissors, left by an oversight lying about, has
been grasped, the first impulse of the mother is to snatch the danger
hurriedly from the child's hands, and her action will generally be
followed by resistance and a storm of weeping. She will do better to
approach him quietly, telling him that scissors hurt babies, and show
him where to place them out of harm's way. Watch a child at play after
his midday meal. He has been out in his perambulator half the morning,
and for the other half has been deep in his midday sleep. Now that
dinner is over he is for a moment master of his time and busily
engaged in some pursuit dear to his heart. At two o'clock inexorable
routine ordains that he must again be placed in the perambulator and
wheeled forth on a fresh expedition. If the nurse does not know her
business she will swoop down upon him, place him on her knee, and
begin to envelop his struggling little body in his outdoor clothes,
scolding his naughtiness as he kicks and screams. If she has a way
with children she will open the cupboard door and call on him to help
find his gaiters and his shoes because it is time for his walk. In a
moment he will leave his toys, forgetting all about them in the joy of
this new activity.

If the reason for things is explained to children they grow quick to
understand quite complicated explanations. A little girl, not yet two,
was playing with her Noah's Ark on the dining-room table with its
polished surface. The mother interposed a cloth, explaining that the
animals would scratch the table if the cloth were not there. Within a
few minutes the child twice lifted the cloth, peering under it and
saying, "Not scratch table." Yet how often do we find
facetiously-minded persons confound their reasoning and confuse their
judgment by foolish speeches and cock-and-bull tales, which, just
because of their foolishness, seem to them well adapted to the infant
intelligence.

An attempt to deceive the child is almost always wrong, and because of
our tendency to underestimate the child's intelligence it generally
fails. If a little girl has a sore throat, and the doctor comes to see
her, she knows quite well that she is the prospective patient. It is
useless for the mother to begin proceedings by trying to convince her
that this is not so--that mother has a sore throat too. Such a plan
only arouses apprehension, because the child scents danger in the
artifice.

Closely connected with the reasoning powers of the child is the
difficult question of the growth of his appreciation of right and
wrong, or, to put it in another way, the growth of obedience or
disobedience. Sooner or later the child must learn to obey; on that
there can be no two opinions. Nevertheless, I think there can be no
doubt that far more harm is done by an over-emphasis of authority than
by its neglect. If the nurse or mother is of strong character, and the
authority is exercised persistently and remorselessly, so that the
whole life of the child is dominated, much as the recruit's existence
in the barrack yard is dominated by the drill sergeant, his
independence of nature is crushed. He is certain to become a
colourless and uninteresting child; he runs a grave risk of growing
sly, broken-spirited, and a currier of favour. If a child is
ruthlessly punished for disobedience from his earliest years, there
is, it need hardly be said, a grave risk that he will learn to lie to
save his skin. I have seen a few such cases of what I may call the
remorseless exercise of authority, and the result has not been
pleasing. Fortunately, perhaps, not many women have the heart to adopt
this attitude to the waywardness of little children--a waywardness to
which their whole nature compels them by their pressing need to
cultivate tactile sensations, to experiment, and to explore.
Therefore, much more commonly, the authority is exercised
intermittently and capriciously, with the result that the child's
judgment is clouded and confused. Conduct which is received
indulgently or even encouraged at one moment is sternly reprimanded at
another. Every one who has the management of little children must
above all see to it, whatever the degree of stringency in discipline
which they decide to adopt, that their attitude is always consistent.
The less that is forbidden the better, but when the line is drawn it
must be adhered to. If once the child learns that the force which
restrains him can be made to yield to his own efforts, the future is
black indeed. From that day he sets himself to strike down authority
with a success which encourages him to further efforts. I have known a
child of five years terrorise his mother and get his own way by the
threat, "I will go into one of my furies."

The difficulty of successfully enforcing authority, and of carrying
off the victory if that authority is disputed, should make mothers
wary of drawing too tight a rein. The conflict between parent and
child must always be distressing and must always be prejudicial to the
child, whatever its outcome, whether it brings to him victory or
defeat. He learns from it either an undue sense of power or an undue
sense of helplessness, and the knowledge of neither is to his benefit.
Although frequently worsted in the conflict, nurses will often return
to the attack again and again and hour after hour, restraining,
reproving, forbidding, and even threatening. Nor do they see that they
are really goading the children into disobedience by their misdirected
efforts at enforcing discipline. Reproof, like punishment, loses all
its effect when it is too often repeated, and the child soon takes it
for granted that all he does is wrong, and that grown-up people exist
only to thwart his will, to misunderstand, to reprove, or even to
punish.

In the nursery the word "naughty" is far too frequently heard. It is
naughty to do this, it is naughty to do that. There is no gradation in
the condemnation, and the child loses all sense of the meaning of the
word. He himself proclaims himself naughty almost with satisfaction:
his doll is naughty, the dog is naughty, his nurse and mother are
naughty, and so forth. In reality the little child is peculiarly
sensitive to blame, if he is not reproof-hardened. It is hardly
necessary to use words of blame at all. If he is asked kindly and
quietly to desist, much as we would address a grown-up person, and
does not, he can be made to feel that his conduct is unpopular by
keeping aloof from him a little, by disregarding him for the time
being, and by indicating to him that he is a troublesome little person
with whom we cannot be bothered.

Any one who has had much to do with children will realise that, if
wrongly handled, they are apt to take a positive delight in doing what
they conceive to be wrong. There is clearly a delightful element of
excitement in the process of being naughty, of daring and of braving
the wrath to come, with which they are so familiar and for which they
care nothing at all. But the perverseness of which we are now speaking
has a different origin. It arises only when children are reproved,
appealed to, and expostulated with too often and too constantly.
Negativism is a symptom which is common enough in certain mental
disorders. The unhappy patient always does the opposite of what is
desired or expected of him. If he be asked to stand up he will
endeavour to remain seated, or if asked to sit he will attempt to rise
to his feet. Like many other symptoms of nervous disturbance which we
shall study later, this negativistic spirit is often displayed to
perfection by little children when the environment is at fault and
when grown-up people have too freely exercised authority. A mother,
anxious to induce her little son to come to the doctor, and knowing
well that her call to him to enter the room, as he stands hesitating
at the door, will at once determine his retreat to the nursery, has
been heard to say, "Run away, darling, we don't want _you_ here," with
the expected result that the docile child immediately comes forward.
To the doctor, that such a device should be practised almost as a
matter of course and that its success should be so confidently
anticipated, should give food for thought. It may shed light on much
that is to follow later in the interview.

The question of punishment, like that of reproof, is beset with
difficulty. There are fortunately nowadays few educated mothers who
are so foolish as to threaten punishment which they obviously do not
intend to administer and which the child knows they will not
administer. It is clear that punishment must be rare or else the child
will grow habituated to it, and with little children we cannot be
brutal or push punishment to the point of extreme physical pain. It is
more difficult to say, as one is tempted to say, that all punishment
is futile and should be discarded. Probably mothers are like
schoolmasters in that no two schoolmasters and no two mothers obtain
their effects in exactly the same way or by precisely the same means.
Nor do all children accept reproof or submit to punishment in the same
way. Some make light of it and take a pleasure in defying authority.
Others are unduly cast down by the slightest adverse criticism. It is
generally true that extreme sensitiveness to reproof is a sign of a
certain elevation of character. Always we must remember that for a
mother to inflict punishment, whether by causing physical pain or
mental suffering, is to take on her shoulders a certain
responsibility. It is a serious matter if she has misapprehended the
child's act--if the sin was not really a sin, but only some perverted
action, the intention of which was not sinful, but designed for good
in the faulty reasoning of the child. A little girl, in bed with a
feverish cold, was found shivering, with her night-dress wet and
muddy. It was an understanding mother who found that her little
brother, having heard somehow that ice was good for fevered heads, had
brought in several handfuls of snow from the garden, not of the
cleanest, and had offered them to aid his sister's recovery. It need
hardly be said that punishment should always be deliberate. The hasty
slap is nothing else than the motor discharge provoked by the
irritability of the educator, and the child, who is a good observer on
such points, discerns the truth and measures the frailty of his judge.

The frequent repetition of words of reproof and acts of punishment has
a further disadvantage that the older children are quick to practise
both upon their younger brothers and sisters. There is something wrong
in the nursery where the lives of the little ones are made a burden to
them by the constant repression of the older children. But although
set and artificial punishments are as a general rule to be used but
sparingly, the mother can see to it that the child learns by
experience that a foolish or careless act brings its own punishment.
If, for example, a child breaks his toy, or destroys its mechanism,
she need not be so quick in mending it that he does not learn the
obvious lesson. If the baby throws his doll from the perambulator, in
sheer joy at the experience of imparting motion to it, she need not
prevent him from learning the lesson that this involves also some
temporary separation from it. Throughout all his life he is to learn
that he cannot eat his cake and have it too. The use of rewards is
also beset with difficulties. Their coming must be unexpected and
occasional. They must never degenerate into bribes, to be bargained
for upon condition of good behaviour. Rewards which take the form of
special privileges are best.

The æsthetic sense of children develops very early. From the very
beginning of the second year they take delight in new clothes, and in
personal adornment of all sorts. They show evident pleasure if the
nursery acquires a new picture or a new wall-paper. They have
pronounced favourites in colours. Even tiny children show dislike of
dirt and all unpleasant things. Personal cleanliness should be clearly
desired by all children. A sense of what is pleasant and what is
unpleasant should be encouraged. Any delay in its appearance is apt to
imply a backwardness in development of mind or of body. Only children
who are tired out by physical illness or by nervous exhaustion will
lie without protest in a dirty condition.

Affection and the attempt to express affection appear clearly marked
even in the first year. Too much kissing and too much being kissed is
apt to spoil the spontaneity of the child's caresses. We must not,
however, expect to find any trace in the young child of such a complex
quality as unselfishness or self-abnegation. The child's conception of
his own self has but just emerged. It is his single impulse to develop
his own experience and his own powers, and his attitude for many
years is summed up in the phrase: "Me do it." We must not expect him
to resign his toys to the little visitor, or the little visitor to
cease from his efforts to obtain them. In all our dealings with
children we must know what we may legitimately expect from them, and
judge them by their own standards, not by those of adult life. We
cannot expect self-sacrifice in a child, and, after all, when we come
to think of it, obedience is but another name for self-sacrifice. If
the tiny child could possibly obey all the behests that are heaped
upon him in the course of a day by many a nurse and mother, he would
truly be living a life of complete self-abnegation. Surely it is
because the virtue of obedience, the virtue that is proclaimed
proverbially the child's own, is so impossible of attainment that it
is become the subject of so much emphasis. As Madame Montessori has
put it: "We ask for obedience and the child in turn asks for the
moon." Only when we have developed the child's reasoning powers, by
treating him as a rational being, can we expect him deliberately to
defer his wishes to ours, because he has learned that our requests are
generally reasonable.




CHAPTER III

WANT OF APPETITE AND INDIGESTION


The mind of the child is so unstable and yet so highly developed, that
symptoms of nervous disturbance are more frequent and of greater
intensity than in later life. Only rarely and in exceptional cases do
certain symptoms, common in childhood, persist into adult life or
appear there for the first time, and then usually in persons who, if
they are not actually insane, are at least suffering from intense
nervous strain. We have already mentioned the symptom of negativism
and noted its occasional occurrence as an accompaniment of mental
disorder in adult life, and its frequency among children who are
irritable or irritated. Similarly, we may cite the digestive neuroses
of adult life to explain the common refusal of food and the common
nervous vomiting of the second year of life. Thus, for example, there
exists in adult life a disturbance of the nervous system which is
called "anorexia nervosa." A boy of nineteen was brought to the
Out-patient Department of Guy's Hospital suffering from this
complaint. He was little more than a skeleton, unable to stand, hardly
able to sit, and weighing only four and a half stones. His mother,
who came with him, stated that he had always been nervous, and that
lately, after receiving a call to join the army as a recruit, his
appetite, which had for some time been capricious, had completely
disappeared. In spite of coaxing he resolutely refused all food, or
took it only in the tiniest morsels, although at the same time it was
thought that he sometimes took food "on the sly." A careful
examination showed absolutely no sign of bodily disease. He was
admitted to a ward for treatment by hypnotic suggestion, but before
this could be begun he endeavoured to commit suicide by setting fire
to his bed.

A girl of twenty-four years of age had become almost equally
emaciated. Constant vomiting had persisted for many years and had
defied many attempts at cure. It had even been proposed to perform the
operation of gastro-enterostomy in the belief that some organic
disease existed. In suitable surroundings and with the energetic
support of a good nurse, who spent much time and care in restoring her
balance of mind, the vomiting ceased, and she gained over two stones
in weight. Work was found for her in some occupation connected with
the War, and she left the Nursing Home to undertake this, bearing with
her four pounds which she had abstracted from the purse of another
patient.

Those who have not opportunities of observing how all-powerful is the
effect of the mind upon the body, and especially perhaps upon the
process of digestion, may find it hard to believe that these
distressing symptoms and profound changes in the aspect and nutrition
of the patients were due entirely to mental causes and were symptoms
in accord with the attempted suicide or the theft of the money. In
nervous little children we shall not often find such complex actions
as suicide or theft, although they do occur, but combined with other
evidence of nervousness we shall meet commonly enough with a
persistent setting aside of appetite and refusal of food and with
continuous and habitual vomiting, from nervous causes.

The experiments of Pawlow and others have explained the dependence of
digestion upon mental states. They show that even before the food is
taken into the mouth, while the meal is still in prospect, there has
been instituted a series of changes in the wall of the stomach, which
gives rise to the so-called psychic secretion of gastric juice. These
changes are preceded by the sensation of appetite, which is evoked not
by the presence of food in the stomach--for the food has not yet been
swallowed--but by the anticipation of it, by the sight and smell of
food, as well as by more complex suggestions, such as the time of day,
the habitual hour, the approach of home, and so forth.

Emotional states of all sorts--grief, anger, anxiety, or
excitement--put a stop to the process or interfere with its action, so
that the sense of appetite is absent, and the taking of food is apt to
be followed by discomfort or pain or vomiting. No doubt good digestion
leads to a placid mind, but it is equally true that a placid mind is
necessary for good digestion. Therefore we civilised people, living
lives of mental stress and strain, try to increase the suggestive
force of our surroundings and to provoke appetite by all devices
calculated to stimulate the æsthetic sense. The dinner hour is fixed
at a time when all work and, let us hope, all worry is at an end for
the day. The dinner-table is made as pretty as possible, with flowers
and sparkling glass. We are wise to dress for dinner, that with our
working clothes we may put off our working thoughts.

In the treatment of adult dyspepsia we seldom succeed unless we can
place the mind at rest. We may advise a visit to the dentist and a set
of false teeth, or we may administer a variety of stomach tonics and
sedatives, but if the mind remains filled with nameless fears and
anxieties we shall not succeed.

In adult life the nervous person when subjected to excessive stress
and strain is seldom free from dyspeptic symptoms of one sort or
another, and what is true of adult life is even more true of
childhood, when the emotions are more poignant and less controlled.
Then tears flow more readily than in later life, and tears are not the
only secretions which lie under the influence of strong emotion.
Emotional states, which would stamp a grown man as a profound
neurotic, are almost the rule in infancy and childhood, and may be
marked by the same physical disturbances--flushing, sweating, or
pallor, by the discharge of internal glandular secretions as well as
by inhibition of appetite, by vomiting, gastric discomfort, or
diarrhoea. Naturally enough, mothers and nurses are wont to demand a
concrete cause for the constant crying of a little child, and
teething, constipation, the painful passage of water, pain in the
head, or colic and indigestion are suggested in turn, and powders,
purges, or circumcision demanded. There can be no doubt that nervous
unrest is capable of producing prolonged dyspepsia in infancy and
childhood--a dyspepsia which, while it obstinately resists all
attempts to overcome it by manipulation of the diet, is very readily
amenable to treatment directed to quiet the nervous system.

Where a primary dyspepsia exists for any length of time, the growth
and the nutrition of the child is clearly altered for the worse. The
character of the stools, their consistency, smell, and colour, is apt
to be changed because the bacterial context of the bowel has become
abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism,
prolapse of the rectum, and infection with thread-worms are common
complications. No doubt children with primary dyspepsia are often
nervous and restless, and the elements of infection and of neurosis
are frequently combined. Yet often we meet with cases in which the
gastric or intestinal disturbance comes near to being a pure neurosis.
The nutrition, then, seldom suffers to any very great extent, or to a
degree in any way comparable to that which is characteristic of
dyspepsia from other causes. Emaciation, wrinkling of the skin,
dryness and falling out of the hair, decay of the teeth, are not as a
rule part of the picture of nervous dyspepsia. The child may be slim
and thin and nervous looking, but as a rule he is active enough, with
a good colour and fair muscular tone, so that one has difficulty in
believing the mother's statements, which are yet true enough, as to
the trouble which is experienced in forcing him to eat, or as to the
frequency of vomiting.

In early childhood the difficulty of the refusal of food often passes
or diminishes when the child learns to feed himself with precision and
certainty. To teach him to do so, it is not wise to devote all our
attention to making him adept at this particular task. The fault is
that the brain centres which control the movements of hands, mouth,
and tongue have not been developed, because his activities in all
directions have not been encouraged. It is much less trouble for a
nurse to feed a little child than to teach him to feed himself, and if
he is not given daily opportunities of practice he will certainly not
learn this particular action. But the fault as a rule lies deeper. The
child who cannot feed himself cannot be taught until fingers and brain
have been developed in the thousand activities of his daily routine,
by which he acquires general dexterity. A child who is still too young
to feed himself is learning the dexterity which is necessary as a
preliminary in every action of the day. If he can carry the tablecloth
and the cups and saucers to the tea-table, imitating in everything the
action of his nurse, it will be strange if he does not also imitate
her in the central scene, the actual eating of the food. If, on the
other hand, he is waited upon hand and foot, if he is restrained and
confined, sitting too much passively, now in his perambulator, now in
his high chair, now on his nurse's lap, his imitative faculties and
his tactile dexterity alike remain undeveloped. The child who is slow
in learning to feed himself shows his backward development in every
movement of his body. One may note especially the stiff,
"expressionless" hands, indicating a general neuro-muscular defect. I
have seen many children of eighteen months or two years of age in whom
the movements necessary for efficient mastication and swallowing had
failed to develop satisfactorily. In some a pure sucking movement
persisted, so that when, for example, a morsel of bread or rusk was
put in the child's mouth, it would be held there for many minutes and
submitted only to suction with cheeks and tongue. Attempts to swallow
in such a case are so incoordinate that they give rise frequently to
violent fits of choking, which distress the child and produce
resistance and struggling, while at the same time they alarm the
mother or nurse so much that further attempts to encourage the taking
of solid food are hastily and for a long time abandoned. In this
helpless condition the other factors which tend to develop what we
have called negativism have full play. The want of imitation and the
lack of dexterity is not the sole or perhaps the main cause of the
child's refusal of food and of the apparent want of appetite, but it
is the cause of the failure to learn to feed himself, which places
him in a condition which is peculiarly favourable to the operation of
other factors. If only we can teach the child to feed himself, the
difficulties of the situation become much less formidable.

The first of the factors which encourage the persistent refusal of
food is the extreme susceptibility of the child to suggestion. A
particular article of diet may be refused on one occasion, perhaps in
pique, because another more favoured dish was hoped for or expected,
or perhaps because the taste is not yet familiar. Then if on this
occasion a struggle for the mastery is waged, and a painful impression
is made on the child's mind connecting this particular dish with
struggling and tears, from that day forward the child may persistently
refuse it on every occasion it is offered. Matters are made worse if
the nurse, anticipating refusal, attempts to overcome the resistance
by peremptory orders, or by excessive praise extolling the delicious
flavour with such fervour that the child's suspicions are at once
aroused. Previous experience has made him connect these excessive
praises with articles which have aroused his distaste. If these fads
and fancies on the part of the child are to be avoided, it is
essential that we should do nothing to focus his attention on his
refusal. It is better that his dinner should be curtailed on one
occasion than that taste and appetite should be perverted perhaps for
years. Every nurse or mother should cultivate an off-hand, detached
manner of feeding the child, and should patiently continue to offer
the food without uncalled-for comments or exhortations. Let her always
remember the force of suggestion on the child's mind, and that a
confident manner which never questions the child's acceptance will
meet with acceptance, while a hesitating address, from fear of the
impending refusal, will be apt to meet with refusal. Sometimes a still
worse fault manifests itself, when nurse and mother speak before the
child of the smallness of his appetite, and of his persistent refusal
of this or that article of diet. The suggestion then acts still more
powerfully on his mind. He is aware that the whole household is
distressed by his peculiarity, and he grows to identify it with his
own individuality, and to regard himself with some satisfaction as
possessing this mark of distinction. If there is any difficulty of
this sort it is often directly curative to reverse the suggestion and
to speak before him of his improving appetite, and to say that he
begins every day to eat better and better, even if to do so we have to
break a good rule never to say to the child what is not strictly true.
Or once or twice we may take his plate away before he has finished,
saying positively that he has eaten so much that he must eat no more.
If in spite of every care antipathies to certain articles of food
appear and persist, we must be content to bide our time. When the
child grows of an age to reason, we should seize every opportunity to
make him feel that his persistent refusal is a little ridiculous and
childish. Little by little the seed is sown, and will germinate till
one day we shall note with surprise that he has taken of his own
accord that which he has neglected for so long and with such
obstinacy.

