THE NERVOUS CHILD

PUBLISHED BY THE JOINT COMMITTEE OFHENRY FROWDE, HODDER & STOUGHTON17 WARWICK SQUARE, LONDON, E. C. 4

THE

NERVOUS CHILD

BY

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

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

LONDONHENRY FROWDE HODDER & STOUGHTONOXFORD UNIVERSITY PRESS WARWICK SQUARE, E. C. 1920

_First Edition_ 1919_Second Impression_ 1930

PRINTED IN GREAT BRITAINBY MORRISON & GIBB LTD. , EDINBURGH

PREFACE

To-day on all sides we hear of the extreme importance of PreventiveMedicine and the great future which lies before us in this aspect ofour work. If so, it follows that the study of infancy and childhoodmust rise into corresponding prominence. More and more a considerablepart 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 influenceswhich mould the mentality of the child and shape his conduct. Extremesusceptibility 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 Ishould 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 onceslept upon--a little offending pea, a minute disturbance, a triflingdeparture from the normal which grew to the proportions of intolerablesuffering because of the too sensitive and undisciplined nervoussystem of Her Royal Highness. The story, I think, does not tell usmuch else concerning the princess. It does not tell us, for instance, if she was an only child, the sole preoccupation of her parents andnurses, surrounded by the most anxious care, reared with somedifficulty because of her extraordinary "delicacy, " suffering from avariety of illnesses which somehow always seemed to puzzle thedoctors, though some of the symptoms--the vomiting, for example, andthe high temperature--were very severe and persistent. Nor does ittell 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 hadremoved the vermiform appendix, while the other a little later hadperformed an operation for "adhesions. " At any rate, the story withthese later additions, which are at least in keeping with what we knowof her history, would serve to indicate the importance which attachesto the early training of childhood. Among the children even of thewell-to-do often enough the hygiene of the mind is overlooked, andfaulty management produces restlessness, instability, andhyper-sensitiveness, which pass insensibly into neuropathy in adultlife. 

To prevent so distressing a result is our aim in the training ofchildren. No doubt the matter concerns in the first place parents andnurses, school masters and mistresses, as well as medical men. Yetbecause of the certainty that physical disturbances of one sort oranother will follow upon nervous unrest, it will seldom happen thatmedical advice will not be sought sooner or later; and if thephysician is to intervene with success, he must be prepared withknowledge of many sorts. He must be prepared to make a thorough andcomplete physical examination, sufficient to exclude the presence oforganic disease. If no organic disease is found, he must explore thewhole environment of the child, and seek to determine whether theexciting cause is to be found in the reaction of the child to someform of faulty management. 

For example, a child of two or three years of age may be brought tothe doctor with the complaint that defæcation is painful, and thatthere has existed for some time a most distressing constipation whichhas resisted a large number of purgatives of increasing strength. Whenever the child is placed upon the stool, his crying at oncebegins, and no attempts to soothe or console him have been successful. It is not sufficient for the doctor in such a case to make anexamination which convinces him that there is no fissure at the anusand no fistula or thrombosed pile, and to confine himself to sayingthat he can find nothing the matter. The crying and refusal to go tostool will continue after the visit as before, and the mother will beapt to conclude that her doctor, though she has the greatestconfidence in him for the ailments of grown-up persons, is unskilledin, or at least not interested in, the diseases of little children. If, on the other hand, the doctor pursues his inquiries into themanagement of the child in the home, and if, for example, he findsthat the crying and resistance is not confined to going to stool, butalso takes place when the child is put to bed, and very often atmeal-times as well, then it will be safe for him to conclude that allthe symptoms are due to the same cause--a sort of "negativism" whichis 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 anddistress which their conduct occasions. 

If this diagnosis is made, then a full and clear explanation should begiven to the mother, or at any rate to such mothers--and fortunatelythey are in the majority--who are capable of appreciating the point ofpsychology involved, and of correcting the management of the child soas to overcome the negativism. To attempt treatment by prescribingdrugs, or in any other way than by correcting the faulty management, is to court failure. As Charcot has said, in functional disorders itis 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 withfunctional trouble. For example, a girl of eighteen years old sufferedfrom a pain in the left arm which has persisted on and off since theolecranon had been fractured when she was two years of age. She wasthe youngest of a large family, and had never been separated for a dayfrom the care and apprehensions of her mother. The joint was stiff, and there was considerable deformity. The pain always increased whenshe was tired or unhappy. Again, a girl had some slight cystitis withfrequent micturition, and this passed by slow degrees into a purelyfunctional irritability of the bladder, which called for micturitionat frequent intervals both by day and night. In such cases treatmentmust endeavour to control both factors--the local organic disturbancemust if possible be removed, and the faults of management corrected. 