But the force which is acting most strongly in producing this refusal
of food is the force of which we have spoken in a previous
chapter--the force which results in negativism, the force which is in
reality the habit of opposition, the love of power, and the desire to
attract attention. Here again the refusal of food, if due to this
cause, is never the sole manifestation of the fault. Just as the delay
in learning to swallow and to chew properly and to feed himself is
part of a general want of dexterity and capacity manifested in all his
actions, so it will seldom happen that the child's anxiety to oppose
is only seen at meal-times. Watch a nervous child in the nursery
before the dinner hour. He is cross and restless and inclined to cry.
The nurse hands him a doll, and he throws it away saying, "No, no
doll." At the same moment he may catch sight of his ball, and it too
is violently rejected, "No, no ball." Everything in turn is treated in
the same way. Finally he falls upon his nurse, crying and beating her
with his hands, saying, "No, no Nurse." If that long-suffering woman
at that moment summons him to dinner, it will be strange indeed if his
attitude is not "No, no dinner," and "No, no" to every mouthful
offered him. How strong this love of opposition may be is illustrated
by the case of a little boy who was brought to me for refusal of food.
Three weeks before, he had been taken in a motor-car to his
grandfather's to midday dinner on Sunday, when his absolute refusal of
food had spoiled the day and had occupied the attention and the
efforts of the whole party. Doubtless he had enjoyed himself, for
three weeks later, when he caught sight of the car which was to bring
him to me, and which he had not seen in the interval, he at once said,
"Not eat my dinner." This child's father told me that the sight or
sound of the preparation of a meal was enough to bring on a paroxysm
of opposition. Now this force of opposition, as we have seen, only
develops into a serious difficulty when the child's own will has been
opposed too much, when authority has been too freely exercised, and
when the child has been urged and entreated and reproved with too
great frequency. His opposition grows with all counter-opposition. And
he is not really naughty, only irritable and restless from the
thwarting of his natural impulses, and unable to express his thoughts
and desires. Negativism will not often confine itself to meal-times.
It will show clearly in all the actions of the child, and to get him
to eat well and freely we must so change our management of him that
negativism disappears or at least diminishes. There is no other way.
No entreaty, no force, no threats of force will ever succeed, but will
only make him worse, and, since negativism is due to mental unrest,
the struggles and crying will only perpetuate the cause. The one way
to banish negativism and overcome the opposition is to cease to
oppose, and to practise this aloofness not so much at meal-times, for
somehow by patience the child must be got to take his food, but in all
our conduct to him. Repression and reproof, and thwarting of the
child's will, and coaxing and entreaty must cease. There is no fear
that we shall thereby make the child unduly disobedient. We have
already, in another chapter, decided that negativism is not strength
of will on the part of the child which must be broken, but is the
result of constant attempts to oppose his nature, and the consequent
nervous unrest. If we cease to oppose, the symptoms will tend rapidly
to disappear, the child will become busy and contented and happy in
his play, and we shall hear no more of his refusal of food. If
sometimes it recurs for a week or two, we shall know how to deal with
it.

In children, as with us, periods of nervous unrest and unhappiness are
apt to recur in a sort of cycle. This cyclical character of mental
disturbance is often a marked feature. We see it in epilepsy and
in what the French have called Folie Circulaire. We see it in the
dipsomaniac, in the intermittency of his craving for drink and of his
periodical outbursts, and we see it in ourselves in those periods of
depression which recur so often, we know not why. Little children too
sometimes get out on the wrong side of their beds, and never get right
the whole long day. Their own experience of the vagaries of mental
states should lead mothers to be indulgent to the children in their
days of cloud and to be particularly careful not to goad them by
well-intentioned efforts into bursts of naughtiness and passion, each
one of which tends to perpetuate the condition and increase the
nervous unrest. We know how closely dependent is the sensation of
appetite upon emotional states, and we must do all in our power--and
the task is sometimes one of real difficulty--to keep the child's mind
sufficiently at rest to preserve the healthy desire for food
unimpaired. If there is no sign of appetite, but every sign of
restlessness and irritability, we must seek in the management of the
child until we find the fault.

If food is taken mechanically and without appetite, if the preliminary
changes in the stomach wall which are necessary for adequate digestion
do not take place, but are inhibited by the mental unrest, the meal is
apt to be followed by gastric pain and discomfort, or, more commonly
with children, the stomach may promptly reject its contents. At the
worst, nervous vomiting of this sort may follow almost every meal,
although, again, it is curious to note how little, comparatively
speaking, the nutrition of the child suffers. The vomiting too, as in
adults, comes very near being a voluntary act, and mothers and nurses
will often remark that they get the impression that it can be
controlled at will. If once the diagnosis is made that the want of
appetite or the vomiting is of nervous origin, the treatment of the
condition is clear. Sedative drugs directed towards quieting the
nervous excitability may be of service, but tonics, appetisers,
laxatives, and drugs with a direct action on the stomach will have but
little effect. Nor is there as a rule anything to be gained by
modifying the diet or by excluding this or that article of food. The
frequency of the vomiting is such that it is apt to have brought
discredit one after the other upon almost every article of food which
the child can take, with the result that many useful and necessary
foods have been abandoned for long on the ground that they are the
cause of the dyspepsia. A permanent cure will only be effected when
the faults of environment have been overcome, when the cause of the
nervous unrest has been removed, and when the child's mind is at
peace.

Nervous vomiting of this kind is not difficult to control, if those in
charge of the children can be made to understand that the cause lies
in the anxiety which they themselves show before the child, increasing
his own apprehension or adding to his sense of power or importance.
Once the child is convinced that his conduct excites no particular
interest, the vomiting soon ceases. In more than one instance,
vomiting which has persisted for many months has stopped at once after
the matter has been fully explained to the parents. In the most
inveterate case of this sort which has come under my notice, the child
was regularly sick as soon as he caught sight of a white cloth being
laid on the table for meals. Yet even this child never vomited when he
was under the charge of a particular nurse who had to return more than
once to the family, and on each occasion was successful in breaking
the habit.




CHAPTER IV

WANT OF SLEEP


So far, almost all that has been written--and there has been a great
deal of unavoidable repetition--has been devoted to an attempt to
determine the causes which lead the child to refuse food and the
methods which we adopt to prevent or overcome the difficulty. Other
neuroses may be studied in less detail, because they depend for their
existence upon the same causes. For example, the habit of refusing
sleep, which is as common and almost as distressing as the habit of
refusing food, depends both upon a perversion of suggestion and upon
the phenomenon that we have called negativism.

If struggling and crying has occurred upon a series of nights, the
child comes to associate his bed not with sleep but with tears. If a
mother values her peace of mind, if she would spare herself the
discomfort of hearing her child sob himself nightly into uneasy sleep,
she must be wary how this all-important event of going to bed is
approached. With a nervous and restless child the preliminaries of
preparing for bed must be managed carefully and tactfully. The hour
before bedtime is almost universally the most interesting of the
whole day for the child. Then the baby, with his best frock on, and
books and toys, is the centre of interest in the drawing-room, till
the clock strikes and the nurse appears at the door. Suddenly it is
all over, and inexorable routine sends him off to bed. The good nurse
will give the child a little time to recover from the shock of her
arrival, and will not hurry him. She knows that his little mind is
slow to act, and that he must be led gradually to face a new prospect.
If she hurries him, catching him up in her arms from the midst of his
unfinished pursuits, resistance and tears are almost sure to follow,
and the difficult task of the day--the putting to bed--has made the
worst possible start. When this has happened on one or two successive
evenings, the habit of resistance to going to bed becomes fixed, and,
like all bad habits, is difficult to break. A nurse who has a way with
children will arouse his interest in a new pursuit, in which he can
play the chief part, the putting away of his picture books and toys.
If he is too small to carry his own chair or table to its allotted
place in the room, at least he can show his learning by pointing out
the spot. In the waving of good-byes he is expert and takes a
legitimate pride, and upstairs he has learnt that there are new
delights. He himself can turn on the taps in the bathroom, and he can
set every article in the proper place ready for use. All children love
their bath, and if interest and good temper has been so far preserved,
without a break, it will be ill-fortune if even the drying process is
not carried off without a hitch. Afterwards, for a little, nervous
babies, whose brains still teem with all the excitements of the day,
are best left to sit for a few moments by the nursery fire, while the
nurse puts all the garments one by one to bed. Each as it goes to rest
will be greeted by him with cheerful farewells; and so does the force
of suggestion act, till the central figure himself plays his part in
the scene, of which he feels himself the controller and director, and
climbs to bed. But if there has been a hitch anywhere, if the bugbear
of negativism has appeared, if he has been scolded or coaxed or
repressed too much and there have been tears and struggles, then going
to bed is a poor preparation for instant and quiet sleep.

With excitable, highly-strung children, the best laid plans and the
most tactful nurse will not always succeed, and to place him in his
cot is to provoke a storm of angry refusal and resistance. There are
mothers who believe that the best way is then to turn out the light
and leave the child to cry himself to sleep. This is a point on which
no one can lay down rules which are applicable for all children. It
may sometimes succeed, and the child may reason correctly and in the
way we wish him to reason, deciding that the game is not worth the
candle and so give it up. But with nervous, highly-strung children I
doubt if this Spartan conduct is commonly successful. Often if the
attempt is made, the troubled mother, listening to all these
heart-breaking sobs, can bear it no longer, and goes back to the side
of the cot to soothe and persuade him. Then certainly the longer she
has restrained her natural inclination, the longer the child has
sobbed himself into a pitiful little ball of perspiration and tears,
the more difficult will be her task in quieting him, the stronger will
be the impression formed on the child's mind, and the greater will be
the suggestion which will act under the same circumstances to-morrow.
Children who fall a prey to this uncontrolled crying, cry on because
they cannot stop when they have begun. They do not then cry purposely
or with a fixed intention, desiring to attain some object. They cry
because their minds are not at rest, but are irritated and overwrought
by the happenings of the day. We decided that it was useless to
attempt by exhortations at meal-times to induce a nervous child to eat
who habitually refuses food, and that we can only cure the condition
by eliminating from his daily life the elements of repression and
opposition which provoke the counter-opposition. And we must seek the
same solution in this other difficulty of the refusal of sleep. It is
useless to attempt to treat the symptom of refusal of sleep and to
leave the cause of that symptom still constantly in action.

If, in spite of our care to avoid unrest and irritation of the child's
brain, sleep is refused, as may often happen, it is, as a rule, wise
to cut short the crying if we can, before a vicious circle has been
formed and the unrest has been intensified by the emotional storm. It
is useless with little children to urge them to go to sleep or to
coax. It is not usually wise to leave the child for a little and then
to return. Each time the child is left, each time the mother or nurse
returns, the crying bursts forth again with renewed force and vigour.
It is at least one good plan with a little child to turn the light
out, and, treating the whole incident in the most matter-of-fact way
possible, lightly to stroke his head or pat his back rhythmically
without speaking. With older children, if the crying is more
purposeful and less emotional, the mother may busy herself for a
little with some task in the room, ostentatiously neglecting the storm
and making no reference to it. If she speaks to the child at all she
should do so in a matter-of-fact way, referring lightly to other
matters. If only she can convince him that his conduct is a matter of
indifference to her, the victory is won. It is because the child knows
so well that his mother does care that he so often has the upper hand.
It is not difficult to distinguish between a true emotional storm and
the tyrannous cry of a wilful child who demands his own way.

Light and broken sleep is a common accompaniment of a too excitable
and overstimulated brain. The placid child, who eats well, plays
quietly, and does not cry more than is usual, as a rule sleeps so
soundly that no ordinary sounds, such as conversation carried on in
quiet tones in his neighbourhood, have the power to waken him. When he
wakes, he does so gradually, perhaps yawning and stretching himself.
The nervous child may move at the slightest sound, or with a sudden
start or cry is wide awake at once. A hard mattress should be chosen
without a bolster, and with only a low pillow. Flannel pyjamas, which
cannot be thrown off in the restless movements of the child, should be
worn. The temperature of the room should be cool, and the air from the
open window should circulate freely, while draughts may be kept from
striking on the child by a screen. All the sensations of the nervous
child are abnormally acute. Thus, for example, an itching eruption, or
tight clothing, will produce an altogether disproportionate reaction,
and may result in a frenzy of opposition. Especially such a child is
sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool
rooms and warm but light and porous clothing are essential. An
electric torch, which can be flashed on the child for an instant, will
assist the mother or nurse to make sure that the child has not thrown
off all the bedclothing.

Sometimes want of sleep is accounted for by a real want of physical
exercise. Town children especially are apt to suffer from their
limited opportunities of running freely in the open. It is often
considered enough that the child seated in his perambulator should
take the air for three or four hours daily, while much of his time
indoors as well is devoted to sitting. It is necessary for his proper
development that he should have opportunities of daily exercise in the
open. If for any reason this is not always practicable, a large room,
as free as possible from furniture, should be chosen, with windows
thrown wide open, in which the child may romp until he is tired.

It is rare for children of two or of three years of age, whose case
we are now considering, to be troubled by bad dreams, nightmares, or
night-terrors. If these should occur, obstructed breathing due to
adenoid vegetations is sometimes at work as a contributory cause.

Finally, we should always remember that refusal of sleep is, for the
most part, caused and kept up by harmful suggestions derived from
mother and nurse, who allow the child to perceive their distress and
agitation, who speak before the child of his habitual wakefulness, who
unwittingly focus his attention on the difficulty. It is cured in the
moment that the suggestion in the child's mind is reversed, in the
moment when he comes to regard it as characteristic of himself not to
make a fuss about going to bed, but to sleep with extraordinary
readiness and soundness. Let every one join together to produce this
effect. Let the suggestion act strongly on his mind that all these
troubles of sleeplessness are diminishing, that night after night sees
an improvement, and soon his reputation as a good sleeper will be
established, and, as always with children, it will be rigidly adhered
to.

In assisting to break the habit of sleeplessness, and in the process
of altering the character of the suggestions which act on the child's
mind, we can be of the greatest assistance to the mother by
prescribing a suitable hypnotic. As to whether it is right in insomnia
in childhood to prescribe depressant drugs is a question on which very
various opinions are held. That it is wrong and probably ineffective
to trust entirely to the drugs is certainly true, but as a temporary
measure, to break the faulty suggestion and the bad habit, their use
is both legitimate and successful. The dose required in children
relatively to the adult is much smaller. In grown people, some
specific distress of mind, whether real or imaginary, may suffice to
resist very large doses of hypnotic. In children it is rare to find
the same resistance, and comparatively small doses have a very
constant effect. With deeper and more refreshing sleep, the conduct of
the child during the day almost always changes for the better. A sound
sleep, for a few nights in succession, will produce apparently quite a
remarkable change in the whole disposition of the child. When good
temper and interest take the place of fretfulness and restlessness, we
may confidently expect that the symptom of sleeplessness will begin to
abate. Sleeplessness by night and fretfulness by day form a vicious
circle, and attempts must be made to break it at all points.

Chloral occupies the first place as a hypnotic for young children. In
combination with bromide its effects are wonderfully constant and
certain. Two grains of chloral hydrate and two grains of potassium
bromide with ten minims of syrup of orange, given just before bedtime,
will bring sound sleep to a child of a year old. At three years the
dose may be twice as great, and three times at six years. It is seldom
that other means are required. Aspirin for children seems relatively
without effect. For children who are both sleepless and feverish, a
grain of Dover's powder, and a grain of antipyrin, for each year of
the child's age up to three, is very helpful. Lastly, if chloral and
bromide cannot break the insomnia, and the condition of the child is
becoming distressing, we can almost always succeed if we combine the
prescription with an ordinary hot pack for twenty minutes.




CHAPTER V

SOME OTHER SIGNS OF NERVOUSNESS


HABIT SPASM

Next to refusal of food and refusal of sleep perhaps the most frequent
manifestation of nervous unrest is provided by the group of symptoms
which we may call, with a certain latitude of expression, Habit
Spasms. By a habit spasm is meant the constant repetition of an action
which was originally designed to produce some one definite result, but
which has become involuntary, habitual, and separated from its
original meaning. The nervous cough forms a good example of a habit
spasm. A cough may lose its purpose and persist only as a bad habit,
especially in moments of nervousness, as in talking to strangers, in
entering a room, or at the moment of saying "How do you do" or
"Good-bye." Twitching the mouth, swallowing, elongating the upper lip,
biting the lips, wrinkling the forehead so strongly that the whole
scalp may be put into movement, and blepharospasm are all common
tricks of little children which may become habitual and uncontrolled.
In worse cases there may be constant jerking movements of the head,
nodding movements, or even bowing salaam-like movements. In mild
cases we may note hardly more than a restless movement of mouth or
forehead, or constant plucking or writhing of the fingers whenever the
child's attention is aroused, when he is spoken to, or when he himself
speaks. In nervous children these movements, which should properly be
confined to moments of real emotional stress, become habitual, and are
displayed apart from the excitement of particular emotions. Whatever
their intensity, habitual and involuntary movements of this nature
should not be overlooked, and should be regarded as evidence of mental
unrest. They do not commonly appear during the first or second years
of the child's life. They are more frequent after the age of five, but
they may begin to be marked as early as the third year. With refusal
of food and refusal of sleep they form the three common neuroses of
early childhood.

Two of the three qualities which we have mentioned as characteristic
of the child's mind are concerned in the causation of habit spasm. In
the early stages the movement is sometimes due to imitation, but the
susceptibility of the child to suggestion plays the chief part in
determining its persistence. It is an interesting speculation how far
tricks of gesture, attitude, or gait are inherited and how far they
are acquired by imitation. A child by some characteristic gesture may
strikingly call to mind a parent who died in his infancy. A whole
family may show a peculiarity of gait which is at once recognisable.
It is told of the son of a famous man, who shared with his father the
distinctive family gait, that when a boy his ears were once boxed by
an old gentleman who chanced to observe him hurrying to overtake his
parent, and who resented what he took to be an act of impertinent
caricature. In the reproduction by the child of the habitual actions
of his parents, heredity is largely concerned, but imitation too plays
its part. In habit spasm the force of imitation is clearly seen. A
child who has developed a habit spasm of one sort or another will
readily serve as a model to other children. The malady will sometimes
spread through a school almost with the force of a contagious
disorder. A child affected in this way may prove an unwelcome guest.
The little visitor with a trick of contorting his mouth and grimacing
is apt to leave his small host an expert in faithfully reproducing the
action. A cough that is genuine enough in one member of the family may
produce a crop of counterfeits in brothers and sisters.

The force of suggestion acting upon the child's mind can clearly be
traced. Once his attention is focused upon the particular movement by
unwise emphasis on the part of the parents, he loses the power to
control its occurrence. This trio of common neuroses--refusal of food,
refusal of sleep, and habitual involuntary movement--grows only in an
atmosphere of unrest and apprehension. Parents and nurses anxiously
watch their development. They are distressed beyond measure to note
their steady growth in spite of every attempt which they make to
control or forbid them. And of all this unrest and unhappiness the
child is acutely conscious. The whole household may become obsessed
with the misfortune which has befallen it, and the mother, losing all
sense of proportion, feels that she cannot regain her peace of mind
until it has been overcome. The child is in need of mental and moral
support from those around him, and all that he finds is an openly
expressed apprehension and sense of impotence. Even grown-up people,
when their nerves are on edge, are apt to be obsessed by
uncontrollable impulses or by vague and nameless apprehensions, and
surely all have learnt the support they gain from contact and
conversation with some one strong and sane, who treats their worries
in such a matter-of-fact way that immediately they lose their power
and become of no account. The child with habit spasm cannot control
these movements. The more he is reproved or entreated, the less able
does he find himself to hold them in check. He does not wish them to
continue. He has lost control of what he once controlled, and the
realisation of this is not pleasant, and may be alarming to him. Yet
when unconsciously he looks to his mother for support, he finds in her
open dismay that which serves only to increase his uneasiness. She
must subdue her own feelings and give the child strength. If she
treats the whole thing in a matter-of-fact way, as a temporary
disturbance which is of no importance in itself, and only has meaning
because it implies that the brain has been over-stimulated, she will
no longer exercise a prejudicial effect on the child. If the bad habit
is taken as a matter of course, if too much is not made of it, if the
child is encouraged to think that nobody cares much about it at all,
then recovery will soon take place. It goes without saying that habit
spasms and tics of all sorts are made worse by excessive emotional
display and by nervous fatigue. On the other hand, if the child
becomes absorbed in some interesting occupation, the movements will
disappear for the time being.


AIR SWALLOWING, THIGH RUBBING, THUMB SUCKING

At a somewhat earlier age than that in which habit spasms become
common, and before bed wetting appears as a formidable difficulty, we
meet with another group of habitual actions which yet retain their
voluntary character. Among such habitual actions are thumb sucking,
thigh rubbing, and air swallowing. If the child is old enough to
express himself on the subject, he will explain that these actions are
performed because of the satisfaction derived from them, because it is
"comfy" and "nice." Even if the child is too small to speak, the
expression is that of beatitude and content. These actions are not
confined to nervous children, and their occasional practice need not
be taken to imply that there is any strong element of nervous
overstrain. It is only when the action is repeated with great
frequency and persistence, and when signs of irritation ensue if
gratification is not obtained, that we are justified in classing it
among the symptoms of mental unrest.