It is a good physician who can appreciate and estimate accurately thetemperament of his patient, and the need for this insight is nowheregreater than in dealing with the disorders of childhood. It can beacquired only by long practice and familiarity with children. In thehospital wards we shall learn much that is essential, but we shall notlearn this. The child, who is so sensitive to his environment, showsbut little that is characteristic when admitted to an institution. Only in the nursery can we learn to estimate the influences whichproceed from parents and nurses of different characters andtemperaments, and the reaction which is produced by them in the child. 

The body of the child is moulded and shaped by the environment inwhich it grows. Pure air, a rational diet, free movement, givestrength and symmetry to every part. Faults of hygiene debase thetype, although the type is determined by heredity which in theindividual is beyond our control. Mothers and nurses to-day are wellaware of the need for a rational hygiene. Mother-craft is studiedzealously and with success, and there is no lack of books to givesound guidance and to show the mean between the dangerous extremes ofcoddling and a too Spartan exposure. Yet sometimes it has seemed as ifsome mothers whose care for their children's physical health is mostpainstaking, who have nothing to learn on the question of diet, ofexercise, of fresh air, or of baths, who measure and weigh and recordwith great minuteness, have had their attention so wholly occupiedwith the care of the body that they do not appreciate the simultaneousgrowth of the mind, or inquire after its welfare. Yet it is theastounding rapidity with which the mental processes develop that formsthe distinguishing characteristic of the infancy of man. Were it notfor this rapid growth of the cerebral functions, the rearing ofchildren would be a matter almost as simple and uneventful as therearing of live stock. For most animals faults of environment must bevery pronounced to do harm by producing mental unrest andirritability. Thus, indeed, some wild animal separated from itsfellows and kept in solitary captivity may sicken and waste, thoughmaintained and fed with every care. Yet if the whole conditions oflife for the animal are not profoundly altered, if the environment isnatural or approximately natural, it is as a rule necessary to careonly for its physical needs, and we need not fear that the resultswill be spoiled by the reaction of the mind upon the body. But withthe child it is different; airy nurseries, big gardens, visits to theseaside, and every advantage that money can buy cannot achieve successif the child's mind is not at rest, if his sleep is broken, if food ishabitually refused or vomited, or if to leave him alone in the nurseryfor a moment is to evoke a fit of passionate crying. 

The grown-up person comes eventually to be able to control thistremendous organ, this brain, which is the predominant feature of hisrace. In the child its functions are always unstable and liable to beupset. Evidence of mental unrest or fatigue, which is only rarely metwith in grown persons and which then betokens serious disturbance ofthe mind, is of comparatively common occurrence in little children. Habit spasm, bed-wetting, sleep-walking, night terrors, andconvulsions are symptoms which are frequent enough in children, andthere is no need to be unduly alarmed at their occurrence. In adultage they are found only among persons who must be considered asneuropathic. To make the point clear, I have chosen examples from thegraver and more serious symptoms of nervous unrest. But it is equallytrue that minor symptoms which in adults are universally recognised tobe dependent upon cerebral unrest or fatigue are of everydayoccurrence in childhood. Broken and disturbed sleep, absence ofappetite and persistent refusal of food, gastric pain and discomfortafter meals, nervous vomiting, morbid flushing and blushing, headache, irritability and excessive emotional display, at whatever age theyoccur, are indications of a mind that is not at rest. In children, asin adults, they may be prominent although the physical surroundings ofthe patient may be all that could be desired and all that wealth canprocure. It is an everyday experience that business worries andresponsibilities in men, domestic anxieties or childlessness in women, have the power to ruin health, even in those who habitually or grosslybreak none of its laws. The unstable mind of the child is so sensitivethat cerebral fatigue and irritability are produced by causes whichseem to us extraordinarily trivial. In the little life which the childleads, a life in which the whole seems to us to be comprised indressing and undressing, washing, walking, eating, sleeping, andplaying, it is not easy to detect where the elements of nervousoverstrain lie. Nor is it as a rule in these things that the mischiefis to be found. It is in the personality of mother or nurse, in herconduct to the child, in her actions and words, in the tone of hervoice when she addresses him, even in the thoughts which pass throughher mind and which show themselves plainly to that marvellously acuteintuition of his, which divines what she has not spoken, that we mustseek for the disturbing element. The mental environment of the childis created by the mother or the nurse. That is her responsibility andher opportunity. The conduct of the child must be the criterion of hersuccess. If things go wrong, if there is constant crying orungovernable temper, if sleep and food are persistently refused, or ifthere is undue timidity and tearfulness, there is danger that seedsmay be sown from which nervous disorders will spring in the future. 

There are many women who, without any deep thought on the matter, havethe inborn knack of managing children, who seem to understand them, and have a feeling for them. With them, we say, the children arealways good, and they are good because the element of nervousoverstrain has not arisen. There are other women, often very fond ofchildren, who are conspicuously lacking in this power. Contact withone of these well-meaning persons, even for a few days, willdemoralise a whole nursery. Tempers grow wild and unruly, sleepdisappears, fretfulness and irritability take its place. Yet of mostmothers it is probably true that they are neither strikinglyproficient nor utterly deficient in the power of managing children. Ifthey lack the gift that comes naturally to some women, they learn fromexperience and grow instinctively to feel when they have made a falsestep with the child. Although by dearly bought experience they learnwisdom in the management of their children, they nevertheless may notstudy the subject with the same care which they devote to matters ofdiet and hygiene. It is the mother whose education and understandingbest fits her for this task. In this country a separate nursery and aseparate nursery life for the children is found in nearly allhouseholds among the well-to-do, and the care for the physical needsof the children is largely taken off the mothers' shoulders by nursesand nursemaids. That this arrangement is advantageous on the wholecannot be doubted. In America and on the Continent, where the childrenoften mingle all day in the general life of the household, and occupythe ordinary living rooms, experience shows that nerve strain and itsattendant evils are more common than with us. Nevertheless, thearrangement of a separate nursery has its disadvantages. Nurses aresometimes not sufficiently educated to have much appreciation of themental processes of the child. If the children are restless andnervous they are content to attribute this to naughtiness or toconstipation, or to some other physical ailment. Their time is usuallyso fully occupied that they cannot be expected to be very zealous inreading books on the management of children. Nevertheless, inpractical matters of detail a good nurse will learn rapidly from amother who has given some attention to the subject, and who is able togive explicit instructions upon definite points. 

It is right that mothers should appreciate the important part whichthe environment plays in all the mental processes of children, and intheir physical condition as well; that they should understand thatgood temper and happiness mean a proper environment, and that constantcrying and fretfulness, broken sleep, refusal of food, vomiting, unduethinness, and extreme timidity often indicate that something in thisdirection is at fault. 

Nevertheless, we must be careful not to overstate our case. We mustremember how great is the diversity of temperament in children--adiversity which is produced purely by hereditary factors. The task ofall mothers is by no means of equal difficulty. There are children inwhom quite gross faults in training produce but little permanentdamage; there are others of so sensitive a nervous organisation thattheir environment requires the most delicate adjustment, and whenmatters have gone wrong, it may be very difficult to restore health ofmind and body. When a peculiarly nervous temperament is inherited, wisdom in the management of the child is essential, and may sometimesachieve the happiest results. Heredity is so powerful a factor in thedevelopment of the nervous organisation of the child that, realisingits importance, we should be sparing in our criticism of the resultswhich the mothers who consult us achieve in the training of theirchildren. A sensitive, nervous organisation is often the mark ofintellectual possibilities above the average, and the children who arecast outside the ordinary mould, who are the most wayward, the mostintractable, who react to trifling faults of management with the moststriking symptoms of disturbance, are often those with the greatestpotentialities for achievement and for good. It is natural for themother of placid, contented, and perhaps rather unenterprisingchildren, looking on as a detached outsider, seeing nothing of theteeming activities of the quick, restless little brain, and thepersistent, though faulty reasoning--it is natural for her to blameanother's work, and to flatter herself that her own routine would haveavoided all these troublesome complications. The mother of the nervouschild may often rightly take comfort in the thought that her child isworth the extra trouble and the extra care which he demands, becausehe is sent into the world with mechanism which, just because it ismore powerful than the common run, is more difficult to master andtakes longer to control and to apply for useful ends. 