The second of these actions, thigh rubbing, is found for the most
part in little girls, and inasmuch as it consists of a stimulation of
the sexual organs sometimes causes much distress to the parents. It is
in reality a habit of small importance unless exercised with very
great frequency. It is, of course, not associated in the child's mind
with any sexual ideas, and is of precisely the same significance as
the other two actions of the same class. Children who can speak will
refer to it openly without any sense of shame. As a rule the action is
performed in a half-dream state, that condition between sleeping and
waking which is found when the child is lying in the morning in her
cot or in her perambulator after the midday nap. The child's attention
should not be focused on the symptom. She should lie on a hard
mattress, and when she wakes in the morning she should either leave
her cot at once or she should be roused into complete wakefulness by
encouraging her to play with her toys. Little children should be
taught to sleep with their hands folded and placed beside the cheek.
If the movement occurs on going to sleep, it is best left alone and
completely neglected. As a rule each child has his or her own
favourite action of this class, and they are seldom combined in the
same child. If thigh rubbing is very constant and obstinate and does
not yield to the measures suggested, it may even sometimes be a
successful manoeuvre to substitute the thumb-sucking habit in the
expectation that this less distressing habit may eject the other more
objectionable action. As a rule, however, a wise neglect and careful
watching during the drowsy condition that follows sleep in a warm bed
will succeed in stopping the practice of thigh rubbing before the end
of the second or third year. Apparatus designed to restrain movement
of the child's legs or blistering the opposed surfaces of the thighs
are both of no effect. They have indeed the positive disadvantage that
they focus the child's attention on the practice. The habit ceases
only when the child has forgotten all about it, and these devices
serve only to keep it in remembrance. The same may be said of any
system of punishments. Further, we cannot always have the child under
observation, and at some time or other opportunity will be found for
gratification. Of older children, in whom self-control and a sense of
honour can be cultivated, I am not here speaking.

Air swallowing is less common than thigh rubbing, but belongs to the
same group of actions and takes place in the same drowsy condition.
The child will rapidly gulp down air which distends the stomach, and
is then regurgitated with a loud sound. Thumb sucking seldom
distresses the mother to the same extent, and the proper attitude of
tolerance is adopted towards it. If much is made of it, it is
astonishing how persistent the habit may become, surviving all
attempts to forbid it, to break it by rewards or punishments, or to
render it distasteful by the application of a variety of ill-tasting
substances smeared on the offending digit.

PICA AND DIRT EATING

Certain other bad habits will become ingrained if attention is called
to them, because of that curious spirit of opposition which
characterises little children, and because of their susceptibility to
suggestion. Some children will constantly pluck out hairs and eat
them, or will devour particles of fluff drawn from the blankets.
Others will seize every opportunity to eat unpleasant things, such as
earth, sand, mud, or dirt of any sort. All tricks of this sort are
best neglected and treated by attracting the child's attention to
other things. In adult life they are associated with serious mental
disturbance, in early childhood they are of little account, or at most
suggest a certain nervousness which may be due to nervous irritation
from faults of management which we must strive to correct.


CONSTIPATION

As has been already mentioned, much of the common constipation of the
nursery is due to neurosis. The excessive concentration of the nurse's
thoughts on this daily question communicates itself to the child. The
difficulty is emphasised, and an attempt is made to substitute will
power for forces of suggestion which are at once inhibited by
concentration of the mind upon the process. Here also, just as in the
refusal of food, a further stage of "negativism," that is, of active
resistance with crying and struggling, is reached, so that complaint
may be made by the mother that defæcation is painful. The same
negativism may be shown in micturition, and mothers will give
distressing accounts of the suffering of the child during the passing
of water.


BREATH-HOLDING AND LARYNGISMUS STRIDULUS

In some children, in the first two years of life, we find a definite
and measurable increase in the irritability and conductivity of the
peripheral nerves. The strength of current necessary to produce by
direct stimulation of the nerve a minimal twitch of the corresponding
muscle may be many times less than the normal. Of this heightened
irritability of the nervous system, to which the name "spasmophilia"
has been given in America and on the Continent, the most striking
symptom is a liability alike to tetany or carpo-pedal spasm, to
generalised convulsions, and to laryngismus stridulus. In addition, in
most cases it is generally possible to demonstrate the presence of
Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a
visible twitch of the facial musculature, especially of the
orbicularis palpebrarum or of the orbicularis oris, in response to a
gentle tap administered over the facial nerve in front of the ear.
Trousseau's sign is the production of tetany by applying firm and
prolonged pressure to the brachial nerve in the upper arm. The
ætiology of spasmophilia is still a matter for dispute, but the
evidence which we possess is in favour of the view that we have here
to deal with a disturbance of calcium metabolism. The calcium content
both of the blood and of the central nervous system has been shown to
be much lowered. It is in keeping with this that clinically we note
how frequently spasmophilia and rickets occur in the same child. In
some families the condition recurs through many generations.

For our present purpose--the examination of some common neuroses of
nursery life--it would be out of place to enter into a detailed
consideration of this disorder of spasmophilia as a whole. The symptom
of laryngismus stridulus--the so-called breath-holding--alone need
concern us, and that for a special reason. The spasm of the glottis is
produced under the influence of any strong emotion--in anger, for
example, or in fear, in excitement or in crying for any reason. To
control or prevent it we must direct attention not only to the
condition of spasmophilia, but also to the management of the children
who are always excitable and emotional. In these children every burst
of crying, however produced, whether by a fall, by a fright, by the
entrance of a stranger, or by a visit to a doctor, is apt to be
ushered in by a long period of apnoea, due to spasm of the glottis
and of the diaphragm. The first few expirations are not followed by
any inspiration. For several seconds the silence may be complete,
while the child steadily becomes more and more cyanosed, or the body
may be shaken by incomplete expiratory movements and strangled cries
which are suppressed because the chest is already in a position of
almost complete expiration. In the worst cases, when the apnoea
lasts a very long time, there may be convulsive twitching of the
muscles of the face, or the attack may even terminate in general
convulsions. Very occasionally the spasm is actually fatal. In all
fatal cases which have come to my notice the child at the moment of
death had been alone in the room. I have met with no fatal case where
the baby could be picked up and assisted. As a rule, therefore, the
cause and mode of death must be conjectural, but when an infant is
found dead in its cot unexpectedly, it would seem likely that it has
waked from sleep with a sudden start, become excited, and, about to
cry, has been seized by the fatal spasm. In two instances reported to
me a cat had been found in the room with the dead child, and it was
suggested that the animal had lain upon the child's face. Both these
children, however, were vigorous and capable of powerful movements of
resistance. I think it more likely that the cat may have awakened them
in fright, and that the emotional excitement, giving rise to the
spasm, was the cause of the suffocation. That the apnoea in these
extremely rare instances should end fatally produces a difficult
position for the doctor. It need hardly be said that the seizures are
alarming to the parents. For the sake of great accuracy in the
statement of our prognosis are we to add a hundred times to the
mother's alarm by stating the possibility of death? In each case we
must use our own judgment. I believe that in a child over a year old
the risk is almost negligible.

Fortunately in all save the rarest possible instances the apnoea
yields and a deep inspiratory movement follows. As the air rushes past
the glottis, which is still partially closed, a sound recalling the
whoop of pertussis is heard. Often this recurs throughout all the
burst of crying which follows, and each inspiration is accompanied by
a shrill stridulous sound. With the re-establishment of respiration
the cyanosis rapidly fades, to be succeeded in some cases by pallor
and perspiration.

It need hardly be said that we should do all in our power to prevent
these alarming and distressing attacks. Each seizure predisposes to a
repetition. In some children we notice that months and even years
after an attack of whooping-cough, a slight bronchial catarrh may be
sufficient to bring back the characteristic cough. In laryngismus in
the same way we may suppose that the reflex path is made easy and the
resistance lowered by constant use. Fortunately the spasms are not
usually difficult to control. Calcium bromide, in doses of from two to
four grains, according to age, three times daily, is generally
successful with or without the addition of chloral hydrate in small
doses. At the same time we must endeavour in every way possible to
keep the child calm, by paying close attention to nursery management.
The child with spasmophilia is as a rule excitable and easily upset,
and although calcium bromide is a drug which offers powerful aid it is
not able to achieve its effect unless we are able at the same time to
guarantee a reasonable immunity from emotional upsets. It is for this
reason that I have included some description of laryngismus, although
its origin is undoubtedly very different from that of the other
disorders of conduct which we have examined.


MIGRAINE AND CYCLIC VOMITING

The ætiology of cyclic or periodic vomiting in childhood is not yet
completely understood. We do not know how far it is dependent upon
disturbance of the liver, and it is still disputed whether the
acidosis which accompanies it is the cause or the result of the
profuse vomiting. Into these difficult questions we need not at the
moment enter. It is enough in the present connection to recognise that
the great majority of children who suffer from cyclic vomiting are
sensitive, excitable, and nervous, and that every one is agreed that
the nervous system is intimately concerned in its causation.

A close association between cyclic vomiting in children and that form
of periodic headache known as migraine has often been observed. It is
sometimes found that one or both parents of a child with cyclic
vomiting suffer habitually from migraine. In a few instances the one
condition has been observed to be gradually replaced by the other, the
child with cyclic vomiting becoming in adult life a sufferer from
migraine. There is indeed much which is common to the two conditions.
The periodic nature of the seizure, often following a time when the
general health and vigour appear to have been at their optimum, the
extreme prostration, and the comparatively sudden recovery are found
in both. In the cyclic vomiting of children, it is true, little
complaint is made of headache, the visual aura is absent, and the
vomiting is invariably the most prominent symptom.

Cyclic vomiting seldom occurs before the fourth year. It is
characterised by sudden profuse and persistent vomiting and by very
great prostration. All food, it may be even water, is promptly
rejected. The vomited matter is generally stained with bile;
occasionally the violence of the vomiting causes hæmatemesis. In many
cases the temperature is raised; sometimes it may be as high as 103°
F. The duration of an attack varies. In most cases it does not last
longer than forty-eight hours. On the other hand, attacks lasting as
long as a week are by no means unknown. Within a short time of the
onset the urine may be found to contain acetone bodies, the breath may
smell distinctly of acetone, and the child may become torpid and
drowsy or agitated and restless. At times there may be exaggerated and
deepened respiratory movements--the so-called air hunger. In many
cases, however, otherwise characteristic, these more severe
manifestations are absent or but little apparent. Recovery is usually
rapid and complete. The child asks for food, which is retained. A
fatal ending is very rare, though not unknown. The frequency of
attacks is very various. Sometimes months or even years may elapse
between successive seizures; in other cases a fortnightly or monthly
rhythm establishes itself.

It is clear that both the frequency and the severity of the attacks
are much influenced by the general state of the child's health. Like
migraine, cyclic vomiting appears to be a symptom of nervous
exhaustion. It affects, for the most part, children who are
intellectually alert, impressionable, and forward for their age, and
who, when well, throw themselves into work or play with a great
expenditure of nervous energy. Often their physical development is
unsatisfactory, and we must set ourselves to correct this as the first
step in prevention. It is highly important that children suffering in
this way should have free opportunities for exercise in the open
country, and that all the excretory organs--the skin, kidneys, and
bowels--should be acting freely and efficiently. The child should live
a life of ordered routine. Sleep should be sound and sufficient in
amount. The diet must not exceed the strict physiological needs. Many
of these children appear to have a lowered tolerance for fats of all
sorts, and it may be necessary to limit strictly the consumption of
milk, cream, butter, and so forth. A daily administration of a small
dose of alkali by the mouth is credited with preventing attacks. In
the present connection, however, we shall not do wrong to emphasise
the part played by the nervous system in the production of the
attacks. In all cases of cyclic vomiting it should be our endeavour to
recognise and remove the elements in the daily life of the child which
are proving too exhausting.

UNEXPLAINED PYREXIA

In nervous children we sometimes meet with inexplicable rises of
temperature. The pyrexia may have the same periodic character as that
just noted in cases of cyclic vomiting. At intervals of three, four,
or five weeks there may be a rise of temperature to 103° F., or even
higher, which may last for two or three days before subsiding. In
other cases the chart shows a slight persistent rise over many weeks
or months. That in nervous children the temperature may be very
considerably elevated without our being able to detect much that is
amiss does not of course make it any the less necessary to be careful
to exclude organic disease. Pyelitis, tuberculosis, and latent otitis
media occur with nervous children as with others and must not be
overlooked. If, however, organic disease can be excluded, and if the
pyrexia is the only circumstance which prevents the decision that the
child is well and should be treated as well, then the thermometer may
be overruled and the pyrexia neglected.




CHAPTER VI

ENURESIS


I have dealt in previous chapters with certain common disorders of
conduct in childhood, which show clearly their origin in the
apprehensions of the grown-up people who have charge of the children,
and in the unwise suggestions which they convey to them. The same
forces are at work in the production of enuresis, or bed wetting,
although the matter is here often complicated by the development later
on of a sense of shame and unhappiness in the child. There comes a
time when the child passionately desires to regain control and is
miserable about her failure, until the concentration of her thoughts
on the subject becomes a veritable obsession. Every night she goes to
bed with this only in her mind. Every night she falls asleep,
miserably aware that she will wake to find the bed wetted. The
suggestion impressed in the first place on the mind of the tiny child
by injudicious management has become fixed by the growing sense of
shame and the complete loss of self-confidence.

It is usually taught that a great variety of causes is concerned in
producing enuresis. It is said to be due to a partial asphyxia during
sleep from adenoid vegetation. It is said to be caused by phimosis,
and to be cured by circumcision. It is said that the urine is often
too acid and so irritating that the bladder refuses to retain it for
the usual length of time. It is said that enuresis may be due to a
deficiency of the thyroid secretion, and that it can be cured by
thyroid extract. Such a number of rival causes may make us hesitate to
accept the claims of any one of them. Certainly I have not been able
to satisfy myself that any one of these conditions exercises any
influence at all or is commonly present in cases of enuresis. I think
that if we examine a large number of cases of bed wetting in children
we can come to no other conclusion than that the cause of the trouble
is due to just such a pervasion of suggestion as we have been
considering above.

There are certain points in the behaviour of a child with enuresis
which seem to point to this conclusion.

_(a)_ In the first place, the trouble is seldom serious or very well
developed in early childhood, and the reason for this, I take it, is
that an occasional lapse in a child of perhaps two or three years of
age is usually treated lightly and in the proper spirit of tolerance.
It is only with children a little older that nurses and parents become
distressed and begin unwittingly by urging the child to present the
suggestion to her mind, that the bed may or will be wetted. Hence the
usual history is that control was partially acquired in the second
year, but that, instead of later becoming complete, relapses began to
be more frequent, and that since that time all that can be done seems
only to make matters worse.

_(b)_ In the second place, the influence of suggestion is shown by the
behaviour of the child when removed to a hospital for observation. It
is the invariable experience that the enuresis then promptly stops. In
hospital the attitude of those around the child is entirely different.
She has the comfortable and consoling feeling that in wetting the bed
she is doing exactly what is expected of her. There is even a feeling
that otherwise she is showing herself to be something of a fraud, and
that she has then been admitted to the hospital on false pretences.
Hence, perhaps for the first time in many years, the child is free
from the obsession, and the bed is not wetted.

_(c)_ In the third place, it is easy to recognise in the history of
many of the cases, the ill-effects of circumstances which add new
force to the fear of failure or shake the confidence in the control
which had been regained. Thus a boy, an only child, who had suffered
from enuresis till his seventh year, had regained complete control
till his eleventh year, when he went to school. In his dormitory at
school was a boy who had enuresis, and who was being fined and
punished by the schoolmaster. The enuresis at once reappeared and
continued unchecked so long as he was at school. As might be expected,
school life is very inimical to cure, unless the trouble can be kept
from the knowledge of the other boys. Anything which directly
increases the nervousness of the child--an illness, for example, with
loss of weight and failure of nutrition, or some mental stress, such
as the approach of an examination--is apt to accentuate the enuresis.

_(d)_ In the fourth place, the incontinence sometimes spreads to the
daytime, and the child is wet both by day and night. Further, in bad
cases it is not uncommon to find incontinence of fæces making its
appearance also. These extensions of the fault only take place when
the management continues to be very faulty, when the grown-up people
around them are more than usually distressed and pessimistic, and have
redoubled their expostulations and appeals.

Now these peculiarities of enuresis seem to me only explicable if we
assume that the want of control is due to auto-suggestion, dependent
at the beginning on the unwise attitude adopted towards the fault by
the nurses and parents, and later kept up by the sense of shame and
the mental distress involved.

The forms of treatment which have been recommended from time to time
are, as might be expected, very numerous.

_(a) Operative._--(i) Removal of tonsils and adenoids, (ii)
Circumcision.

_(b) Manipulative._--(i) Injection of saline solution under the skin
in the perineal and pubic regions, with object of lowering the
excitability of the bladder by counter-irritation. (ii) Gradual
distension of the bladder by hydrostatic pressure, (iii) Tilting the
foot of the bed so as to throw the urine to the fundus of the
bladder, in order to protect the sensitive trigone from irritation.

_(c) Educative._--(i) Curtailing the fluid drunk. (ii) Waking the
child at intervals during the night by an alarm clock or otherwise.
(iii) Rewards and punishments.

_(d) Medicinal._--(i) Belladonna. (ii) Thyroid extract.

_(e) By Suggestion._--(i) By simple suggestion. (ii) By hypnotic
suggestion.

I do not think that any single one of these various forms of treatment
outlined under the first four heads has any effect other than to aid
the suggestion of cure which we proffer in adopting it. Removal of
tonsils and adenoid vegetations might conceivably cure an enuresis
which is nocturnal, it cannot account for an incontinence which
spreads to the day. We might believe that to distend the bladder by
hydrostatic pressure was a cure for incontinence of urine, and that it
acted by removing the local cause,--the smallness and contraction of
the bladder,--were it not that the loss of control is so apt to spread
to the rectum as well. There is no evidence that the urine is
peculiarly irritating. Indeed, such evidence as we have goes to show
that, as in some other neuroses, the urine in enuresis is unduly
copious, and of very low specific gravity. Incidentally, we have in
this polyuria a further argument against the view recently advanced
that a small and contracted irritable bladder is the cause of
enuresis. We do, of course, meet with cases of irritable bladder often
enough, but the complaint is then not of incontinence, but always of
the discomfort of having to rise so frequently for micturition.

To deprive the child of fluid, to wake her many times at night, to
tilt the foot of the bed, are devices which may help in the hands of
some one who is confident of his ability to cure the condition and can
communicate the confidence to the child. Carried out hopelessly and
pessimistically by a tired and exasperated mother, they are well
calculated to strengthen the hold which the obsession has on the
child, so that often we meet with a mother who rightly enough
maintains that the more she wakes the child, the oftener the bed is
wet, till she wonders where it all comes from.

The treatment of enuresis to be successful must be conducted through
and by means of the grown-up persons who have the control of the
children. To stop the development of enuresis in early infancy we must
intervene to prevent the concentration of the child's mind on the
difficulty. During the time when control is ordinarily developed, in
the second and third year, judicious management of the child is
essential. The emphasis should be laid upon successes, not upon
failures. For every child his reputation will sway in the balance for
a time. He must be helped and encouraged to self-confidence, not
rendered diffident or self-conscious.

If the case is well established before it comes under our notice, the
mother, the nurse, the schoolmaster, or whoever is responsible for the
child's management, must understand clearly the nature of the trouble.
The suggestion acting on the child's mind must be altered, and
self-confidence restored. The child must learn to see that the thing
is not so desperately tragic. He should be told that the trouble
always gets well, and that it only goes on now because he is worried
about it and keeps thinking of it. If the whole environment of the
child is bad, so that such a change of suggestion is not possible, and
if enuresis is but one of many symptoms of mental or moral
instability, it may be necessary to remove the child and place him
under the influence of some one else. Sometimes the prescription of a
rubber urinal, which the child can slip on at night, is directly
curative. A public school boy, who was about to be sent away from
school for this failing, fortified by the possession of this
apparatus, wrote six months later to say that he knew now that it must
be all worry that caused the trouble, because with the urinal in
position he had not once had the incontinence.

In inveterate cases hypnotic suggestion is always, I think,
successful. It is obvious, however, that in many cases there are
objections to its use. Often enuresis is evidence that the child's
home environment has been at fault, and that his mental and moral
development has been retarded. It is the management which must be
modified or the home, if necessary, changed. Hypnotic suggestion will
make this one symptom disappear promptly enough, but it will rather
perpetuate than combat the cause--that undue susceptibility to
suggestion, which is characteristic alike of the little child and of
many older neuropathic persons.




CHAPTER VII

TOYS, BOOKS, AND AMUSEMENTS


Any one who has an opportunity of watching little children must have
observed that they are happiest and most contented when playing alone.
The education of the little child is carried on by means of games and
toys. Handling the various objects which we give him, imparting
movement to them, transferring them from hand to hand and from one
situation to another, he learns dexterity and precision of movement,
and in the process hand and brain grow in power. When at play, his
whole energies should be absorbed to the exclusion of everything else.
He will often be oblivious to everything that is going on around him,
intent only on the purpose of the moment. In order to permit this
fervour of self-education it is necessary that the child should be
accustomed to playing alone, and it is well, if only for convenience'
sake, that he should be accustomed to playing in a room by himself.
Something is wrong if the child cannot be left for a few moments
without breaking into tears or displaying bad temper. Engrossed in his
own tasks, he should be content to leave his nurse to move in and out
of the room without protest. If this fault has appeared and the child
cannot be left alone, our whole educational system is undermined, and
play will be profitless and over-exciting, because it demands the
constant participation of grown-up people. As a preliminary to all
improvement in the management of a nervous child, we must see to it
that he becomes accustomed to being alone. We must so arrange his
nursery that he can do no damage to himself. Scissors and matches must
not be left lying about, and a fireguard must be fixed in position so
that it cannot be disturbed. Then, disregarding his protests, the
nurse must leave him to himself, at first only for a moment or two,
re-entering the room in a matter-of-fact way without speaking to him,
and again leaving it. Soon he will learn that a temporary separation
does not mean that we have abandoned him for all time. Then the period
of absence can be gradually lengthened till all difficulty disappears.
Once his attention is removed from the grown-up people who mean so
much to him, his natural impulse to explore and experiment with his
playthings will show itself. Those toys are best which are neither
elaborate nor expensive. For a little child a small box containing a
miscellaneous collection of wooden or metal objects, none of them
small enough to be in danger of being swallowed, forms the material
for which his soul craves. Everything else in the room may be out of
his reach. A dozen times he will empty the box and then replace each
object in turn. He will arrange them in every possible combination,
and then sweep the whole away to start afresh.