It is through the mother, and by means of her alone, that the doctorcan influence the conduct of the child. Without her co-operation, orif she fails to appreciate the whole situation, with the best will inthe world, we are powerless to help. Fortunately with the majority ofeducated mothers there is no difficulty. Their powers of observationin all matters concerning their children are usually very great. It istheir interpretation of what they have observed that is often faulty. Thus, in the example given above, the mother observes correctly thatdefæcation is inhibited, and produces crying and resistance. It isher interpretation that the cause is to be found in pain that is atfault. Again, a mother may bring her infant for tongue-tie. She hasobserved correctly that the child is unable to sustain the suctionnecessary for efficient lactation, and has hit upon this fanciful andtraditional explanation. The doctor, who knows that the tongue takesno part in the act of sucking, will probably be able to demonstratethat the failure to suck is due to nasal obstruction, and that thechild is forced to let go the nipple because respiration is impeded. The opportunities for close observation of the child which mothersenjoy are so great that we shall not often be justified indisregarding their statements. But if we are able to give the trueexplanation of the symptoms, it will seldom happen that the motherwill fail to be convinced, because the explanation, if true, will fitaccurately with all that has been observed. Thus the mother of thechild in whom defæcation is inhibited by negativism may have madefurther observations. For example, she may have noted that theso-called constipation causes fretfulness, that it is almost alwaysbenefited by a visit to the country or seaside, or that it has becomemuch worse since a new nurse, who is much distressed by it, has takenover the management of the child. To this mother the explanation mustbe extended to fit these observations, of the accuracy of which thereneed be no doubt. Fretfulness and negativism with all children whosemanagement is at fault come in waves and cycles. The child, naughtyand almost unmanageable one week, may behave as a model of proprietythe next. The negativism and refusal to go to stool are the outcome ofthe nervous unrest, not its cause. Again, the nervous child, like theadult neuropath, very often improves for the time being with everychange of scene and surroundings. It is the _ennui_ and monotony ofdaily existence, in contact with the same restricted circle, thatbecomes insupportable and brings into prominence the lack of moraldiscipline, the fretfulness, and spirit of opposition. Lastly, theconduct of the nervous child is determined to a great extent bysuggestions derived from the grown-up people around him. Refusal offood, refusal of sleep, refusal to go to stool, as we shall see later, only become frequent or habitual when the child's conduct visiblydistresses the nurse or mother, and when the child fully appreciatesthe stir which he is creating. The mother will readily understand thatin such a case, where constipation varies in degree according asdifferent persons take charge of the child, the explanation offered isthat which alone fits with the observed facts. A full and freediscussion between mother and doctor, repeated it may be more thanonce, may be necessary before the truth is arrived at, and a line ofaction decided upon. Only so can the doctor, remote as he is from theenvironment of the child, intervene to mould its nature and shape itsconduct. 

If the doctor is to fit himself to give advice of this sort, he mustbe a close observer of little children. He must not consider itbeneath his dignity to study nursery life and nursery ways. There hewill find the very beginnings of things, the growing point, as itwere, of all neuropathy. A man of fifty, who in many other ways showedevidence of a highly nervous temperament, had especially onewell-marked phobia, the fear of falling downstairs. It had never beenabsent all his life, and he had grown used to making the descent ofthe stairs clinging firmly to the stair-rail. Family traditionassigned this infirmity to a fall downstairs in early childhood. Butall children fall downstairs and are none the worse. The persistenceof the fear was due, I make no doubt, to the attitude of the parentsor nurse, who made much of the accident, impressed the occasionstrongly on the child's memory, and surrounded him thereafter withprecautions which sapped his confidence and fanned his fears. 

In what follows we will consider first the subject of nurserymanagement, searching in it for the origin of the common disorders ofconduct both of childhood and of later life. I have grouped thesenursery observations under the heads of four characteristic featuresof the child's psychology--his Imitativeness, his Suggestibility, hisLove of Power, and his acute though limited Reasoning Faculties. Ifeel that some such brief examination is necessary if we are tounderstand correctly the ætiology of some of the most troublesomedisorders of childhood, such as enuresis, anorexia, dyspepsia, orconstipation, disorders in which the nervous element is perhaps to-daynot sufficiently emphasised. Finally, we can evolve a kind of nurserypsycho-therapeutics--a subject which is not only of fascinatinginterest in itself, but which repays consideration by the successwhich 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 therapidity of the development of the mental processes is most apparent, and it is with that age that we may begin a closer examination. Atfirst sight it might seem more reasonable to adopt a strictlychronological order, and to start with the infant from the day of hisbirth. Since, however, we can only interpret the mind of the child byour knowledge of our own mental processes, the study of the olderchild and of the later stages is in reality the simpler task. Theyounger the infant, the greater the difficulties become, so that ourtask is not so much to trace the development of a process from simpleand early forms to those which are later and more complex, as tofollow a track which is comparatively plain in later childhood, butgrows faint as the beginnings of life are approached. 

At the age, then, of two or three the first quality of the child whichmay arrest our attention is his extreme imitativeness. Not that theimitation on his part is in any way conscious; but like a mirror hereflects in every action and in every word all that he sees and hearsgoing on around him. We must recognise that in these early days hiswords and actions are not an independent growth, with roots in his ownconsciousness, but are often only the reflection of the words andactions of others. How completely speech is imitative is shown by thereadiness with which a child contracts the local accent of hisbirthplace. The London parents awake with horror to find their baby anindubitable Cockney; the speech of the child bred beyond the Tweedproclaims him a veritable Scot. Again, some people are apt to adopt asomewhat peremptory tone in addressing little children. Often they donot trouble to give to their voices that polite or deferentialinflection which they habitually use when speaking to older people. Listen to a party of nurses in the Park addressing their charges. Asif they knew that their commands have small chance of being obeyed, they shout them with incisive force. "Come along at once when I tellyou, " they say. And the child faithfully reflects it all back, and isheard ordering his little sister about like a drill sergeant, orcurtly bidding his grandmother change her seat to suit his pleasure. If we are to have pretty phrases and tones of voice, mothers must seeto it that the child habitually hears no other. Again, mothers willcomplain that their child is deaf, or, at any rate, that he has thebad habit of responding to all remarks addressed to him by saying, "What?" or, worse still, "Eh?" Often enough the reason that he does sois not that the child is deaf, nor that he is particularly slow tounderstand, but simply that he himself speaks so indistinctly that nomatter what he says to the grown-up people around him, they bend overhim and themselves utter the objectionable word. 

We all hate the tell-tale child, and when a boy comes in from his walkand has much to say of the wicked behaviour of his little sister onthe afternoon's outing, his mother is apt to see in this a most horridtendency towards tale-bearing and currying of favour. She does notrealise that day by day, when the children have come in from theirwalk, she has asked nurse in their hearing if they have been goodchildren; and when, as often happens, they have not, the nurse hasduly recounted their shortcomings, with the laudable notion of puttingthem to shame, and of emphasising to them the wickedness of theirbacksliding--and this son of hers is no hypocrite, but speaks only, asall children speak, in faithful reproduction of all that he hears. Those grown-up persons who are in charge of the children must realisethat the child's vocabulary is their vocabulary, not his own. It isunfortunate, but I think not unavoidable, that so often almost theearliest 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 babysounds with reduplication of consonants to which in course of timedefinite meaning becomes attached, as "Ba-ba, " "Ma-ma, " "Na-na, ""Ta-ta, " and so forth. Action only becomes imitative at a somewhatlater stage. The first purposive movements of the child's limbs arecarried out in order to evoke tactile sensations. He delights tostimulate and develop the sense of touch. At first he has no knowledgeof distance, and his reach exceeds his grasp. He will strain to touchand hold distant objects. Gradually he learns the limitations ofspace, and will pick up and hold an object in his hand with precision. Often he conveys everything to his mouth, not because his teeth areworrying him, or because he is hungry, as we hear sometimes alleged, but because his mouth, lips, and tongue are more sensitive, becausemore plentifully furnished with the nerves of tactile sensation. Byconstant practice the sense of touch and the precision of the movementof his hands are slowly developed, and not these alone, for the childin acquiring these powers has developed also the centres in the brainwhich control the voluntary movements. When the child can walk hecontinues these grasping and touching exercises in a wider sphere. Asthe child of fifteen or eighteen months moves about the room, noobject within his reach is passed by. He stretches out his hand totouch and seize upon everything, and to experience the joy ofimparting motion to it. The impulse to develop tactile sensation andprecision in the movements of his hands compels him with irresistibleforce. It is foolish to attempt to repress it. It is foolish, becauseit is a necessary phase in his development, and moreover a passingphase. No doubt it is annoying to his elders while it lasts, but theonly wise course is to try to thwart as little as we can hislegitimate desire to hold and grasp the objects, and even to assisthim in every way possible. But the mother must assist him only byallowing free play to his attempts. To hand him the object is todeprive the exercise of most of its value. Incidentally she may teachhim the virtue of putting things back in their proper places, anaccomplishment in which he will soon grow to take a proper pride. Ifshe attempts continually to turn him from his purpose, reproving himand snatching things from him, she prolongs the grasping phase beyondits usual limits. And she does a worse thing at the same time. Lestthe quicker hands of his nurse should intervene to snatch the prizeaway before he has grasped it, he too learns to snatch, with a suddenclumsy movement that overturns, or breaks, or spills. If left tohimself he will soon acquire the dexterity he desires. He may overturnobjects at first, or let them fall, but this he regards as failure, which he soon overcomes. A child of twenty months, whose developmentin this particular way has not been impeded by unwise repression, willpick out the object on which he has set his heart, play with it, finger it, and replace it, and he will do it deliberately andcarefully, with a clear desire to avoid mishap. Dr. Montessori, whohas developed into a system the art of teaching young children tolearn precision of movement and to develop the nerve centres whichcontrol movement, tells in her book a story which well illustratesthis point. [1]