At eighteen months of age observation and imitative capacity will
have made more complex pursuits possible. As a rule the objects which
are most prized and which have most educative value are those which
lend themselves best to the actions with which alone the child is
familiar. Hence the supreme importance of the doll and the doll's
perambulator. The doll will be treated exactly as the child is treated
by the nurse. It will be washed, and dressed, and weighed, and put to
bed in faithful reproduction of what the child has daily experienced.
Dusting, and sweeping, and laying the table will be exactly copied. If
a child has no opportunity of being familiar with horses, if he has
not seen them fed, and watered, and groomed, and harnessed, he may not
find any great satisfaction in a toy horse, or pay much attention to
it, no matter how costly or realistic it may be.

In the third year more precise tasks, such as stringing beads,
drawing, and painting, will play their part, while at the same time
the increased imaginative powers will give attraction to toy soldiers
or a toy tea-service. Playing at shop, robbers, and rafts are
developments of still later growth. In the child's games we recognise
the instinct of imitation--playing with dolls, sweeping and dusting,
playing at shop or visitors; the instinct of constructiveness--making
mud pies and sand castles, drawing or whittling a stick; and the
instinct of experiment--letting objects fall, rattling, hammering,
taking to pieces. All this activity must be encouraged, never unduly
repressed or destroyed. But whatever form it takes, the bulk of the
play must be carried on without the intervention of grown-up persons,
or it will lose its educative value and prove too exacting. If
grown-up people attempt to take part, the child will lose interest in
the play and turn his attention to them.

Children differ very much in their attitude towards books. One child
quite early in the second year will be happy poring over picture
books, while another will seldom glance at the contents and finds
pleasure only in turning over the pages, opening and shutting them,
and carrying them from place to place. Such differences are natural
enough and foreshadow perhaps the permanent characteristics that
divide men and women, and produce in later life men of thought and men
of action, women who are Marthas and women who are Marys.
Nevertheless, we should bear in mind that there is danger in a
training that is too one sided, and that books and toys have both
their part to play in developing the powers of the child. All the
activities of the child should be used in as varied a way as possible.
The eye is but one doorway to knowledge and understanding, the ear is
another, the hand a third.

From pictures an imaginative child will derive very strong
impressions, and mothers should be careful in their choice. It is
foolish to confuse the growth of æsthetic perceptions by presenting
children with books which depict children as grotesquely ugly beings
with goggle eyes and heads like rubber balls. Children love animals
and endow them with all their own reasoning attributes, and in
stories of the home life of rabbits, and bears, and squirrels they
take a pure delight. Books of the "Struwwelpeter" type are less to be
recommended. The faults which they are intended to eradicate become
peculiarly attractive from much familiarity. A little boy of two and a
half who resolutely refused all food for some days was in the end
detected to be playing the part of that Augustus, once so chubby and
fat, who reduced himself to a skeleton, saying, "Take the nasty soup
away; I don't want any soup to-day." Tales of naughty children who
meet with a distressing fate may either frighten the child unduly, or
else produce in a child of inquiring mind the desire to brave his fate
and put the matter to the test. Pictures should not be terrifying or
horrible. Ogres devouring children are out of place as subjects for
pictures and may cause night-terrors.

Children should be taught to be careful of books and toys. The
indestructible book, generally falsely so called, is often responsible
for the immediate dissolution of all others less protected which come
to hand. The sympathy which little children have with the sufferings
of all inanimate objects and their habit of endowing them with their
own sensations may be made of use in teaching them care and
gentleness. They are naturally prone to sympathise with the doll that
has been crushed or the book that has been torn. They will learn very
easily to be kind to a pet animal and to be solicitous for its
feelings, and the lesson so learnt will be applied to inanimate
objects as well.

There is, however, another side to the question. It is true that if
the child is not to be over-stimulated upon the psychical side, we
must see to it that his play, for the most part, is not dependent upon
the participation of grown-up persons. In practice this excessive
stimulation is the common fault with which we meet. There are few
children in well-to-do homes, with loving mothers and devoted nurses,
who suffer from too little mothering and nursing. Too many show signs
of too much. To observe the opposite fault we must seek the infants
and children who for a long time are inmates of institutions,
orphanages, infirmaries, hospitals, and so forth. In such surroundings
the mental life of the child may languish. His physical wants are
cared for, but there the matter ends. In a rigid routine he is washed
and fed, but he may not be talked to or played with or stimulated in
any way. His day is spent passively lying in his cot, unnoticed and
unnoticing. I have seen a poor child of three years just released from
such a life, and after eighteen months returned to his mother, unable
to talk and almost unable to walk, crying pitifully at the novelty and
strangeness of the noisy life to which he had returned, worried by
contact with the other children, and without any desire or power to
occupy himself in the home. For an hour in the day mothers may devote
themselves wholeheartedly to the children, and if they set them
romping till they are tired out, so much the better. In the garden or
in an airy room with the windows open, a game with a ball or a toy
balloon, or a game of hide-and-seek, will be all to the good, and the
children may climb and be rolled over and swung about to their heart's
content. With an only child, especially with a child whose home is in
town, and whose outings are limited to a sedate airing in the park,
such free play is especially necessary. It may help more than anything
else to quiet restless minds and tempers that are on edge all day long
from excessive repression.

On the other hand, those forms of entertainment which are known as
"children's parties" are generally fruitful of ill results, at any
rate with nervous and highly-strung children. Sometimes they entail a
postponement of the usual bedtime, and nearly always they involve
over-heated and crowded rooms. Perverse custom has decreed that these
gatherings shall take place most commonly in the winter, when dark and
cold add nothing to the pleasure and a great deal to the risk of
infection which must always attend the crowding of susceptible
children together in a confined space with faulty ventilation. There
is clearly on the score of health much less objection to summer garden
parties for children, but these for some reason are less the vogue. As
a rule parties are not enjoyed by nervous children. There is intense
excitement in anticipation, and when at length the moment arrives,
there is apt to be disillusion. Either the excitement of the child may
pass all bounds and end in tears and so-called naughtiness, or the
unfamiliar surroundings may leave him distrait with a strange sense of
unreality and unhappiness. It is not always fair to blame the want of
wisdom in his hostess's choice of eatables, if the excited and
overstimulated child fails in the work of digestion and returns to the
nursery to suffer the reaction, with pains and much sickness.

The same arguments may be urged against taking little children to the
theatre. The nerve strain is apt to be out of proportion to the
enjoyment gained. If children must go to theatres and parties, the
treat should be kept secret from them until the moment of its
realisation, in order that the period of mental excitement should be
contracted as much as possible, and grown-up people should be advised
to treat the whole expedition in a matter-of-fact sort of way that
does nothing to add to the excitement or increase the risk of
subsequent disillusion.




CHAPTER VIII

NERVOUSNESS IN EARLY INFANCY


We may now pass back to consider the nervous system of the child in
infancy. There, too, from the moment of birth there are clearly-marked
differences between individuals. The newborn baby has a personality of
his own, and mothers will note with astonishment and delight how
strongly marked variations in conduct and behaviour may be from the
first. One baby is pleased and contented, another is fidgety,
restless, and enterprising. At birth the baby wakes from his long
sleep to find his environment completely changed. Within the uterus he
lies in unconsciousness because no ordinary stimulus from the outer
world can reach him to exert its effect. He lies immersed in fluid,
which, obeying the laws of physics, exercises a pressure which is
uniformly distributed over all points of his body. No sound reaches
him, and no light. After birth all this is suddenly changed. The sense
of new points of pressure breaks in upon his consciousness. Cold air
strikes upon his skin. Loud sounds and bright lights evoke a
characteristic response. A placid child who inherits a relatively
obtuse nervous organisation will be but little upset by this sudden
and radical change in the nature of his environment. His brain is
readily but healthily tired by the new sensations which stream in from
all sides, and he falls straight away into a sleep from which he
rouses himself at intervals only under the impulse of the new
sensation of hunger.

Babies of nervous inheritance, on the other hand, will show clearly by
the violence of the response provoked that their nervous system is
easily stimulated and exhausted. They will wriggle and squirm for
hours together, emitting the same constant reflex cry. The whole body
will start convulsively at a sudden touch or a loud sound which would
evoke no response from a more stolid infant. The sleeplessness and
crying exhaust the baby, rendering the nervous system more and more
irritable, while the sensation of hunger which is delayed in other
children by twelve hours or more of deep sleep appears early and is of
extreme intensity. We must see to it that sense stimuli are reduced to
the lowest possible level. True, we cannot again restore the child to
a bath of warm fluid, of the same temperature as his body, where he
can be free from irksome pressure and from all sensations of sound and
light, but we can so arrange matters that he is not disturbed by loud
sounds and bright lights, and that he is not moved more than is
necessary. Sudden unexpected movements are especially harmful. Jogging
him up and down, patting him on the back, expostulation, and
entreaties are all out of place and do all the harm in the world. The
first bath should be as expeditious as possible, and above all the
baby must not be chilled by tedious exposure. Cold irritates his
nervous system more than anything else, unless it be excessive warmth.
In preserving the proper temperature so that we do not render the
child restless by excess of heat or by excess of cold, we
too-civilised people have made our own difficulties. We have
exaggerated the completeness of the sudden separation of mother and
child which nature decrees. It is the function of all mother animals
to approximate the unstable temperature of the newly born to their own
by the close contact of their bodies, which provide just the proper
heat. Labour is nowadays so complicated and exhausting a process for
mothers that, all things considered, we are wise in completing the
separation of mother and child and in removing the baby to his own
cot. But the difficulty remains, and we must arrange that any
artificial heating needed is constant and of proper degree.

If the baby is very restless and irritable, too wide awake and too
conscious of his surroundings, the all-important task of getting him
to the breast and getting him to draw the milk into the breast is apt
to be difficult. His sucking is a purely reflex and involuntary act.
It can be produced by anything which gently presses down the tongue,
and a finger placed in the proper position will provoke the movement
without the child's consciousness being aroused. The placid child
whose mind is at rest will suck well and strongly. If, on the other
hand, the brain is too much stimulated and the child is restless and
irritable, the reflex act of suction is inhibited, and it is a
difficult matter to get the child to the breast. He is too eager,
mouthing, and gulping, and spluttering. Or sometimes his mental
sufferings seem too much for his appetite, and though wide awake and
crying loudly, he refuses to grasp the nipple, turning his head away
and wriggling blindly hither and thither. This effect of mental unrest
on the newborn infant is often disastrous, because it is one of the
common causes of the failure of women to nurse their children. This is
not the place to sketch in detail a scheme for the proper technique of
breast nursing, a matter which is much misunderstood at the present
day. It will be enough shortly to say that an efficient supply of milk
depends upon the complete and regular emptying of the breast. The
breasts of all mothers will secrete milk if strong and vigorous
suction is applied to the nipple by the child. If anything interferes
with suction, the milk does not appear or, if it has appeared, it
rapidly declines in amount. The mother's part is to a great extent a
passive one, provided that she can supply one essential--a nipple that
is large enough for the child to grasp properly. Within wide limits
what the mother eats or drinks, whether she be robust or whether she
has always been something of an invalid, matters not at all. A frail
woman may naturally not be able to stand the strain of nursing for
many months, but that is not here the point in question. We are
dealing only with the establishment of lactation and with the milk
supply of the early days and weeks which is of such vital importance
for the child. If the mother is ill, if, for example, she has
consumption, we may separate her from the child in the interests of
both; but if this is not done, she will continue to secrete milk for a
time as readily as if she were in perfect health, and the breasts of
many a dying woman are to be seen full of milk. Mothers are too apt to
attribute the disappointment of a complete failure to nurse to some
weakness or want of robustness in their own health. This is never the
reason of the failure, and the fault, if the mother has a well-formed
nipple, is generally to be found in some disturbance in the child.
Prematurity, with extreme somnolence, breathlessness from respiratory
disease, nasal catarrh, which hinders breathing through the nose,
infections of all sorts, are common causes of this failure to suck
effectively. But perhaps the most common cause of all is the
inhibition from nervous unrest of that reflex act of sucking which
works so well in the placid and quiet child. It is a point to which
too little attention is paid, and mothers and the books which mothers
read commonly neglect the nervous system of the child and devote
themselves to such considerations as the relative merits of two-hourly
and four-hourly feedings--important points in their way, but less
important than this.

The matter is complicated in two other ways. In the first place, the
nervous baby, just because he is so active and wakeful and restless,
is apt rapidly to lose weight and to have an increased need for food.
The restlessness is generally attributed to hunger, and this is true,
because hunger is soon added to the other sensations from which he
suffers, and like them is unduly acute. It is difficult not to give
way and to provide artificial food from the bottle. Yet if we do so we
must face the fact that these restless little mortals are quicker to
form habits than most, and once they have tasted a bottle that flows
easily without hard suction, they will often obstinately refuse the
ungrateful task of sucking at a breast which has not yet begun to
secrete readily. The suction that is devoted to the bottle is removed
from the breast, and the natural delay in the coming in of the milk is
increased indefinitely. At the worst, the supply of milk fails almost
at its first appearance. We must devote our attention to quieting the
nervous unrest by removing all unnecessary sensory stimulation from
the baby. He must be in a warm cot, in a warm, well-aired, darkened,
and silent room, and the necessary handling must be reduced to a
minimum. Sometimes sound sleep will come for the first time if he is
placed gently in his mother's bed, close to her warm body. If he is
apt to bungle at the breast from eagerness and restlessness, it is not
wise always to choose the moment when he has roused himself into a
passion of crying to attempt the difficult task. So far as is possible
he should be carried to the breast when he is drowsy and sleepy, not
when he is crying furiously, and then the reflex sucking act may
proceed undisturbed.

In the second place, we must guard against the ill effect which the
ceaseless crying of these nervous babies has upon the mother. She may
be so exhausted by the labour that her nerves are all on edge, and she
grows apprehensive and frightened over all manner of little things.
The tired mother is apt to fear that she will have no milk, and her
agitation grows with each failure on the part of the child. Now the
first secretion of milk is very closely dependent upon the nervous
system of the mother. We have said that within wide limits her
physical condition is of less importance, but her peace of mind is
essential. And so it is wise for some part of the day to keep the
nervous baby out of hearing of the mother, and so far as possible to
choose moments when the child is quiet to put him to the breast. A
nurse with a confident, hopeful manner will effect most; a fussy,
over-anxious, or despondent attitude will do untold harm. We shall
sometimes fail if the nervous unrest is very obstinate either in
mother or in child, but we shall fail less often if we diagnose the
cause correctly in the cases we are considering. Lastly, it is
possible to control the condition in both mother and child by the
careful use of bromide or chloral.

It is not, of course, suggested that these drugs should be given
freely or as a routine to every hungry baby wailing for the breast, or
that we can hope to combat or ward off an inherited neuropathy by a
few doses of a sedative. There are, however, not a few babies in whom
there develops soon after birth a sort of vicious circle. They can
suck efficiently and digest without pain only when they sleep soundly.
If they are put to the breast after much crying and restlessness,
each meal is followed by flatulence, colic, and renewed crying. The
only effective treatment is to secure sleep and to carry a slumbering
or drowsy infant to the breast. Then the sucking reflex comes to its
own again, the breast is drained steadily and well, and digestion
proceeds thereafter without disturbance and during a further spell of
sleep. Two or three times in the day we may be forced, as meal-time
approaches, to cut short the restlessness of the child by giving a
teaspoonful of the following mixture:

Pot. brom.,           grs. ii. [2 grains]

Chloral hydrate,      gr. i. [1 grain]

Syrup,                M x. [10 minims]

Aq. menth. pip., ad   3 i. [1 dram]

After this has been taken the child should be laid down for a quarter
of an hour until soundly asleep. Then very gently he can be carried to
his mother and the nipple inserted. If in this way a few days of sound
sleep and less disturbed digestion can be secured, the difficulty will
in most cases permanently be overcome. The steadier suction and more
efficient emptying of the breast will promote a freer flow of milk,
and the deeper and more prolonged sleep will lower greatly the needs
of the child for food. Most of the babies who show this fault are
thin, meagre, and fidgety, and with some increase of muscular tone.
The head is held up well, the limbs are stiff, the hands clenched, the
abdomen retracted, with the outline of the recti muscles unusually
prominent. If we can relax this exaggerated state of nervous tension,
if we can help them to become fatter and to put on weight, the
dyspepsia will disappear with the other symptoms.

It is a question still to be answered whether the rare conditions of
pyloric spasm and pyloric hypertrophic stenosis are not further
developments of the same disturbance. Certainly these grave
complications appear most commonly in infants with a pronounced
nervous inheritance, and, as might be expected, they are more commonly
found in private practice than among the hospital classes.

In passing, we may note that there are babies who exhibit the opposite
fault, and in whom the contrary regimen must be instituted. Premature
children, children born in a very poor state of nutrition, and
children born with great difficulty, so that they are exhausted by the
violence of their passage into the world, are apt to show the opposite
fault of extreme somnolence. They are so little stimulated by their
surroundings, and they sleep so profoundly, that the sucking reflex is
not aroused. Put to the breast they continue to slumber, or after a
few half-hearted sucking movements relapse into sleep. We must rouse
such children by moving them about and stirring them to wakefulness
before we put them to the breast.

Once the child has been got to the breast, once the milk has become
firmly established, we have overcome the first great difficulty which
besets us in the management of nervous little babies, but it is by no
means the last. Restlessness and continual crying must be combated or
digestion suffers, and may show itself in a peculiar form of explosive
vomiting, which betokens the reflex excitability and unrest of the
stomach.

The sense of taste is as acute as all other sensations. If the child
is bottle-fed, the slightest change in diet is resented because of the
unfamiliar taste, and the whole may promptly be rejected. The tendency
to dyspeptic symptoms is apt to lead to much unwise changing of the
diet, and everything tried falls in turn into disrepute, until perhaps
all rational diets are abandoned, and some mixture of very faulty
construction, because of its temporary or accidental success, becomes
permanently adopted--a mixture perhaps so deficient in some necessary
constituent that, if it is persisted with, permanent damage to the
growth of the child results. We must pay less attention to changes of
diet and explore our management of the child to try and find how we
can make his environment more restful.

It is wise to accustom a nervous child from a very early age to take a
little water or fruit juice from a spoon every day. Otherwise when
breast-feeding or bottle-feeding is abandoned one may meet with the
most formidable resistance. Infants of a few months can be easily
taught; the resistance of a child of nine months or a year may be
difficult to overcome. The difficulty of weaning from the breast
recurs with great constancy in nervous children. By this time the
influence of environment has become clearly apparent. The child is
often enough already master of the situation, and is conscious of his
power. Such children will sometimes prefer to starve for days
together, obstinately opposing all attempts to get them to drink from
a spoon, a cup, or even a bottle. When this happens, sometimes the
only effective way is to change the environment and to send the baby
to a grandmother or an aunt, where in new surroundings and with new
attendants the resistance which was so strong at home may completely
disappear. When weaning is resented, and difficulties of this sort
arise, it is clear that the mother, whose breast is close at hand, is
at a great disadvantage in combating the child's opposition.

For nervous infants, alas! broken sleep is the rule. What, then, is to
be done? It is astonishing to me that any one who has studied the
behaviour of only a few of these nervous and restless infants should
uphold the teaching that the crying of the young infant is a bad
habit, and that the mother who is truly wise must neglect the cry and
leave him to learn the uselessness of his appeals. It is true that the
youngest child readily contracts habits good or bad. Either he will
learn the habit of sleep or the habit of crying. Mercifully the
inclination of the majority is towards sleep. But to encourage habits
of restlessness and crying there is no surer way than to follow this
bad advice and to permit the child to cry till he is utterly exhausted
in body and in mind. It is unwise _always_ to rock a baby to sleep; it
is also unwise to allow him to scream himself into a state of
hysteria. A quiet, darkened room, the steady pressure of the mother's
hand in some rhythmical movement, will often quiet an incipient
storm. The longer he cries, the more trouble it is to soothe him.
Sleep provokes sleep, so that often we find restlessness and sound
sleep alternating in a sort of cycle, a good week perhaps following a
bad one. The nurse who is quick to cut short a storm of crying and to
soothe the child again to sleep is helping him to form habits of
sleep. The nurse who leaves him to cry, believing that in time he will
of his own accord recognise the futility of his behaviour, is making
him form habits of crying. A rigid routine in sleep is a good thing,
but the routine belongs to the baby, not to the nurse. The child must
be educated to sleep, not taught to cry. A baby has but little power
of altering his position when it becomes strained or uncomfortable. He
cannot turn over and nestle down into a new posture. If we watch him
wake, the first stirring may be very gradual, and in a moment he may
fall again to sleep. A few minutes later he stirs again more strongly,
and is wider awake and for longer. It may only be after a third
waking, by a summation of stimuli, that he is finally roused and
breaks into loud crying. The nurse who is on the watch, who, sleeping
beside him, wakes at the slightest sound and is quick to turn him over
and settle him into a new position of rest, will probably report in
the morning that the baby has had a good night. The nurse who lets the
child grow wide awake and start crying loudly, will spend perhaps many
hours before quiet is again restored. Of the voluntary, purposive
crying of infants a little older I am not here speaking. Infants in
the second six months are quite capable of establishing a "Tyranny of
Tears" and feeling their power. Fortunately it requires no great
experience to distinguish one from the other, and to adopt for each
the appropriate treatment.