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

"The directress of the Casa del Bambini at Milan constructed under oneof the windows a long, narrow shelf, upon which she placed the littletables containing the metal geometric forms used in the first lessonin design. But the shelf was too narrow, and it often happened thatthe children in selecting the pieces which they wished to use wouldallow one of the little tables to fall to the floor, thus upsettingwith great noise all the metal pieces which it held. The directressintended to have the shelf changed, but the carpenter was slow incoming, and while waiting for him she discovered that the children hadlearned to handle these materials so carefully that in spite of thenarrow and sloping shelf, the little tables no longer fell to theground. The children, by carefully directing their movements, hadovercome the defect in this piece of furniture. "

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

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

The grasping phase is but a preliminary to more complex activities. Just as in schooldays we were taught with much labour to makepot-hooks and hangers efficiently before we were promoted to realattempts at writing, so before the child can really perform tasks witha definite meaning and purpose, he must learn to control the finermovements of his hands. Once the grasping phase, the stage ofpot-hooks, is successfully past--and the end of the second year in awell-managed child should see its close--the child sets himself withenthusiasm to wider tasks. To him washing and dressing, fetching hisshoes and buttoning his gaiters, all the processes of his simplelittle life, should be matters of the most enthralling interest, inwhich he is eager to take his part and increasingly capable of doingso. In the Montessori system there is provided an elaborate apparatus, the didactic material, designed to cultivate tactile sensation and theperception of sense stimuli. It will generally suffice to advise themother to make use of the ordinary apparatus of the nursery. Theimitativeness of the young child is so great that he will repeat inalmost every detail all the actions of his nurse as she carries outthe daily routine. At eighteen months of age, when the electric lightis turned on in his nursery, the child will at once go to the curtainsand make attempts to draw them. At the same age a little girl willweigh her doll in her own weighing-machine, will take every precautionthat the nurse takes in her own case, and will even stoop downanxiously to peer at the dial, just as she has seen her mother andnurse do on the weekly weighing night. But at a very early agechildren appreciate the difference between the real and themake-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 thenursery table is kept. He will fetch the tablecloth and help to put itin place, spoons and cups and saucers will be carried carefully to thetable, and when the meal is over he will want to help to clear it allaway. All this is to him a great delight, and the good nurse willencourage it in the children, because she sees that in doing so theygain quickness and dexterity and poise of body. The first purposivemovements of the child should be welcomed and encouraged. It isfoolish and wrong to repress them, as many nurses do, because thechild in his attempts gets in the way, and no doubt for a time delaysrather than expedites preparations. The child who is made to sitimmobile in his chair while everything is done for him is losingprecious hours of learning and of practice. It is useless, and to mymind a little distasteful, to substitute for all this wonderful childactivity the artificial symbolism of the kindergarten school in whichchildren are taught to sing songs or go through certain semi-dramaticactivities which savour too much of a performance acquired by preciseinstruction. If such accomplishments are desired, they may be addedto, but they must not replace, the more workaday activities of thelittle child. The child whose impulses towards purposive action areencouraged is generally a happy child, with a mind at rest. When thoseimpulses are restrained, mental unrest and irritability are apt toappear, and toys and picture books and kindergarten games will not besufficient 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 asecond and closely related quality, his suggestibility. His conceptionof himself as a separate individual, of his ego, only graduallyemerges. It is profoundly modified by ideas derived from those aroundhim. Because of his lack of acquired experience, there is in the childan extreme sensitiveness to impressions from outside. Take, forexample, a matter that is sometimes one of great difficulty, thechild's likes and dislikes for food. Many mothers make complaint thatthere 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, orvegetables, or milk puddings. There are people who believe that thesepeculiarities of taste correspond with idiosyncrasies of digestion, and that children instinctively turn from what would do them harm. Ido not believe that there is much truth in this contention. If wewatch an infant after weaning, at the time when his diet is graduallybeing enlarged to include more solid food, with new and variedflavours, we may see his attention arrested by the strange sensations. With solid or crisp food there may be a good deal of hesitation andfumbling before he sets himself to masticate and swallow. With theunaccustomed flavour of gravy or fruit juice there may be seen on hisface a look of hesitation or surprise. In the stolid and placid childthese manifestations are as a rule but little marked, and pleasurablesensations clearly predominate. With children of more nervoustemperament it is clear that sensations of taste are much more acute. Even in earliest infancy, children have a way of proclaiming theirnervous inheritance by the repugnance which they show to even triflingchanges in the taste or composition of their food. We see the samesensitiveness in their behaviour to medicines. The mixture which onechild will swallow without resentment, and almost eagerly, provokesevery expression of disgust from another, or is even vomited at once. In piloting the child through this phase, during which he startsnervously at all unaccustomed sensations and flavours, the attitude ofmother and nurse is of supreme importance. It is unwise to attemptforce; it is equally unwise, by excessive coaxing, cajoling, andentreaty, to concentrate the child's attention on the matter. Ifeither is tried every meal is apt to become a signal for strugglingand tears. The phase, whether it is short or long continued, must beaccepted as in the natural order of things, and patience will see itsend. The management of this symptom, --refusal of food and anapparently complete absence of desire for food, --which is almost thecommonest neurosis of childhood, will be dealt with later. Here it ismentioned because I wish to emphasise that if too much is made of apassing hesitation over any one article of food, if it becomes thebelief of the mother or nurse that a strong distaste is present, thenif she is not careful her attitude in offering it, because she isapprehensive of refusal, will exert a powerful suggestion on thechild's mind. Still worse, it may cause words to be used in thechild's hearing referring to this peculiarity of his. By frequentrepetition it becomes fixed in his mind that this is part of his ownindividuality. He sees himself--and takes great pleasure in thethought--as a strange child, who by these peculiarities createsconsiderable interest in the minds of the grown-up people around him. When the suggestion takes root it becomes fixed, and as likely as notit will persist for his lifetime. It may be habitually said of a childthat, unlike his brothers and sisters, he will never eat bananas, andthereafter till the day of his death he may feel it almost a physicalimpossibility 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 yetdeclare themselves incapable of swallowing a pill. 

Another example of the force of suggestion, whether unconscious oropenly exercised by speech, is given us in the matter of sleep. Amongadults the act of going to bed serves as a powerful suggestion toinduce sleep. Seldom do we seek rest so tired physically that we dropoff to sleep from the irresistible force of sheer exhaustion. Yet assoon as the healthy man whose mind is at peace, whose nerves are noton edge, finds himself in bed, his eyes close almost with the force ofa hypnotic suggestion, and he drops off to sleep. With some of us thesuggestion is only powerful in our own bed, that on which it has actedon unnumbered nights. We cannot, as we say, sleep in a strange bed. Itis suggestion, not direct will power, that acts. No one can absolutelywill himself to sleep. In insomnia it is the attempt to replace theunconscious auto-suggestion by a conscious voluntary effort of willthat causes the difficulty. A thousand times in the night we resolvethat now we _will_ sleep. If we could but cease to make thesefruitless efforts, sleep might come of itself and the suggestion orhabit be re-established. 

In little children the suggestion of sleep, provoked by being placedin bed, sometimes acts very irregularly. Often it may succeed for aweek or two, and then some untoward happening breaks the habit, andnight after night, for a long time, sleep is refused. The wakefulchild put to bed, resents the process, and cries and sobs miserably, to the infinite distress of his mother. It then becomes just as likelythat the child will connect his bed in his mind, not with rest andsleep, but with sobbing and crying on his part, and mingled entreatiesand scoldings from his nurse or mother. An important part in thisperversion of the suggestion is played by the attitude of the personwho puts the child to bed. Often the nurse is uniformly successful, while the mother, who is perhaps more distressed by the sobbing of thechild, as consistently fails, because she has been unable to hide herapprehension from him, and has conveyed to his mind a sense of his ownpower. 

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

Every mother must be made to realise the ease with which theseunconscious suggestions act upon the mind of the little child, andshould school herself to be strong to make her child strong, and tosee to it that all this suggestive force is utilised for good and notfor evil. 