Again, in elementary teaching upon the management of infants stress is
laid, rightly enough, upon the importance of regularity in the times
of feeding, and on the observance in this respect also of a very
strict routine. But in the case of the very nervous infant a certain
latitude should be allowed to an experienced nurse or mother. We may
wreck everything by a blind adhesion to a too rigid scheme, which may
demand that we leave the child to scream for an hour before his meal,
or that, when at length he has fallen into a sound sleep after hours
of wakefulness, we should proceed to wake him.

Symptoms of dyspepsia which are due to continued nervous excitement
demand treatment which is very different from that which would be
appropriate to dyspepsia which is due to other causes, such as
overfeeding or unsuitable feeding. The temporary restriction of food,
which is commonly ordered in dyspepsia from these causes, is very
badly supported by the nervous infant. Hunger invariably increases the
unrest, and the unrest increases the dyspepsia.

The difficulties of managing a nervous infant are very real, and call
for the most exemplary patience on the part of the mother and the
clearest insight into the nature of the disturbance.




CHAPTER IX

MANAGEMENT IN LATER CHILDHOOD


In the early days in the nursery the actions of the infant, for the
most part, follow passively the traction exercised by nurses and
mothers, sometimes consciously, but more often unconsciously. We have
now to consider a period when the child becomes possessed of a driving
force of his own, and moves in this direction or that of his own
volition. In this new intellectual movement through life he will not
avoid tumbles. He will feel the restraints of his environment pressing
upon him on all sides, and he will often come violently in contact
with rigid rules and conventions to which he must learn to yield. From
time to time we read in the papers of some terrible accident in a
picture-palace, or in a theatre. Although there has been no fire,
there has been a cry of fire, and in the panic which ensues lives are
lost from the crowding and crushing. Yet all the time the doors have
stood wide open, and through them an orderly exit might have been
conducted had reason not given place to unreason. It is the task of
those responsible for the children's education to guide them without
wild struggling along the paths of well-regulated conduct towards the
desired goal, influenced not by the emotions of the moment, but only
by reason and a sense of right; not ignorant of the difficulties to be
met, but practised and equipped to overcome them.

It is easy thus to state in general terms the objects of education,
and the need for discipline. To apply these principles to the
individual is a task, the immeasurable difficulty of which we are only
beginning to appreciate with the failure of thirty years of compulsory
education before us. A recent writer[2] gives it as his opinion that
the aim of education is to equip a child with ideals, and that this
task should not be difficult, because the lower savages successfully
subject all the members of their tribe to the most ruthless
discipline. Their lives, he says, "are lived in fear, in restraint, in
submission, in suffering, subject to galling, unreasoning,
unnecessary, arbitrary prohibitions and taboos, and to customary
duties equally galling, unreasoning, unnecessary, and arbitrary. They
endure painful mutilations, they submit to painful sacrifices.... How
are these wild, unstable, wayward, impulsive, passionate natures
brought to submit to such a rigorous and cruel discipline? By
education; by the inculcation from infancy of these ideals. In these
ideals they have been brought up, and to them they cling with the
utmost tenacity." One might as well contend that it was easy to teach
all men to live the self-denying life of earnest Christians because
some savage tribe was successful in maintaining among its members a
universal and orthodox worship of idols. The ideals set before the
child are too high and too complex to be inculcated by physical force,
or even by force of public opinion. A rigid discipline, with many
stripes and with terrible threats of a still worse punishment in the
world to come, was the almost invariable lot of children until the
last century was well advanced. Yet has this drastic treatment of
young children fulfilled its purpose? Were the men of fifty years ago
better conducted and more controlled than the men of to-day? In any
one family did a greater proportion turn out well? Is it not true that
at least among the educated classes the relaxation of nursery and
schoolroom discipline which the last fifty years has seen has been
justified by its results? Is it not true that the childhood of our
grandmothers was often lived "in fear, in restraint, in submission, in
suffering subject to galling, unreasoning, unnecessary, arbitrary
prohibitions and taboos, and to customary duties equally galling,
unreasoning, unnecessary, and arbitrary." And though perhaps the
grandmothers of most of us may not have been much the worse for all
this discipline, is it not true that of the little brothers who shared
the nursery with them a surprising number broke straightway into
dissipation when the parental restraints were removed? If we are to
teach a child to be gentle to the weak it is not wise to beat him. The
qualities which we wish him to possess are not more subtle than the
means by which we must aid him to their possession.

[Footnote 2: _The Principles of Rational Education_, by Dr. C.A.
Mercier.]

Education comprises physical, mental, and moral training. In earlier
times physical strength and the power to fight well, alone were prized
and were the chief objects to be gained in the education of youth.
Later, under the stress of intellectual competition for success in
life, mental acquirements have come to occupy the first place. We are
only now learning to lay emphasis upon the supreme need for moral
training. Not that it is possible to separate the sum of education
into its constituent parts, and to regard each as distinct from the
others. That many men of great intellectual activity, and many men
pre-eminent for their moral qualities have harboured a great brain or
a noble character in a weakly or deformed body, forms no argument to
disprove the general rule that a healthy, vigorous physique is the
only sure foundation upon which to build a highly developed intellect
and a stable temperament. In childhood the intimate connection between
vigour of mind and vigour of body is almost always clearly shown. A
child with rickets, unable to exercise his body in free play, as a
rule shows a flabbiness of mind in keeping with his useless muscles
and yielding bones. Such children talk late, are infantile in their
habits and ways of thought, and are more emotional and unstable than
healthy children of the same age. The connection between bodily
ailments and instability of nervous control is even more clearly seen
in the frequent combination of rheumatism and chorea. A very high
proportion of older children suffering from the graver neuroses, such
as chorea, syncopal attacks, phobias, tics, and so forth, show
defective physical development. Scoliosis, lordosis, knock-knee, flat
foot, pigeon chest, albuminuria, cold and cyanosed extremities, are
the rule rather than the exception. If the body of the child is
developed to the greatest perfection of which it is capable we shall
not often find a too sensitive nervous system. The boy of fine
physique may have many faults. He may be bad-tempered or untruthful or
selfish, but such faults as he has are as a rule more primitive in
type, more readily traced to their causes, and more easy to eradicate
than the faults which spring from that timidity, instability, and
moral flabbiness which has so often developed in the lax delicate
child reared softly in mind and body.


PHYSICAL TRAINING

Children thrive best in the healthy open-air life of the country, and
if there is any tendency to nervous disturbances the need for this
becomes insistent. Physical training, further, includes the manual
education of the child. The system of child-training advocated by Dr.
Montessori is based upon the cultivation of tactile sensations and the
development of manual dexterity. Exercises such as she has devised
have an immediate effect in calming the nervous system and in changing
the restless or irritable child into a self-restrained and eager
worker. Lord Macaulay, whose phenomenal memory as a child has become
proverbial, was so extraordinarily unhandy that throughout life he had
considerable difficulty in putting on his gloves, while he had such
trouble with shaving that on his return from India there were found in
his luggage some fifty razors, none of which retained any edge, and
nearly as many strops which had been cut to pieces in his irritated
and ineffectual efforts. If we teach a child manual dexterity it is an
advantage to him, because manual dexterity is seldom associated with
restlessness and irritability of mind. To excel in some handicraft not
only bespeaks the possession of self-control, it helps directly to
cultivate it. The teaching of Froebel and Montessori holds good after
nursery days are over.


MENTAL TRAINING

Mental training enables the child to retain facts in his memory, to
obtain information from as many sources as possible, to understand and
piece them together, and finally to reach fresh conclusions from
previously acquired data. So far as is possible the teacher must
satisfy the natural desire to know the reason of things. It must be
his endeavour to prevent the child from accepting any argument which
he has not fully understood, and which, as a result, he is able not to
reconstruct but only to repeat. Mental work which is slovenly and
perfunctory is as harmful to the child's education as mechanical work
which is bungled and ineffective. Taking advantage of his natural
aptitudes, his interest should be developed and extended in every way
possible. Tasks which are accomplished without enthusiasm are labour
expended in vain, because the knowledge so acquired is not
assimilated and adds nothing to the child's mental growth. There
should be no sharp differentiation between work and play.


MORAL TRAINING

Moral training depends upon the force of example rather than of
precept. Parents must be scrupulously just and truthful to the child,
for his quick perception will detect the slightest deceit, and the
evil impression made on his mind may be lasting. They must confidently
expect conduct from him of a high moral standard, and be careful at
this early age to avoid the common fault of giving a dog a bad name.
If it is said on all sides that a child has an uncontrollable temper,
is an inveterate grumbler, is lacking in all power of concentration,
or has a tendency to deceit, it is likely that the child will act up
to his reputation. He comes in time to regard this failing of his as
part of himself just as much as is the colour of his hair or the
length of his legs. It may be said of a schoolboy that he shows no
aptitude for his work. Term by term the same report is brought home
from school, and each serves only to confirm the boy in his belief
that this failing is part of his nature, and that no effort of his own
can correct it. If one subject only has escaped the condemnation of
his master, then it may be to that study alone that he returns with
zest and enjoyment. Spendthrift sons are manufactured by those fathers
who many times a day proclaim that the boy has no notion of the value
of money.

And so with children! Parents must take it for granted that they will
display all the virtues they desire in them. They must trust to their
honour always to speak the truth, and always to do their best in work
or play whether they are with them or not. Again and again the
children will fail and their patience will be tried to the utmost.
They must explain how serious is the fault, and for the time being
their trust may have to be removed; but with the promise of amendment
it must again be fully restored and the lapse completely forgotten. If
the child feels he is not trusted he ceases to make any effort, and
lapse will succeed lapse with increasing frequency.

In efforts at moral training there is often too great an emphasis laid
upon negative virtues. It is wrong to do this: to do that is
forbidden. Children cannot progress by merely avoiding faults any more
than a man may claim to be an agreeable companion at table because he
does not eat peas with a knife or drink with his mouth full. There
must be a constant effort to achieve some positive good, to acquire
knowledge, to do service, to take thought for others, to discipline
self, and the parent will get the best result who is comparatively
blind to failure but quick to encourage effort and to appreciate
success. When the child knows well that he is doing wrong, exhortation
and expostulation are usually of little avail if repeated too often,
and serious talks should only take place at long intervals.

We know how effective the so-called "therapeutic conversation" may be
in helping some overwrought and nervously exhausted man or woman to
regain peace of mind and self-control. After an intimate conversation
with a medical man who knows how to draw from the patient a free
expression of the doubts, anxieties, and fears which are obsessing
him, many a patient feels as though he had awakened in that instant
from a nightmare, and passes from the consulting-room to find his
troubles become of little account. Not a few patients return to be
reassured once more, and derive new strength on each occasion. Yet
visits such as these must be infrequent or they will lose their power.
Now, just as the physician is well aware that his intervention if too
frequently repeated will lose its effect, so the parent must be chary
of too frequent an appeal to the moral sense of the child. At long
intervals opportunity may be taken with all seriousness to set before
the child ideals of conduct, to-speak to him of the meaning of
character and of self-discipline, and of the standards by which we
judge a man or woman to be weak and despicable, or strong and to be
admired. The effect of such an intimate conversation, never repeated,
may persist throughout life. Constantly reiterated appeals, on the
other hand, do more harm than good. To tell a child daily that he is
"breaking mother's heart," or that he is "disappointing his father,"
is to debase the moral appeal and deprive it of its strength.

For everyday use it is best to cultivate a manner which can indicate
to the child that he is for the moment unpopular, but which at the
same time denies to the small sinner the interest of attempting his
own defence. On the other hand, should the child be reasonably in
doubt as to the nature of his offence we must spare no trouble in
explaining it to him. Punishment will be most effective when the child
is convinced that he is rightly convicted. If it is to act as a real
deterrent, he must agree to be punished--a frame of mind which, if it
can be produced, may be welcomed as a sure sign that training is
proceeding along the right lines.

By physical training, mental training, and moral training the child's
character is formed and self-discipline is developed. With the child
of neuropathic disposition and inheritance matters may not proceed so
smoothly. Reasoning and conduct may be alike faulty, and the nervous
disturbances may even cause detriment to the physical health. Not that
the nervous child requires an environment different from that of the
normal child. The difficulties which the parents will encounter and
the problems which must be solved differ not in kind but in degree. An
error of environment which is without effect in the normal child may
be sufficient to produce disastrous results in the neuropathic.

It must be granted that there are some unfortunate children in whom
the moral sense remains absent and cannot be developed--children who
steal and lie, who seem destitute of natural affection, or who appear
to delight in acts of cruelty. These moral degenerates need not be
considered here. Serious errors of conduct, however, in children who
are not degenerate or imbecile, frequently arise directly from faults
of management and can be controlled by correcting these faults.
Suppose, for example, that a child is found to have taken money not
his own. The action of the parents faced with this difficulty and
disappointment will determine to a great extent whether the incident
is productive of permanent damage to the child's character. The
peculiar circumstances of each case must be considered. For example,
the parent must bear in mind the relation in which children stand to
all property. The child possesses nothing of his own; everything
belongs in reality to his father and mother, but of all things
necessary for him he has the free and unquestioned use. Unless his
attention has been specially directed to the conception of ownership
and the nature of theft, he may not have reasoned very closely on the
matter at all. Very probably he knows that it is wrong to take what is
not given him, but he does not regard helping himself to some dainty
from a cupboard as more than an act of disobedience to authority. He
may have imbibed no ideas which place the abstraction of money from a
purse belonging to his parents on a different plane, and which have
taught him to regard such an action as especially dishonourable and
criminal. Finally, a child who, undetected, has more than once taken
money belonging to his father and mother, may pass without much
thought to steal from a visitor or a servant. To deal with such a case
effectively, to ensure that it shall never happen again, requires much
insight. If the father, shocked beyond measure to find his son an
incipient criminal, differing in his guilt in no way from boys who are
sent to reformatories as bad characters, convinces the child that
although he did not realise it, he has shown himself unworthy of any
further trust, untold harm will be done. Almost certainly the child
will act in the future according to the suggestions which are thus
implanted in his mind. If the household eyes him askance as a thief,
if confidence is withdrawn from him, he sees himself as others see him
and will react to the suggestions by repeating the offence. The
seriousness of what he has done should be explained to him, and after
due punishment he must be restored completely and ostentatiously to
absolute trust. Only by showing confidence in him can we hope to do
away with the dangers of the whole incident. To inculcate good habits
and encourage good behaviour we must let the child build up his own
reputation for these virtues. It need not make him priggish or
self-satisfied if parents let him understand that they take pride in
seeing him practise and develop the virtue they aim at. For example,
it is desired above all that he should always speak the truth. Then
they must ostentatiously attach to him the reputation of truthfulness
and show their pride in his possessing it. If he falls from grace they
must remember that he is still a child, and that if that reputation is
lightly taken from him and he is accused of a permanent tendency
towards untruthfulness, he is left hopeless and resigned to evil. Let
any mother make the experiment of presenting to her child in this way
a reputation for some particular virtue. For example, if an older
child shows too great a tendency to tease and interfere with the
younger children, let the mother seize the first opportunity which
presents itself to applaud some action in which he has shown
consideration for the others. Let her comment more than once in the
next few days on how careful and gentle the older child is becoming in
his behaviour to the little ones, and in a little the suggestion will
begin to act until the transformation is complete. If, on the other
hand, the mother adopts the opposite course and rebukes the child for
habitual unkindness, she will be apt to find unkindness persisted in.
The criminal records of the nation show too often the truth of the
saying that "Once a thief always a thief." Deprived of his good
repute, man loses his chief protection against evil and his incentive
to good.

The inability of a child--and especially of a nervous and sensitive
child--to form conceptions of his own individuality except from ideas
derived from the suggestions of others, gives us the key to our
management of him and to our control of his conduct. He has, as a
rule, a marvellously quick perception of our own estimate of him, and
unconsciously is influenced by it in his conception of his own
personality, and in all his actions. Parents must believe in his
inherent virtue in spite of all lapses. If they despair it cannot be
hid from the child. He knows it intuitively and despairs also. It is
then that they call him incorrigible. If it happens that one parent
becomes estranged from the child, despairs of all improvement, and
sees in all his conduct the natural result of an inborn disposition to
evil, while the other parent holds to the opinion that the child's
nature is good, and to the belief that all will come right, then often
enough the child's conduct shows the effect of these opposite
influences. In contact with the first he steadily deteriorates,
affording proof after proof that judgment against him has been rightly
pronounced. In contact with the other, though his character and
conduct are bound to suffer from such an unhappy experience, he yet
shows the best side of his nature and keeps alive the conviction that
he is not all bad.

The force of suggestion is still powerful to control conduct and
determine character in later childhood. The impetus given by the
parents in this way is only gradually replaced by the driving power of
his own self-respect--a self-respect based upon self-analysis in the
light of the greater experience he has acquired.




CHAPTER X

NERVOUSNESS IN OLDER CHILDREN


In older children the line which separates naughtiness, fractiousness,
and restlessness from definite neuropathy begins to be more marked.
The nature of the young child, taking its colour from its
surroundings, is sensitive, mobile, and inconstant. With every year
that passes, the normal child loses something of this impressionable
and fluid quality. With increasing experience and with a growing power
to argue from ascertained facts, character becomes formed, and if
tempered by discipline will come to present a more and more unyielding
surface to environment, until finally it becomes set into the
stability of adult age.

We may perhaps, with some approach to truth, look upon the adult
neurotic as one whose character retains something of the
impressionable quality of childhood throughout life, so that, to the
last, environment influences conduct more than is natural.

All the emotions of neurotic persons are exaggerated. Disappointments
over trifles cause serious upsets; grief becomes overmastering.
Violent and perhaps ill-conceived affection for individuals is apt to
be followed by bitter dislike and angry quarrelling. On the physical
side, sense perception is abnormally acute, and many sensations which
do not usually rise up into consciousness at all become a source of
almost intolerable suffering. To these most unhappy people summer is
too hot and winter too cold; fresh air is an uncomfortable draught,
while too close an atmosphere produces symptoms of impending
suffocation.

In some neurotics there is an excessive interest in all the processes
of the life of the body, and when attention is once attracted to that
which usually proceeds unconsciously, symptoms of discomfort are apt
to arise. Thus so simple an act as swallowing may become difficult, or
for the time being impossible. To breathe properly and without a sense
of suffocation may seem to require the sustained attention of the
patient; or again, the voice may be suddenly lost.

More commonly, perhaps, neuropathy exhibits itself in an undue
tendency to show signs of fatigue upon exertion of any sort, mental or
physical. Sustained interest in any pursuit or task becomes
impossible. Nameless fears and unaccountable sensations of dread
establish themselves suddenly and without warning, and may be
accompanied on the physical side by palpitation, flushing, headache,
or acute digestive disturbances.

All these manifestations are best controlled by selecting a suitable
environment, and as a rule the character of the environment is
determined by the temperament and disposition of those who live in
close contact with the patient. Like the tiny children with whom we
have dealt so far, the behaviour of neuropathic persons is subject
wholly to the direction of stronger and more dominant natures. With
faulty management at the hands of those around them, no matter how
loving and patient these may be, the conduct of the neurotic tends to
become abnormal.

In children beyond earliest infancy we recognise a gradual approach to
the conditions of adult life. Fractiousness and naughtiness,
ungovernable fits of temper, inconsolable weeping and inexplicable
fears should disappear with early childhood even if management has not
been perfect. If they persist to older childhood we shall find in an
increasing percentage of cases evidence of definite neuropathic
tendencies which urgently call for investigation and for a precise
appreciation of the nature of the abnormality. It may be that the only
effective treatment is that which we recognise as essential in the
grosser mental disturbances--removal from the surroundings in which
the abnormal conduct has had free play, and separation from the
relatives whose anxiety and alarm cannot be hidden.

In young nervous children fear is the most prominent psychical
symptom. The children are afraid of everything strange with which they
come in contact. They are afraid of animals, of a strange face, or an
unfamiliar room. Older children usually manage to control themselves,
suppress their tears, and prevent themselves from crying out, but it
is nevertheless easy to detect the struggle.

Often we find those distressing attacks to which the name
"night-terrors" has been given. The child wakes with a cry,--usually
soon after he has gone to sleep,--sits up in bed and shows signs of
extreme terror, gazing at some object of his dreams with wide-open
startled eyes, begging his nurse or mother to keep off the black dog,
or the man, or whatever the vision may be. Even after the light is
turned up and the child has been comforted, the terror continues, and
half an hour may elapse before he becomes quiet and can be persuaded
to go back to bed. In the morning as a rule he remembers nothing at
all.

Phobias of all sorts are common in nervous children, and result from a
morbid exaggeration of the instinct for self-preservation. Some cannot
bear to look from a height, others grow confused and frightened in a
crowd; dread of travelling, of being in an enclosed space such as a
church or a schoolroom, or of handling sharp objects may develop into
a constant obsession. I have known a little girl who was seized with
violent fear whenever her father or mother was absent from the house,
and she would stand for hours at the window in an agony of terror lest
some harm should have befallen them. As if with some strange notion of
propitiating the powers of darkness these children will often
constantly perform some action and will refuse to be happy until they
have done so. The same little girl who suffered such torments of
anxiety in her parents' absence would always refuse to go to bed
unless she had stood in turn on all the doormats on the staircase of
her home. Other children feel themselves forced to utter certain words
or to go through certain rhythmical movements. They fully understand
that the fear in their mind is irrational and devoid of foundation,
but they are unable to expel it. Often it is hugged as a jealous
secret, so that the childish suffering is only revealed to others
years afterwards, when adult age has brought freedom from it. We will
do well to try by skilful questioning to gain an insight into the
mental processes of a child when we find him showing an uncontrollable
desire to touch lamp-posts or to stand in certain positions; or when
he develops an excessive fear of getting dirty, or is constantly
washing his hands to purify them from some fancied contamination.

The treatment of all these symptoms calls for much insight. The
child's confidence must be completely secured, and he must be
encouraged to tell of all his sensations and of the reasons which
prompt his actions. The nervous child has a horror of appearing unlike
other children, and will suffer in silence. If his troubles are
brought into the light of day with kindness and sympathy they will
melt before his eyes. Even night-terrors are, as a rule, determined by
the suppressed fears of his waking hours. If they are provoked by his
experiences at school, by the fear of punishment or by dismay at a
task that has proved beyond his powers, he should be taken away from
school for the time being. Night-terrors are said to be aggravated by
nasal obstruction due to adenoid vegetations. Clothing at night should
be light and porous, and particular attention should be paid to the
need for free ventilation.

We have spoken in an earlier chapter of the trouble sometimes
experienced in inducing a nervous child to go to sleep. In older
children insomnia is common enough. Even when sleep comes it may be
light and broken, as though the child slept just below the surface of
consciousness and did not descend into the depths of sound and
tranquil slumber. We have often noticed how different is the estimate
of the patient from that of the nurse as to the number of hours of
sleep during the night. The sick man maintains that he has hardly
slept at all, whilst the nurse, drawing us aside, whispers in our ear
that he has slept most of the night. In estimating sleep we have to
consider not only its duration, but also its depth, and the patient
who denies that he has slept at all has lain perhaps half the night
with an active restless brain betwixt sleep and wakefulness. Often
enough when he comes to consider in the morning the problems that
vexed his soul at midnight, he is quite unable to recall their nature,
and recognises them as the airy stuff that dreams are made of.
Although in a sense asleep he may have retained a half-consciousness
of his surroundings and a sense of despair at the continued absence of
a sounder sleep.

With nervous children we are apt to find sleep which is of little
depth and which constantly shows evidence of a too-active brain. The
body is tossed to and fro, words are muttered, and the respiration is
hurried and with a change in rhythm, because there is no depth of
anæsthesia. The body still responds to the impulses of the too-active
brain. From the nature of his dream--as shown by chance words
overheard--we may sometimes gather hints to help us to find where the
elements of unrest in his daily life lie. Sleep-walking is only a
further stage in this same disorder of sleep, in which the dream has
become so vivid that it is translated into motor action.

If a child begins to suffer from active sleeplessness we must not make
the mistake of urging him to sleep. He is no more capable than we are
ourselves of achieving sleep by an effort of will power. To urge him
to sleep is likely to cause him to keep awake because we direct his
attention to the difficulty and make him fear that sleep will not
come. If he understands that all that he needs is rest, he will
probably fall asleep without further trouble.

Day-dreams also may become abnormal, and tell of an unduly nervous
temperament. Any one who watches a little child at play will realise
the strength of his power of imagination. The story of Red Riding Hood
told by the nursery fire excites in the mind of the child an
unquestioning belief which is never granted in later life to the most
elaborate efforts of the theatre. All this imaginative force is
natural for the child. It becomes abnormal only when things seen and
acts performed in imagination are so vivid as to produce the
impression of actual occurrences, and when the child is so under the
sway of his day-dreams that he fails to realise the difference between
pretence and reality. Imagination which keeps in touch with reality by
means of books and dolls and toys is natural enough. Not so
imagination which leads to communion with unseen familiars or to acts
of violence due to the organisation of "conspiracies" or "robber
bands" amongst schoolboys.

If evidence of abnormal imagination appears, the child must be kept in
close touch with reality. We must give him interesting and rational
occupation, such as drawing, painting, the making of collections of
all sorts, gardening, manual work, and so forth. In older children we
must especially supervise the reading.

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]

[Footnote 3: If we accept as hysterical all symptoms which are
produced by suggestion and which can be removed by suggestion, we may
correctly speak of a physiological hysteria of childhood, which
includes a very large number of the symptoms discussed. The term is
used here in its older more limited sense.]

(1) A GROUP WITH PERSISTENCE OF CERTAIN INFANTILE CHARACTERISTICS

During the first year or eighteen months of life, the rounded
infantile shape of body persists. The limbs are short and thick, the
cheeks full and rounded, the thorax and pelvis are small, the abdomen
relatively large and full. The great adipose deposit in the
subcutaneous tissue serves as a depôt in which water is stored in
large amounts. In the healthy child of normal development by the end
of the second year a great change has taken place. The shape of the
body has become more like that of an adult in miniature. The limbs
have grown longer and slimmer. The thorax and pelvis have developed so
as to produce relatively a diminution in the size of the abdomen. The
body fat is still considerable, but no longer completely obliterates
the bony prominences of the skeleton. Delay in this change, in this
putting aside of the infantile habit of body, is commonly associated
with a corresponding backwardness in the mental development. Such
children walk late, talk late, learn late to feed themselves, to bite,
and to chew effectively. Watery and fat, they carry with them into
later childhood the infantile susceptibility to catarrhal infections
of the lung, bowel, skin, etc., and they are apt to suffer, in
consequence, from a succession of pyrexial attacks. Nasal catarrh,
bronchitis, otitis media, enteritis, eczema, urticaria papulata, are
apt to follow each other in turn, giving rise in many cases to a
persistent enlargement of the corresponding lymphatic glands. The
effect upon the different tissues of the body of these repeated
infections is very various. We are probably not wrong in attributing
the failure to develop and the persistently infantile appearance to a
prejudicial effect upon the various ductless glands in the body. The
condition is associated with an excessive retention of fluid in the
body, secondary in all probability to alterations in the concentration
and distribution of the saline constituents of the body. A rapid
excretion of salts may be followed by a correspondingly speedy
dehydration of the body, a retention of salts by a sudden increase of
weight. The parathyroid glands are probably closely concerned in
regulating the retention and excretion of salts, and especially of
calcium, a circumstance which becomes of significance when we remember
how frequently rickety changes, tetany, and other convulsive seizures
form part of the clinical picture which we are now considering. While
it is difficult to determine the effect of repeated infections upon
the functions of the endocrine glands, we have clear evidence of the
deleterious influence upon almost all the tissues of the body, the
functioning of which it is more easy to estimate. For example, the
cells of the skin and of the mucous membranes which happen to be
visible to the eye show clear evidence of diminished vitality and
increased vulnerability. Physiological stimuli, incapable of producing
any visible reaction in healthy children, habitually determine widely
spread and persistent inflammatory reactions. For example, the
licking movements of the tongue at the corners of the mouth produce
the little unhealthy fissures which the French call _perlèche_. The
physiological stimulus of the erupting tooth is capable of causing a
painful irritation of the gum, so that the child is said to suffer
from teething, accompanied, it may be, and the association is
significant, by "teething convulsions." The irritation of the urine
produces rawness and excoriation of the skin of the prepuce, contact
with intestinal contents not in themselves very abnormal, an
intractable dermatitis of the buttocks or a persistent diarrhoea and
enteral catarrh. Improvement in the general health, the result of the
cessation for the time being of the recurrent infections, perhaps
consequent upon improved hygienic conditions, always determines the
rapid disappearance of all these accompaniments of the general
diminution of tissue vitality.

The muscular system and the bones are commonly also involved, so that
rickety changes are often found in these infantile and watery
children. In early childhood the processes of calcification and
decalcification proceed side by side and with great rapidity, and in
health there is always a balance on the side of the constructive
process. In the children whom we are now considering, saturated as
they are, from time to time, with the toxins resulting from repeated
infection, ossification may be so interfered with as to cause
softening and bending, with the evolution of a state of rickets.
Between bone and muscle, too, we find a close relationship. We do not
find powerful muscles with softened bone, nor flabby muscle with
rigid and well-formed bone.

In the nervous system, the conditions are somewhat different. In skin,
in bone, and in muscle new cell elements are constantly being formed,
and the life of the individual cell is relatively short. In the
nervous system, on the other hand, the individual cells are long
lived. Their life-history may even be coterminous with that of the
individual, and if destroyed they are not replaced. Nevertheless, they
do not escape undamaged in the general disturbance. In a deprivation
of calcium we have, in all probability, the explanation of the
increased irritability of peripheral nerves and of the tendency to
convulsive seizures of all sorts which is a common accompaniment of
the condition. Convulsions, laryngismus stridulus, tetany, or
carpopedal spasm are all frequently met with. In crying, the children
hold their breath to the point of producing extreme cyanosis, ending,
as the spasm relaxes, with a crowing inspiration, which resembles and
yet differs in tone from both the whoop of whooping-cough and the
crowing inspiration of croup.

Apart, however, from this tendency to convulsive seizures the nervous
system of these children is abnormal. As a rule they are excitable,
and develop late the power to control their emotions. Lagging behind
in physical development and in the capacity to interest themselves in
the pursuits of normal children, their emotional state remains that of
a much younger child. In the infant classes at schools they are
recognised as dullards, learning slowly, speaking badly, and lacking
co-ordination in all muscular movements.

The clinical picture so depicted is encountered with extreme frequency
among the children of the poor in our large cities. To find a name for
the condition is no easy matter. To call it "rickets" is to place an
undue emphasis upon the bony changes which, though common, are by no
means invariable. Elsewhere I have suggested the name status
catarrhalis, on an analogy with the name status lymphaticus, which in
the post-mortem room is used to describe the secondary overgrowth of
lymphatic tissue which is found in these catarrhal children. In the
present connection it is of interest to us to note how commonly the
nervous system is involved in the general picture and the frequency
both of convulsive disorders and of neuropathy.

The nervous symptoms of both sorts are to be allayed only by improving
the general hygiene of the child and raising its resistance against
infection. A sufficiency of fresh air and of sunlight, and a
management which encourages independence of action in the child, are
both necessary. The diet is of the first importance. It should be
sufficient, and no more than sufficient, to cover the physiological
needs of the child for food. The majority of these children have
enormous appetites, and excess of food, and especially of carbohydrate
food, plays some part in the production of the disturbance. We must
guard against overfeeding, against want of air and want of exercise,
and against those errors of management described in previous chapters,
which produce the maximum of disturbance in this type of child.


(2) A GROUP WITH MUSCULAR ATROPHY, LORDOSIS, AND POSTURAL ALBUMINURIA

At an older age, in children from the fifth year onwards, a second
type of physical defect associated with pronounced nervous disturbance
presents itself with some frequency. The body is thin and badly
nourished, and the muscular system especially poorly developed and
very lax in tone. The most striking feature is the extreme lordosis,
accompanied usually by a secondary and compensatory curve in the
cervico-dorsal region, so that the shoulders are rounded, with the
head poked forward. Viewed from in front the abdomen is seen to be
prominent, overhanging the symphysis pubis, while the shoulders have
receded far backwards. The scapulæ have been dragged apart, as though
by the weight of the dependent arms, with eversion of their vertebral
borders and lowering of the points of the shoulders. The position
which they adopt is that into which the body falls when it ceases to
be braced by strong muscular support. The muscular system is here so
weakly developed and so toneless that the posture is determined by the
bony structure and its ligamentous attachments.

The lordosis resembles the similar deformity which develops in cases
of primary myopathy, when the spinal muscles have undergone complete
atrophy. As in myopathy the movements are very uncertain. The
children are apt to fall heavily when the centre of gravity is
suddenly displaced, because their upright posture is maintained by
balancing the trunk upon the support of the pelvis. The frequency and
severity of the falls which these children suffer is a common
complaint of the mother. The faulty posture is often associated with
slight albuminuria. Its appearance is very capricious, but it is
dependent to a great extent upon the assumption of the erect posture.
There has been much discussion as to its explanation. It has been
argued that the lordosis itself produces the albuminuria by mechanical
compression of the renal vein, and it is said that albuminuria can be
produced, even in the prone position, by placing the child in a
plaster jacket applied so as to maintain the position of lordosis.
Other observers, however, have not obtained this result. It seems most
likely that the albuminuria is due to defective tone in the vasomotor
musculature, comparable in every way to the defective tone in the
muscles of the skeleton. We have often further evidence of vasomotor
weakness. Fainting attacks are so common as to be the rule rather than
the exception. Again, mothers are likely to complain of the child's
pallor and of dark lines under the eyes, especially after exertion or
in the reaction which follows excitement of any sort. As a rule a
blood count will not show any very striking evidence of true anæmia.
The pallor is of vasomotor origin, determined by faults in the
distribution of the blood from vasomotor weakness and not by deficient
blood formation. Circulatory and vasomotor disturbance probably also
accounts for the dyspeptic pains and vomiting which commonly accompany
any emotional excitement, or follow any unusual exertion or fatiguing
experience. Constipation is a common, and mucous diarrhoea an
occasional, symptom. The abdomen is often pigmented. The hands and
feet are usually cold and cyanosed.

The extreme nervousness of the children is the point upon which most
stress may be laid in the present connection. The association of
albuminuria with neurosis in childhood has been noticed by many
observers. The gastric and intestinal symptoms are especially
characteristic. If the condition of the children is not materially
improved, and if the symptoms, both of the physical defect and of the
nervous disturbance, are not cut short, we may predict that in adult
age their lives will be made miserable by a variety of abdominal
symptoms dependent both on the vasomotor disturbance and upon the
accompanying neurosis. Now that surgery forms so large a part of our
therapeutic proceedings, they may not reach middle life without being
submitted to one or more surgical operations. With good management
both on the physical side and on the moral or psychological side they
can be made into strong and useful members of society.

The treatment of these cases may be summed up as follows:

_(a)_ We must search for any source of infection, a source which is
often to be found in the condition of the tonsils. Enucleation may
then be indicated as the first step in treatment.

_(b)_ Massage and gymnastic exercises calculated to improve the
muscular tone, while every effort is made to secure for the child as
perfect hygiene in the environment as possible.

_(c)_ The stimulating effect of cold douches is often very evident in
improving the vasomotor tone. These children, however, will not stand
well the abstraction of heat from their thin and chilly little bodies,
so that it is a good plan before the colder douche to immerse the
child in a hot bath and to return again to the bath momentarily
afterwards. With these precautions children will often enjoy a cold
spray, the temperature of which may be constantly lowered as they
become used to it. Prolonged hot bathing has a correspondingly
prejudicial effect.

_(d)_ We must be on the watch to prevent the development of further
postural deformities, such as scoliosis. If a child of strong muscular
tone and good physique habitually adopts some posture, curled up, it
may be, in some favourite easy-chair, there is little likelihood that
its constant assumption will produce deformity. When the muscular
system is lax and weak, on the other hand, deformity such as scoliosis
is very readily caused. It is important, for example, to see that the
child does not habitually incline to one side in reading or writing.
When there is little energy for free and energetic play the children
are apt to become great bookworms. If there is shortsightedness, the
dangers are correspondingly increased. A special chair may be made
with a well-fitting back and the seat a little tilted upwards so as to
throw the child's trunk on to the support of the back. Lastly, a desk,
the height of which can be regulated at will, can be swung into the
proper position. The child, sitting straight and square, with the
weight supported by the foot-rest and back as well as by the seat of
the chair, should be taught to write with an upright hand, avoiding
the slope which leads to sitting sideways with the left shoulder
lowered.

(e) Malt extract, cod liver oil, Parrish's food, and other tonics may
be of undoubted service.


(3) RHEUMATISM AND CHOREA

It is certain that there is a close association between rheumatism in
childhood and the common nervous affection known as chorea. We are
still ignorant of the precise nature of the infection which we know as
rheumatism. There is much to suggest that in rheumatism we have to
deal only with a further stage in those catarrhal infections to which
so much infantile ill-health is to be attributed, and that
endocarditis and arthritis, when they arise, signalise the entry of
these catarrhal, non-pyogenic organisms into the blood stream,
overcoming at last the barrier of lymphoid tissue which has
hypertrophied to oppose their passage. Certainly the connection of
rheumatism with catarrhal infections of the mucous membranes and
adenoid enlargements of all sorts is a close one. Whatever its
nature, the rheumatic infection in childhood is more lasting and
chronic than in adult life. Rheumatism in childhood is not manifested
by acute and short-lived attacks of great severity so much as by a
long-continued succession of symptoms of a subacute nature, a
transient arthritis, perhaps, succeeding an attack of sore throat with
torticollis, to be followed by carditis, to be followed again by
another attack of tonsillitis. And so the cycle of symptoms revolves.
In most cases the child grows thin and weak; in most cases he becomes
restless, irritable, and unhappy; often there is definite chorea. Of
this cerebral irritability chorea is the expression. In adults, chorea
is perhaps more obviously associated with mental stress of all sorts
and with states of excitement and agitation. In the case of little
children it is often only the mother who really appreciates how
radical an alteration the child's whole nature has undergone, and how
great the element of nervous overstrain has been before the chorea has
appeared.

Of the treatment of chorea there is no need to speak. It is purely
symptomatic. Isolation, best perhaps away from home, as might be
expected, gives the best results. If there are pronounced rheumatic
symptoms, the salicylates will be needed; if there is anæmia, arsenic
and iron; if there is sleeplessness and great restlessness, bromides
or chloral. Hypnotism is often almost instantly successful, but, apart
from hypnosis, curative suggestions proceeding from the attendants
form the principal means at our disposal.


(4) EXHAUSTION AND KATATONIA

A large number of children, in convalescence from infective disorders,
when the nutrition of the body has fallen to a low ebb, show as
evidence of cerebral exhaustion a group of symptoms which in a sense
are the reverse of those which characterise cerebral irritation and
chorea. The healthy child is a creature of free movement. The children
we are now considering will sit for a long time motionless. The
expression of their faces is fixed, immobile, and melancholy. If the
arm or leg is raised it will be held thus outstretched without any
attempt to restore it to a more natural position of rest for minutes
at a time. The posture and expression remind us at once of the
katatonia which is symptomatic of dementia præcox and other stuporose
and melancholiac conditions in adult life. Symptoms of this sort are
especially common in children with intestinal and alimentary
disturbances of great chronicity.

The symptom is so frequently met with that it is strange that it
should have attracted so little attention as compared with the
contrasting condition of chorea. And yet it is of more serious
significance, more difficult to overcome, and with a greater danger
that permanent symptoms of neurasthenia will result. In early
childhood a careful dietetic régime, suitable hygienic surroundings,
and a stimulating psychical atmosphere will often effect great
improvement. As in chorea, however, relapses are frequent, and there
are cases which for some unexplained reason are peculiarly resistant
to all remedial influences.


(5) HYSTERIA

In hysteria, in contrast to the types previously described, the
infective element may be completely absent. Except in some special
features of minor importance the symptoms of hysteria do not differ
from those of adults, and, as in adult age, the condition of hysteria
may be present although the physical development may be perfect. We
cannot here speak of any physical characteristics which are associated
with the nervous symptoms.

The third or fourth year represents the age limit, below which
hysterical symptoms do not appear. Thereafter they may be occasionally
met with, with increasing frequency. At first, in the earlier years of
childhood, there is no preponderance in the female sex. As puberty
approaches, girls suffer more than boys.

It may be said to be characteristic of hysteria in childhood that its
symptoms are less complex and varied than in adult life. The naive
imagination of the child is content with some single symptom, and is
less apt to meet the physician half-way when he looks for the
so-called stigmata. Similarly mono-symptomatic hysteria is
characteristic of oases occurring in the uneducated or peasant class.
In children, hysterical pain, hysterical contractures or palsies,
mutism, and aphonia are the most usual symptoms. Hysterical deafness,
blindness, and dysphagia are manifestations of great rarity in
childhood.




CHAPTER XII

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.




CHAPTER XIII

NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS


In this chapter I approach with diffidence a subject which is rightly
enough occupying a great deal of attention at the present time: the
instruction of our children in the nature, meaning, and purpose of
sexual processes. It is a subject filled with difficulties. Every
parent would wish to avoid offending the sense of modesty which is the
possession of every well-trained child, and finds it difficult to
escape the feeling that discussion on such matters may do more harm
than good. There is certainly some risk at the present time that,
putting reticence on one side, we may be carried too far in the
opposite direction. The evils which result from keeping children in
ignorance are well appreciated. We have yet to determine the effect
upon them of the very frank and free exposure of the subject which is
recommended by many modern writers. Nevertheless, it must be granted
that it is not right to allow the boy or girl to approach adolescence
without some knowledge of sex and the processes of reproduction. If
nothing is said on such subjects, which in the nature of things are
bound to excite a lively interest and curiosity in the minds of older
children, evil results are apt to follow. Because parents have never
mentioned these subjects to their child, they must not conclude that
he is ignorant of all knowledge concerning them. It is not unlikely
that the question has often occupied his thoughts, and that his
speculations have led him to conclusions which are, on the whole,
true, although perhaps incorrect in matters of detail. Most children,
unable to ask their mother or father direct questions upon matters
which they feel instinctively are taboo, have pieced together, from
their reading and observation, a faulty theory of sexual life. The
pursuit of such knowledge, in secret, is not a healthy occupation for
the child. His parents' silence has given him the feeling that the
unexplored land is forbidden ground. In satisfying his curiosity he is
most certainly fulfilling an uncontrollable impulse, but he has been
forced to be secretive, and to look upon the information he has
acquired as a guilty secret. So far even the best of children will go
upon, the dangerous path. If training has been good, and if the child
has responded well to it, he will go no further. Though he can hardly
be expected to refrain from constructing theories and from testing
them in the light of any chance information which may come his way, he
will instinctively feel that the subject is one best left alone. He
will not talk of it with other boys--not even with those who are older
than himself and whose superior knowledge in all other matters he is
accustomed to respect. We need not be surprised, however, that the
majority of children do not attain to this high standard of conduct,
and that the interest and excitement of exploring the unknown and the
forbidden proves too great. Children will consult with each other
about such matters, and knowledge of evil may spread rapidly from the
older to the younger. In some schools, as is well known, there may
grow up with deplorable facility an unhealthy interest in sexual
matters. On the surface of school life all may seem fair enough, but
beneath, hidden from all recognised authority, lies much that is
unspeakable. If the boy has not been taught to have clean thoughts
upon matters which are essentially clean, if he has not learned to
know evil that he may avoid it, he may not escape great harm. The
fault in us which kept him in ignorance will recoil upon our own
heads. He will maintain the barrier which was erected in the first
place by our own unhappy reticence, and we may find it a hard task to
penetrate behind it and prevent his constant return to secret thoughts
and imaginings or secret habits and practices. Certain physiological
processes come to have for him an unclean flavour which is yet
perniciously attractive. He knows little of the real meaning of sexual
processes or of the great purpose for which they are designed. It is
only that an unhealthy interest becomes attached to all subjects which
are scrupulously avoided in general conversation. In secret he
develops a wrong attitude to all these matters.

Oliver Wendell Holmes[4] tells us that in religion certain words and
ideas become "polarised," that is to say, charged with forces of
powerful suggestion, and must be "depolarised."

[Footnote 4: _The Professor at the Breakfast Table_, Oliver Wendell
Holmes.]

       *       *       *       *       *

"I don't know what you mean by 'depolarising' an idea, said the
divinity-student.

"I will tell you, I said. When a given symbol which represents a
thought has lain for a certain length of time in the mind, it
undergoes a change like that which rest in a certain position gives to
iron. It becomes magnetic in its relations--it is traversed by strange
forces which did not belong to it. The word, and consequently the idea
it represents, is polarised.

"The religious currency of mankind, in thought, in speech, and in
print, consists entirely of polarised words. Borrow one of these from
another language and religion, and you will find it leaves all its
magnetism behind it. Take that famous word, O'm, of the Hindoo
mythology. Even a priest cannot pronounce it without sin; and a holy
Pundit would shut his ears and run away from you in horror, if you
should say it aloud. What do you care for O'm? If you wanted to get
the Pundit to look at his religion fairly, you must first depolarise
this and all similar words for him. The argument for and against new
translations of the Bible really turns on this. Scepticism is afraid
to trust its truths in depolarised words, and so cries out against a
new translation. I think, myself, if every idea our Book contains
could be shelled out of its old symbol and put into a new, clean,
unmagnetic word, we should have some chance of reading it as
philosophers, or wisdom-lovers, ought to read it--which we do not and
cannot now, any more than a Hindoo can read the 'Gayatri' as a fair
man and lover of truth should do."

       *       *       *       *       *

Now in the minds of many boys and some girls certain words and ideas
connected with certain physiological processes become polarised. It is
the parents' duty to depolarise them. It is a task which cannot well
be deputed to others; nor can much help be derived from books, though
many have been written with the object of initiating children into the
mysteries of sex. No one but a parent is likely to be on sufficiently
intimate terms with the child to enable the subject to be approached
without restraint or awkwardness, and no book can adapt itself to the
varying needs of individual children. An exposition in cold print, or
a single formal lecture on the subject, is apt to do more harm than
good. I have seen instructions to parents to deliver themselves of set
speeches, examples of which are given, which seem to me well
calculated to repel and frighten the nervous child. Still more
dangerous is the advice to make sexual hygiene a subject for class
study. The task requires that parents should be upon very intimate
terms with their children, and on suitable occasions, when this
feeling of intimacy is strong, children should be encouraged to speak
freely and to ask for explanations. By a judicious use of such
opportunities piece by piece the whole may be unfolded. In order that
the child may approach the subject in the proper spirit we may
stimulate interest by a few lessons in Natural History. A child of
eight or ten years of age is not too young to learn a little of the
outlines of anatomy and physiology. If he is told a few bald facts
about the skeleton, about the circulation and the processes of
digestion such as any parent can teach at the cost of a few hours'
study of a handbook, this will lead naturally enough, in later
lessons, to a similar talk upon the excretory organs, reproduction,
and the anatomy and processes of sex, suitable to the individual. To
achieve "depolarisation," there is nothing more efficacious than the
frankness and explicitness of scientific statement, however
elementary. Later a little knowledge of Botany and Zoology will enable
a parent to sketch briefly the outlines of fertilisation and
reproduction. The child may grasp the conception that the life of all
individual plants and animals is directed towards the single aim of
continuing the species. He can be told how the bee carries the male
pollen to the female flower, how all living things habitually
conjugate, the lowest in the scale of development as well as the
highest, and how the fertilised egg becomes the embryo which is
hatched by the mother or born of her. As the child grows older and
understands more and more of these natural processes an opportunity
can be used to make the presentation of the subject more personal. He
can be told that during childhood his own sexual processes have been
undeveloped, but that as he grows older they will awake. That with
their awakening in adolescence new temptations to self-indulgence in
thought or action may assail him, but that these temptations are
delayed by the wisdom of Nature until his understanding has grown and
his man's strength of character has developed. A high ideal of purity
should be set before boy and girl alike, and the conception of sex
from the beginning should be associated in their minds with the high
purpose to which some day it may be put. Before the boy goes to a
boarding-school he should have imbibed from his father the desire for
moral cleanliness, the knowledge of good and of evil, and a cordial
dislike for everything that is sensual, self-indulgent, or nasty.
Talks on such subjects should be very infrequent, but I believe that,
if "depolarisation" is to be achieved, they must be repeated every now
and then during later childhood and in adolescence. To attempt to
impart all this interesting information in a single constrained and
awkward interview is to court failure, or at least to run the risk
that the explanation is not fully understood, so that the child is
mystified, or even offended in his sense of propriety.

I have dwelt at some length upon this question of sex education,
because it is one of especial difficulty when we have to deal with a
child of nervous inheritance, or with a child in whom symptoms of
neurosis have developed in a faulty home environment. Misconduct in
sexual matters is a sign of deficient nervous and moral control, and
when the conduct in other respects is ill-regulated, the development
of sexual processes must be watched with some anxiety. There are those
who see a still more intimate relationship between errors of conduct
or symptoms of neurosis in childhood and the sexual instincts.

It is perhaps necessary here briefly to refer to the teaching of
Sigmund Freud of Vienna, because his views have attracted a great deal
of attention in this country and have become familiar to a great part
of the reading public. Freud believes that the origin of many abnormal
mental states and of the disturbances of conduct which are dependent
upon them is to be traced back to forgotten experiences, the
recollection of which has faded from the conscious mind, but which are
still capable of exerting an indirect influence. He regards the
process of forgetting, not as merely a passive fading of mental
impressions, but as an active process of repression, by which the
experience, and especially the unpleasant experience, is thrust and
kept out of consciousness. There thus arises a mental conflict between
the forces of repression and the forces which tend to obtrude the
recollection into consciousness, and at times the energy engendered in
this conflict escapes from the censorship of the repressing forces and
finds vent in the production of abnormal mental states or disorders of
conduct. Thus to take a simple example, a business man who has had a
trying day at the office, on returning home in the evening may succeed
in thrusting out of his consciousness the thought of his
disappointments and worries, yet the disturbance in his mind may show
itself in quarrels with his wife or complaints of the quality of the
cooking at dinner.

Freud has called attention to the part which the suppressed and
long-forgotten experiences of early childhood play in the production
of neuroses of all sorts at a later date, and he has laid especial
emphasis on sexual experiences as peculiarly fruitful causes of such
disturbances. Those who have embraced Freud's teaching have gone even
farther than he in this direction, and by psycho-analysis--that is to
say, by attempting in intimate conversation to arouse the dormant
memory and lay bare the buried complex, the suppression of which has
produced the conflict in the mind of the sufferer--will seldom fail to
discover the influence of sexual forces and sexual attractions which,
while capable of causing disorders of mind and of conduct, show
themselves only obscurely and indirectly, as, for example, in dreams
or in symbolic form.

So far as the nervous disorders of children are concerned, much that
is written to-day upon the influence of repressed sexual experiences
may be dismissed as grotesque and untrue. The conclusions to which the
psycho-analyst is habitually led, and which he puts forward with such
confidence, can be convincing only to those who have replaced the
study of childhood by the study of the writings of Freud and his
school. Thus it is common enough to find a mother complaining that her
child of two or three years of age is bitterly jealous of the new baby
who has come to share with him his mother's love and attention.
According to the views of Freud, we are to recognise in this jealousy
an exhibition of the sexual instincts of the older child, who scents a
possible rival for the affections of his mother. Even if we give to
the term sexual the widest possible meaning, it is difficult for a
close observer of children to detect any truth in this conclusion. The
behaviour of the older child to the newly born will be determined
mainly by the attitude adopted by the grown-up persons around him and
by the unconscious suggestions which his impressionable mind receives
from them. If the mother is fearful of what may happen, and refuses to
leave the children alone, she will find it hard to hide from the older
child her conviction that danger is to be apprehended from him. If
this suggestion acts upon his mind, and if the reputation that he is
jealous of the new baby becomes attached to him, he will assuredly not
fail to act up to it, and her daily conduct will appear to prove the
justness of his mother's apprehension. Fortunately, mothers are
commonly able to divest themselves of such fears as these. The older
child is brought freely to the baby to admire him, to bestow caresses
on him, and to speak to him in the very tones of his elders. In a few
days his reputation is established, that he is "so fond of the baby,"
and to this reputation too he faithfully conforms. We have seen in an
earlier chapter that constantly and ostentatiously to oppose a child's
will is to produce a counter-opposition which because of its
persistence and vigour appears to have behind it the strongest
possible concentration of mind and power of will. Yet if we cease to
oppose, the counter-opposition which appeared so formidable at once
dissolves, and the difficulty is at an end. We took as an example the
child's apparent determination to approach as near as possible to the
fire, the one place in the room which our fear of accident forbids
him. The difficulty with the new baby is but another example of the
same tendency. If he does not know that the ground is forbidden, if we
do not concentrate his attention on the prohibition, he will show no
particular desire to approach it. His apparent jealousy of his little
brother is the result not of the rivalry of sex, but of bad
management.

Again, it is occasionally a subject of complaint that children will
apparently dislike their father, that they will shrink from him or
burst into tears whenever he approaches them. There is no need to see
in this the child's jealousy of the father as a rival in the
affections of his mother, which is the explanation proffered by the
school of Freud. Every action and every occupation of the child during
the whole day can be made a pleasure or a pain to him, according to
the attitude of his nurse and mother towards it. Eating and drinking
should be pleasant and are normally pleasant. The same forces which
are sufficient to make every meal-time a signal for struggling and
tears, are sufficient to produce this dislike, apparently so
invincible, to the father of his being.

Although the nervous troubles of infancy are not commonly due, as
Freud and his numerous followers would have us believe, to suppressed
sexual desires or experiences, it is clear that in the sensitive mind
of the child the reception of a severe shock may have effects long
after the memory of it has disappeared from consciousness. In a
medical journal there was recently recounted the case of an officer of
the R.A.M.C. who all his life had suffered from claustrophobia--the
fear of being shut up in a closed space. By skilful questioning, the
remembrance of a terrifying incident in his childhood was regained. As
a child of five he had been shut in a passage in a strange house by
the accidental banging to of a door, unable to escape from the
attentions of a growling dog. A complete cure was said to follow upon
the discovery that in this incident lay the origin of the phobia.
Nevertheless, observation would lead me to lay the greater stress not
upon any one particular shocking or terrifying experience, but upon
the attitude of parents and nurses in focusing the child's attention
upon the danger, and in sapping his confidence by showing their own
apprehensions and communicating them to him.

As a method of treatment for neuroses of childhood, psycho-analysis is
not only unsuccessful, it has dangers and produces ill effects which
far outweigh any advantage which may be gained from it.

There can be no doubt that Freud has exaggerated the part which sexual
impulses play in causing neurosis. It will be sufficient for us to
recognise that for the nervous child the sexual life has especial
dangers, and we should redouble our efforts to prevent his ideas on
the subject becoming "polarised." For the child whose environment has
been well regulated and who has developed strength of character,
self-control, and self-respect, there need be no fear.




CHAPTER XIV

THE NERVOUS CHILD AND SCHOOL


At the onset of puberty childhood comes to an end, and the period of
adolescence begins. Into these further stages of development it is not
proposed to enter, but it may be well to consider a question which is
apt to present itself for answer at this period: "Should the boy, or
girl, of nervous temperament, or whose development up to this point
has been accompanied by symptoms of nervous disorder, be sent to a
boarding-school?" So long as the child remains at home the home
environment is the force which alone is concerned in moulding his
character. We have seen how plastic the young child is, how imitative,
how suggestible, how prone to form habits good or bad. The diversity
of type shown by the homes is reflected in the diversity of character
and conduct exhibited by the children. The home is the culture medium,
and in no two homes is its composition the same. For each child home
influence remains to a great extent unchanged, and in great part
unchangeable. Its action upon the child is constant and long
sustained. Hence, it is not surprising that the growth of his
character and powers is commonly unequal. At one point we may find a
good crop of virtues, at another a barren tract; and the home
influences which have ripened the one and blighted the other are
calculated by the lapse of time to increase the contrast rather than
to diminish it.

I suppose it is for this reason that the custom of sending children to
boarding-schools has so firm a hold among us. The boarding-school
forms an environment selected to correct the inequalities which result
from the special action upon the child of individual homes. The life
of a boy in one of our large public schools is well calculated to act
as a corrective in this way not only by reason of its ordered routine
and discipline, but still more because it is affected, perhaps for the
first time, by the strong force of public opinion. It is the strength
of this public opinion which gives to our public schools their
peculiar character and produces their peculiar effects. That which the
schoolboy most despises is what he calls "Bad Form," and he bows down
and worships an idol he himself has set up, the name of which is "Good
Form." Public opinion forms the code of morals observed in the school.
The standard set is commonly not so high as to be very difficult of
attainment. It demands many good qualities. To lie, to sneak, to tell
tales, to bully, to "put on side," are bad form. In some respects the
definition of what is virtuous may be a little hazy. Thus it may be
wrong to cheat to gain a prize, but to copy from one's neighbour only
so much as will enable one to pass muster and escape condemnation is
no great sin. In short, good form demands that a boy should have all
the social virtues: that he should be a good fellow, easy to live
with, and possessed of a high sense of public spirit--good qualities
certainly, though perhaps not those which help to make the reformers
or martyrs of this world.

The school life is the life of the herd, and to be successful in it
the boy must mingle with the herd, not break from it or shun it. Good
form--if we came to analyse the conception that underlies it--consists
only in a close approximation to the standard pattern; bad form, in
any deviation from it. It is this similarity of type and community of
ideals which makes it so easy for most public-school boys to get on
well with one another. When in after life they are thrown among a set
of men who know nothing of their conception of good form, and whose
training has been on completely different lines, there may be a
corresponding difficulty.

Now what is true of public-school life is of course also true of the
larger life after schooldays are over for which all education is a
preparation. These qualities of sociability and good sportsmanship
will stand a man in good stead throughout life. Even the most ardent
and active spirit will benefit by being subjected for some years to
this steady pressure of public opinion. The most part will learn from
it good sense, consideration for others, and self-control. As they
pass from the lower forms to the higher in the school they will learn
too to support authority without doing injustice, and to bring the
weight of public opinion to bear upon others. And to all this
training many a man owes his happiness in after life--a happiness
which he could not have secured if his character had been moulded only
by the environment of his home, or by the home in combination with the
less-powerful corrective of a day school. For the nervous child the
passage from home to school life may involve considerable mental
strain. He may be morbidly self-conscious and timid, or, unknown to
himself--because he has as yet no power of self-analysis and has no
opportunities of comparing himself with others--he may have developed
certain eccentricities. In most cases the plunge into school life will
be taken well enough; in a few the little vessel will not right
itself, and proves permanently unseaworthy. No doubt as a rule a
private school will have preceded the public school, and this
gradation should make the entrance to the public school a lesser
ordeal. But it often happens that it is just in the case of the
nervous child that this intermediate stage has been omitted, and that
his thirteenth birthday finds him still in the home circle.

If the boy's father has first-hand knowledge of life in the lower
forms of public schools, his experience may enable him to form some
estimate of the effect of school life upon the nervous system of his
son. It is when parents or guardians have no such experience of their
own to guide them that mistakes are most liable to be made. I can
myself remember the unhappy state of some solitary and eccentric
schoolfellows of mine who aroused the resentment of "the Herd" by
their behaviour or opinions. If it is clear that the boy has a
peculiar temperament and is likely to suffer in this way, some _via
media_ must be found. The home has failed so that he must leave home
and come under the influence of some one who understands the nature of
the difficulty and can adapt the boy to school life. A change of
environment of this sort as a preliminary to the public school is
often all that is needed. If his age permits, every effort should be
made in this way to obtain for the nervous child who has developed
peculiarities or faults the benefits of a public-school education.

Some types of nervous children will show immediate improvement when
they go to school. The boy who is passionate and disobedient, and
whose parents cannot control him, is best at school. Boys who, from
being much with grown-up people, have become too precocious and have
acquired the habits and tastes of their elders, will dislike school at
first, but it will do them good. Their fault shows that they are quick
to learn and sensitive to the influences of others, and they will soon
adapt themselves to their new surroundings. Boys who are dreamy and
imaginative, who early adopt a "specialist" attitude towards life,
who, however ignorant they may be of everything else, cultivate a
reputation for omniscience in some particular subject, such as
Egyptology, astronomy, or the construction of battleships, are usually
nervous boys whose symptoms will disappear at school. Where undue
timidity, phobia, or habit spasm is present, the question is more
difficult to decide. Every individual case must be studied as a whole,
and our object should be not unnecessarily to deprive the boy of the
wholesome training of public-school life.

There are parents who from sheer ignorance add to the difficulties
which the boy encounters in going to school. Failure to appreciate
very small points may cause unnecessary suffering. To be the only boy
in the school to wear combinations is not a distinction that any new
boy craves, however strong his nerves may be. A friend of mine still
relates with feeling how, twenty years ago, he arrived at school with
shirts which _buttoned_ at the neck! At night when every one else in
the dormitory was asleep he sat for hours on his bed, miserable beyond
words, removing the buttons and doing his best in the dark to bore
buttonholes which would admit what every other boy in the school
had--a collar stud.

With girls perhaps this question of fitness for school life does not
arise in so urgent a way. Girls are usually older when they go to
school, and girls' schools are perhaps less terrifying and more like
home. There is, however, one important point which should be borne in
mind. The date of the onset of puberty varies much in both sexes. If
the boy grows to a great hulking fellow at fourteen, and even displays
a desire secretly to borrow his father's razor, he is at no particular
disadvantage as compared with his fellows. He is so much bigger and
stronger than the others that he may thereby early enjoy the
distinction of playing at "big side," or of getting a place in the
school Eleven. He is probably much envied by those of the same age
who, with the aid of their youthful aspect, can still occasionally
extract compensation by inducing the railway company to let them
travel to school at half fare. But with girls it is different. Many at
fourteen or fifteen are children still; some are grown up, with the
tastes, feelings, and attraction of maturity. Those who have developed
fastest are often, for that very reason, kept backward in school
learning. Often they are nervously the least stable. Now that large
schools for girls on the model of our public schools are become the
fashion, such precociously developed and nervously unstable girls are
apt to find themselves in the very uncongenial society of little girls
of twelve or thirteen. The elder girls commonly hold aloof, while
mistresses are apt to view this precocious development with
disapproval, and to attempt to retard what cannot be retarded by
insisting that the young woman has remained a child. I remember being
called in consultation by a surgeon who had been asked to operate for
appendicitis upon a girl of fourteen. I found a tall, well-grown girl,
with an appearance and manner that made her look four years older. I
could find no signs of appendicitis, but I learned from her that she
had been for three months at a large girls' school, and that in a few
days' time her second term was due to begin. As we became friends, she
agreed that her appendicitis and her resolve not to return to school,
where she was unhappy, were but different ways of saying the same
thing. She was an only child who had travelled a great deal with her
parents, had found her interests in their pursuits, and had grown
backward in school work. The little girls with whom she was expected
to associate seemed to her mere children. The elder girls did not want
her friendship, and snubbed her. I prescribed a change to a small
boarding-school with only a few girls, where age differences would not
matter so much, and where she could make friends with girls older than
herself, though not more mature.

Into their school life we need not follow the children. Happily the
time is past when schoolmasters and schoolmistresses were incapable of
understanding their charges, and confounded nervous exhaustion with
stupidity or timidity with incapacity.

And so we come back to the point from which we started:

The nervous infant, restless, wriggling, and constantly crying! The
nervous child, unstable, suggestible, passionate, and full of nameless
fears! The nervous schoolboy or schoolgirl prone to self-analysis,
subject-conscious, and easily exhausted! And how many and how various
are the manifestations of this temperament! Refusal of food, refusal
of sleep, negativism, irritability, and violent fits of temper,
vomiting, diarrhoea, morbid flushing and blushing, habit spasms,
phobias--all controlled not by reproof or by medicine, but by good
management and a clear understanding of their nature.

The hygiene of the child's mind is as important as the hygiene of his
body, and both are studies proper for the doctor. Neuropathy and an
unsound, nervous organisation are often enough legacies from the
nervous disorders of childhood.




INDEX


Abdomen, prominent

Abdominal symptoms of neurosis

Accent, local, facility with which acquired

Acetone, in breath and urine during cyclic vomiting

Acidosis, accompanying cyclic vomiting

Action, imitativeness of
  liberty of, in early childhood

Activities in the nursery
  not to be restrained
  without intervention of grown-up people
  wonderful nature of

Adenoid vegetations, night-terrors aggravated by
  removal of, in treatment of enuresis

Adolescence, and education on sexual matters

Adults, child in relation to the society of

Æsthetic sense, in early childhood

Affection, in the child

Air hunger, in cyclic vomiting

Air swallowing, habitual action of

Albuminuria, associated with faulty posture
  cause of, in neuropaths

Allimentary disturbances, symptom of

Alkali, in treatment of cyclic vomiting

Anæmia, of neuropaths

Anorexia nervosa
  A case illustrating

Apnoea, fatal cases of
  following burst of crying
  twitching of facial muscles in

Appetite, emotional states affecting
  loss of,
    case illustrating
    causes and characteristics
    treatment
  means of stimulating
  nature of the sensation of

Apprehension, causes of
  growth of neuroses in atmosphere of

Artificial feeding

Aspirin

Asthma, treatment of

Attention, child's love of attracting
  examples of

Authority, delight in defying
  over-exercise of, by parents, results of


Babies. _See_ Newborn Baby

Backward development
  signs of

"Bad form"

Bad habits

Bath, baby's first experience of

Bed, dislike of
  how overcome
  efforts to resist preparation for

Bedroom, airing and temperature of

Bedtime
  management at

Bed wetting. _See_ Enuresis

Behaviour. _See_ Conduct

Bladder, hydrostatic distension of, for enuresis

Boarding-schools, object of

Bodily ailments, and instability of nervous control, connection between
  _See also_ Disorders

Body,
  and mind, development of
  development of
    environment influencing
  effect of mind on
  gradual alterations in the shape of
  infantile characteristics in later childhood

Bone, and muscle, changes in, in infantile children

Books,
  child's attitude towards
  educative value of
  kinds most suitable

Brachial nerve, pressure causing tetany

Breast-feeding,
  best time for
  causes of failure in
  observations on
  _See also_ Lactation

Breath-holding
  action during
  fatal cases of
  phenomena of

Bromides, administration of
  to newborn baby


Cajoling, futility of

Calcium bromide, in treatment of spasms

Calcium metabolism, disturbance of

Care, ill effects of excess of

Carpo-pedal spasm

Catarrhal infections
  connection of rheumatism with, 155

Cerebral anæmia

Cerebral circulation, stagnation of

Cerebral exhaustion. _See_ Mental Exhaustion

Cerebral functions,
  rapid growth of
  unstable in the child
  _See also_ Mental

Character,
  formation of
  during school life
  home influence in the development of
  ideals of, how inculcated

Children's parties, disadvantages of

Chloral, administration of
    to newborn baby
  in treatment of spasms

Chorea,
  and rheumatism, association between
  symptom of cerebral irritability
  treatment of

Chvostek's sign, characteristics and nature of

Circulation, cerebral,
  stagnation of
  nervous control of

Claustrophobia

Clothing,
  kind suitable
  new, child's delight in

Coaxing,
  futility of

Cold douches, improving vasomotor tone

Coldness of extremities

Conduct,
  control of, factors in
  errors of, and sexual instincts
    control of
    correction of
    due to faults of management
    in neuropathic children
  excessive introspection influencing
  ideals of, how inculcated
  influence of environment on
  influenced by suggestion
  mother's influence on
  of neuropaths
  perverse
  suggestion in the control of

Constipation,
  mental causes of
  negativism in
  perversion of suggestion a common cause of
  suggestion in relation to

Constitution, delicacy of

Convulsions, fatal cases of
  generalised

Convulsive disorders

Cough, nervous

Counter-opposition, child's opposition growing with

Crying, constant
  formation of habit of
  in emotional and excitable children
  management of
  mechanism of
  phenomena of
  purposeful

Cyclic or periodic vomiting. _See_ Vomiting


Day-dreams, indicating nervous temperament

Deceit

Defæcation, inhibition of
  painful

Delicacy of constitution

Delirium, tendency to

Depolarisation of ideas

Depression, recurrence of periods of

Dexterity, lack of
  manual, advantages of
  toys developing

Diaphragm, spasm of

Diarrhoea, mucous

Diet, likes and dislikes for articles of
  opposition to
  of newborn child, changes in
  _See also_ Food

Digestion, emotional states affecting

Digestive disorders, mental causes of

Digestive neuroses

Digestive system, symptoms of extreme sensibility of

Dirt eating

Discipline
  in later childhood
  in the school
  misdirected efforts at enforcing
  severe, effects of

Dishonesty

Disobedience,
  growth of
  habit of
  personality and
  perverse attitude of
  reproof and coaxing causing

Disorders, ætiology of
  associated with neurosis
  common
  environment as cause and cure of
  of neuropaths
  treatment of
  trifling

Diuresis, excessive

Doll, child's care of, an example of imitativeness
  educative value of

Douches, cold, improving vasomotor tone

Dover's powder

Dreams,
  nature of, indicating nature of mental unrest

Drugs, in sleeplessness

Ductless glands, in relation to infantile characteristics

Dullards

Dyspepsia, complications of
  course and effects of
  mental aspects of
  nervous symptoms of
  symptoms in newborn infant
  treatment


Early childhood, care during
  impulse of opposition in
  love of power in

Early childhood, nervousness in
  reasoning power in
  three common neuroses of
  toys, books, and amusements in
  _See also_ Newborn Baby

Education, aim of
  by games and toys
  on sexual matters

Educative value, of books, games, and toys

Emotional states, appetite affected by
  causing spasm
  management of
  of neurotics, exaggeration of
  physical disturbances due to
  producing laryngismus stridulus

Emotional storms

Endocrine glands

Enuresis,
  causal factors in
  characteristics and peculiarities of
  condition of urine during
  mental aspects of
  mistakes in treatment of
  perversion of suggestion as cause of
  removal of tonsils in
  treatment, essentials in
    hypnotic suggestion in
    methods of

Environment, body moulded and shaped by
  change of, beneficial effects of
  effect in developing child's powers
  effect on common disorders
  errors of, and neuropathic children
  essentials of
  faulty contact with, in neuropathic children
  for neuropaths
  influence on conduct in later childhood
  influence on mental processes
  influence on personality
  irritating nature of the adult mind in
  of the home, reflected in the child
  of school life
  stimulus of
  susceptibility to influences of

Epilepsy, cyclical character of

Evil, inborn disposition to

Excitable children, management of

Exercise, sleep in relation to

Exhaustion. _See_ Mental Exhaustion

Expostulation, frequent, bad effects of
  _See also_ Reproof

Expressions, to attract attention


Facial muscles, twitching of
  associated with apnoea

Fæces, incontinence of

Fainting fits,
  cause and characteristics
  control of
  of neuropaths

Fatigue, mental, physical, and visceral

Fats, lowered tolerance to

Faults, correction of
  not corrected by too frequent reproof

Fear,
  causes of
  phenomena of
  prominent psychical symptom of neuropathic children
  treatment of

Feeding,
  artificial
  factors in
  of newborn infant, regularity in

Fertilisation, method of imparting knowledge of

Food, force of suggestion in relation to
  healthy desire for
  likes and dislikes for
    how overcome
  phenomena of the desire of
  refusal of
    nervous causes of
    persistent, factors encouraging
    suggestion in relation to
    treatment of

Force and cajoling, futility of

Freud, teaching of

Functional disturbances, in combination with organic disease


Gait, peculiarity of

Games, educative value of

Gastric disturbances

Gastric juice, psychic secretion of

Gastric symptoms, of neurosis

Gastro-intestinal derangement, causes of
  environment as cause and cure of

Gentleness,
  inculcation of

Girls' schools

Glottis, spasm of, strong emotion causing

"Good form"

Grasping habit, reproof in relation to

Growing pains


Habit spasms, age of appearance of
  cause of
  definition of
  examples of
  spread of
  suggestion in relation to
  treatment of

Habits, regulation of
  suggestion in relation to

Habitual actions, infant's pleasure in
  mental unrest in relation to
  of the parent, reproduction in the child
  varieties and characteristics

Habitual wakefulness

Hands, control of movement of
  expressionless

Happiness and contentment, of child when playing alone

Headache, periodic. _See_ Migraine

Heat and cold, newborn baby in relation to

Heat and flushing, sudden sensations of

Heredity, and temperament
  and type of child
  nervous disorders in relation to

Home influence, in development of character
  reflected in the child

Hunger, of the newborn baby

Hypnotic suggestion, in treatment of enuresis

Hypnotics

Hysteria,
  age of appearance of
  suggestion in relation to
  symptoms of

Hysterical girls, characteristics of


Ideals, inculcation of

Ideas, polarisation and depolarisation of

Illness. _See_ Sickness

Imagination, abnormal, correction of
  child's stories and tales in relation to
  developed by toys

Imitativeness, age at which apparent
  extent of
  illustration of
  lack of
  of action
  of speech
  tell-tale child an illustration of

Incontinence of urine

Incorrigible children

Infantile characteristics,
  ductless glands in relation to
  nervous system in relation to

Infective disorders,
  convalescence from
  producing nervous symptoms
  relation of neurosis to

Inflammatory reactions

Insomnia. _See_ Sleeplessness

Intellect, compared with physique

Intelligence, in early childhood

Intestinal disturbance
  of neurosis
  symptom of

Intoxications, violent reaction to

Introspection, and neuropathic children
  excessive, evidences of
    influencing conduct

Irritation, child to be free from


Joint pains


Kindergarten school, artificial symbolism of

Kindness, inculcation of


Lactation,
  care of child during
  care of mother during
  causes of failure in
  establishment of
  tongue-tie in relation to

Laryngismus stridulus. _See_ Breath-holding

Later childhood,
  infantile characteristics in
  management in
  mental backwardness in

Likes and dislikes

Lordosis
  and neurosis
  producing albuminuria


Manual dexterity, advantages of

Massage, improving tone of muscles

Medicines, sensitiveness to

Melancholy children

Mental aspects, of digestive disorders
  of enuresis
  of management in early childhood

Mental backwardness,
  and infantile characteristics
  in later childhood

Mental disturbances,
  cyclical character of
  indicating neuropathic tendencies
  irregularities of sleep due to
  psycho-analysis of

Mental exhaustion,
  during convalescence from infective disorders
  easily produced in nervous children

Mental irritability, chorea a symptom of

Mental life of the child

Mental power,
  active before beginning of speech
  in early childhood

Mental processes, development of
  age at which most apparent
  in later childhood
  effect of unconscious suggestions on
  heredity in relation to
  influence of environment on

Mental training
  compared with physical training
  objects and advantages of

Mental unrest,
  avoidance of
  crying in relation to
  digestive disturbances due to
  growth of neuroses in atmosphere of
  habitual actions in relation to
  in the adult
  in the child
  negativism due to
  of newborn infant, effects of
  _See also_ Nervous Unrest

Micturition,
  functional disorder of
  negativism in
  regulation of
  _See also_ Enuresis

Migraine,
  periodic vomiting associated with
  symptom of nervous exhaustion

Mind,
  and body, development of
  effect on the body
  vigour of, in relation to that of body

Money, theft of

Montessori system of training

Moral degeneracy

Moral standard of school life

Moral training
  importance and effects of
  negative virtues and
  objects and advantages of
  parents' responsibilities in

Morals, public opinion forming code of

Morbid introspection

Mothers,
  ability and inability to manage children
  attitude in regard to temperament of child
  care of, during lactation
  conduct of child influenced by
  inability to understand nature of child's disorders
  influence of, on tone and manner of speech
  mental environment of child created by
  personality of
  relation to the child

Motionless children

Mouth, habit of conveying everything to, cause of

Movements,
  precision of
  purposive, development of
  self-command of

Muscular atrophy, and neurosis

Muscular system,
  changes in infantile children
  weak development of

Muscular tone, how improved

Myopathy, primary


Nasal obstruction
  and failure of lactation
  night-terrors aggravated by

Natural history, sexual matters taught by

Naughtiness, child's delight in

Naughty, use of the term

Negative virtues, and moral training

Negativism,
  cause of
  characteristics
  factors developing
  in constipation
  in micturition
  spirit of
  treatment of
  want of sleep depending on

Nerve centres, controlling movement, development of

Nervous control, instability of, connection between bodily ailments and

Nervous cough

Nervous disorders,
  and psycho-analysis
  common, causes, characteristics, and treatment
  frequency of

Nervous exhaustion, cyclic vomiting and migraine symptoms of

Nervous instability, stigma of

Nervous system, abnormal in children
  in relation to cyclic vomiting
  increased irritability of
  infantile characteristics of

Nervous unrest, environment in relation to
  factors increasing
  manifestations of
  recurrence of periods of
  symptoms of
  _See also_ Mental Unrest

Nervous vomiting. _See_ Vomiting

Nervousness, and digestive disorders
  and neuropathy
  in early infancy
  in older children
  parents' attitude causing

Nettlerash

Neurasthenia

Neuropathic children, common symptoms of
  conduct of
  faulty contact with environment in
  fear the prominent symptom of
  introspection and self-consciousness of
  management of
  training of

Neuropathic tendencies, evidence of, in older children

Neuropaths, adult
  faulty management in child life leading to
  phenomena of
  phobias of
  selection of suitable environment for
  symptoms of

Neuroses, and psycho-analysis
  association of albuminuria with
  constipation frequently due to
  examination of
  growth in atmosphere of unrest and apprehension
  relation of, to infection of the body
  treatment of

Neurotics, and physique
  characteristics
  exaggeration of emotions of

Newborn baby, administration of sedatives to
  artificial feeding of
  breast feeding of
  case of
  effect of mental unrest on
  first impressions of
  formation of habits of sleep and crying in
  heat and cold in relation to
  hunger of
  induction of the sucking movements of
  of nervous inheritance
  personality of
  prevention of restlessness and crying
  reduction of sense stimuli in
  reflex action of sucking in
  sense of taste of
  symptoms of dyspepsia in
  times of feeding
  weaning of

Night-terrors, aggravation of,
  causes of
  of neuropathic children

Nursery, activities in, child's interest in
  importance of child's being alone in
  observations in

Nursery life, advantages of

Nursery psycho-therapeutics

Nurses, ability and inability to manage children
  influence of, on tone and manner of speech
  mental environment of child created by
  personality of

Nursing, during sickness
  of the newborn infant


Obedience
  and perverse pleasure
  growth of

Obsession of bed wetting

Opposition
  and counter-opposition
  during sickness
  force of, factors influencing development
  habit of
  impulse of
  love of, in early childhood
  to food

Organic disturbance, in combination with functional trouble


Pain, frequent loss of sense of, in neuropaths

Pallor
  sudden attacks of

Palpitation, example of visceral fatigue

Parathyroid glands, function of

Parents,
  and children, conflict between
  and silence on sexual matters
  habitual actions of, reproduced in the child
  mental attitude of, in relation to conduct
  over-exercise of authority by, results of
  responsibilities in moral training of child
  suggestions unconsciously conveyed by, evil results of

Parties, disadvantages of

Patient, temperament of, physician in relation to

Pelvis, development of

Peripheral nerves, increase in irritability and conductivity of

Personal adornment, delight in

Personality,
  and disobedience
  child's own conception of
  environment influencing
  in early childhood
  of newborn baby

Perspiration, abundant, sudden attacks of, 141

Phobias,
  characteristics and varieties
  frequency of
  treatment of

Physical defects, accompanying neurosis

Physical disturbances, due to emotion

Physical exercise, lack of, causing want of sleep

Physical fatigue, easily produced in nervous children

Physical phenomena of neuropaths

Physical training,
  objects and advantages of

Physician,
  and the temperament of his patient
  examination by
  diagnosis by
  difficulties of

Physique, intellect compared with

Pica and dirt eating

Picture books,
  educative value of
  kinds most suitable

Play,
  happiness of child during
  in the nursery
  with grown-up persons

Pleasure, sense of, in early childhood

Polarisation of ideas

Postural albuminuria

Posture, faulty
    prevention of

Power, child's love of

Precision of movement, development of

Psycho-analysis,
  dangers of
  observations on

Public schools, character and effects of

Punishment,
  deserved and undeserved
  frequent, disadvantages of
  observations on

Purity, inculcation of high ideals of,

Purposive movements, earliest,
  cause of
  encouragement of

Pyloric spasm

Pyrexia,
  organic disease in relation to


Rational hygiene

Reasoning power,
  active before advent of speech
  factors influencing development of

Regulation of habits

Repression, by older children of younger

Reproduction, method of imparting knowledge of

Reproof,
  cases in which useless
  causing disobedience
  effects of
  extreme sensitiveness to
  perverse pleasure of
  too frequent repetition of, futility of

Restlessness, during sickness

Rewards, use and dangers of

Rheumatism,
  and chorea, association between
  characteristics in childhood
  subacute
  treatment of

Rickets,
  mental and intellectual condition in
  in infantile children
  occurrence with spasmophilia

Right and wrong, appreciation of, in early childhood

Round shoulders


St. Vitus's dance

Salts, excretion of

School life,
  and sexual matters
  moral standard of
  moral training and
  moulding of character during
  of boys
  of girls

Schools, public, character and effects of

Scoliosis, prevention of

Secretions, anomalies of

Self, child's conception of

Self-conscious children, complaints of

Self-consciousness, of neuropathic children

Self-discipline, development of

Self-education, in the nursery

Self-feeding

Self-preservation, morbid instinct of

Self-sacrifice, not to be expected in early childhood

Sensations,
  acuteness of
  bodily, of neuropaths

Sense perception, of neuropaths

Sense stimuli,
  cultivation of perception of
  in newborn babies

Sexual matters,
  education on
  method of
  errors of conduct and
  parents' silence in regard to
  psycho-analysis in relation to
  school life in relation to

Sickness
  evil effects of suggestions unconsciously conveyed by parents during
  management during
  nurse and mother during
  opposition during
  temperature during
  therapeutic measures in
  therapeutic procedures concentrating child's mind on his symptoms

Sleep, estimation of the amount of
  force of suggestion in relation to
  formation of habit of
  light and broken, cause of
    of newborn infant
  sound, beneficial effects of

Sleeping attire

Sleeplessness, breaking of the habit of
  causes and characteristics
  drugs in
  in older children
  lack of physical exercise causing
  suggestion in relation to
  treatment of

Sleep-walking

Snatching, habit of

Spasmophilia
  ætiology of
  drugs in treatment of
  occurrence of rickets with

Spasms, control of
  fatal

Speech, beginnings of
  facility with which local accent is acquired
  imitativeness of
  infant's reasoning power present before advent of
  influence of nurses and mothers on tone and manner of

Spinal deformity, prevention of

Spinal muscles, atrophy of

Spoon feeding

Status catarrhalis

Status lymphaticus

Story-telling

Sucking movements, of newborn child, induction of
  _see also_ Lactation

Suggestion, and habit spasms
  appetite in relation to
  bed wetting in relation to
  bodily habits in relation to
  characteristics
  conduct influenced by
  constipation in relation to
  effect on mental processes
  food in relation to
  force of, on child's mind
  hysteria in relation to
  perverse influence of
    bad habits due to
    causing constipation
    want of sleep depending upon
  refusal of food in relation to
  sleep in relation to
  susceptibility to
  unconsciously conveyed by parents, evil results of

Suicide

Suspicions, aroused in the child

Syncopal attacks, causes and characteristics


Tactile sensation. _See_ Touch

Taste, perversion of
  sensations of
    how controlled
  sense of, in newborn infant

Teething convulsions

Tell-tale child, characteristics

Temperament, diversity of
  heredity and
  mother's attitude in relation to
  of the patient, physician in relation to

Temperature, during sickness
  inexplicable rises in

Terror, causes, of

Tetany, liability to, in increased irritability of nervous system
  pressure to brachial nerve causing

Theatres, disadvantages of

Theft

Therapeutic conversation

Thigh rubbing,
  avoidance of
  characteristics
  habitual action of

Thorax, development of

Thumb sucking
  persistence of the habit

Tongue-tie, in relation to lactation

Tonics

Tonsils, removal of, in treatment of enuresis

Touch, sense of,
  cultivation of
  early development of
  organs with greatest development of

Toys,
  child's interest in
  educative value of
  kind most suitable

Training, early, importance and object of

Trousseau's sign, nature and production of

Truthfulness
  inculcation of

Twitching of facial muscles

Tyranny of tears


Unkindness, habitual, of children to others

Untruthfulness
  over-exercise of authority encouraging

Urine,
  condition in enuresis
  incontinence of, methods of treatment
    _See also_ Enuresis
  increased secretion of
  irritation of


Vasomotor instability
  conditions indicating
  in neuropaths

Vasomotor tone, how improved

Virtuous, definition of the term

Visceral fatigue, easily produced in nervous children

Vocabulary

Voice, tone of

Voluntary movements, development of cerebral centres controlling

Vomiting, cyclic
  ætiology of
  age at which it occurs
  case illustrating
  causes and characteristics
  class of child affected by
  condition of the child during
  frequency of attacks
  migraine in association with
  nervous system in relation to
  treatment of


Waking states

Weaning, difficulty in

Will, strength of, absence in childhood

Work and play, differentiation between

Writing, correct posture during




Transcriber's Notes

The following typographical errors were corrected:
Page 4: 'sensisive' changed to 'sensitive'.
Page 48: 'self-abnegnatio'n changed to 'self-abnegation'.
page 61: Fixed 'and and'.
Page 125: 'acount' changed to 'account'.
First page of index (191): 'ullimentary' changed to 'Allimentary';
  also 'ilstrating' channged to 'illustrating'.