It is upon this susceptibility to suggestion that a great part of hisearly education reposes. No one who is incapable of profiting by thisnatural disposition of the child can be successful in her managementof him. Turn where you will in his daily life the influence of thisforce of suggestion is clearly apparent. The child does withoutquestioning that which he is confidently expected to do. Thus he willeat what is given him, and sleep soundly when he is put to bed if onlythe appropriate suggestion and not the contrary is made to him. Againwe have seen that a perversion of suggestion of this sort is a commonsource of constipation in early childhood. If the child's attention isdirected towards the difficulty, if he is urged or ordered or appealedto to perform his part, if failure is looked upon as a seriousmisfortune, the bowels may remain obstinately unmoved. In children asin adults a too great concentration of attention inhibits the actionof the bowels, and constipation, in many persons, is due to theattempt to substitute will power for the force of habitual suggestion. No matter what other treatment we adopt, the mother must be careful tohide from the child that his failure is distressing to her. A cheerfuloptimism which teaches him to regard himself as one who isconspicuously regular in his habits, and who has a reputation in thisrespect to live up to is sure to succeed. To talk before him of hishabitual constipation, and to worry over the difficulty, is as surelyto fail. In the same way unwise suggestion can interfere with thepassing of water at regular and suitable intervals. There are childrenwho constantly desire to pass water on any occasion, which isconspicuously inappropriate, because their attention has beenconcentrated on the sensations in the bladder. Often enough when atgreat inconvenience opportunity has been found, the desire has passedaway, and all the trouble has proved needless. It is not too much tosay that every occupation and every action of the day can be madedelightful or hateful to the child, according to the suggestion withwhich it is presented and introduced. Dressing and undressing, eatingand drinking, bathing, washing, the putting away of toys, even goingto bed, can be made matters of enthralling interest or delight, or asubject for tears and opposition, according to the bias which is givento the child's mind by the words, attitude, and actions of nurses andmothers. 

Here we approach very near to the heart of the subject. Stripped ofall that is not essential we see the problem of the management ofchildren reduced to the interplay between the adult mind and the mindof the receptive suggestible child. That which is thought of andfeared for the child, that he rapidly becomes. Placid, comfortablepeople who do not worry about their children find their childrensensible and easy to manage. Parents who take a pride in the daringand naughty pranks of their children unconsciously convey thesuggestion to their minds that such conduct is characteristic of them. Nervous and apprehensive parents who are distressed when the childrefuses to eat or to sleep, and who worry all day long over possiblesources of danger to him, are forced to watch their child acquire areputation for nervousness, which, as always, is passively acceptedand consistently acted up to. Differences in type, determined byhereditary factors, no doubt, exist and are often strongly marked. Yetit is not untrue to say that variations in children, dependent uponheredity, show chiefly in the relative susceptibility orinsusceptibility of the child to the influences of environment andmanagement. It is no easy task to distinguish between the nervouschild and the child of the nervous mother, between the child whoinherits an unusually sensitive nervous system and the child who isnervous only because he breathes constantly an atmosphere charged withdoubt and anxiety. 

(_c_) THE CHILD'S LOVE OF POWER

Let us study briefly a third quality of the child which, for want of abetter name, I have called after the ruling passion of mankind, hislove of power. Perhaps it would be better to call it his love of beingin the centre of the picture. It is his constant desire to make hisenvironment revolve around him and to attract all attention tohimself. Somewhat later in life this desire to attract attention, atall costs, is well seen in the type of girl popularly regarded ashysterical. The impulse is then a morbid and debased impulse; in thechild it is natural and, within limits, praiseworthy. A girl of thissort, who feels that she is not likely to attract attention because ofany special gifts of beauty or intellect which she may possess, becomes conscious that she can always arouse interest by the severityof her bodily sufferings. The suggestion acts upon her unstable mind, and forthwith she becomes paralysed, or a cripple, or dumb, presentinga mimicry or travesty of some bodily ailment with which she is more orless familiar. "Hysterical" girls will even apply caustic to the skinin order to produce some strange eruption which, while it sorelypuzzles us doctors, will excite widespread interest and commiseration. Now little children will seldom carry their desire to attractattention so far as to work upon the feelings of their parents bysimulating disease. They have not the necessary knowledge to play thepart, and even if they make the attempt, complaining of this or thatsymptom which they notice has aroused the interest of their elders, the simulation is not likely to be so successful as to deceive even asuperficial observer. But within the limits of their own powers, children are past masters in attracting attention. The little child isunable to take part in any sustained conversation; most of histalking, indeed, is done when he is alone, and is addressed to no onein particular. But he knows well that by a given action he can producea given reaction in his mother and nurse. A great part of what is saidto him--too great a part by far--comes under the category of reproofor repression. He is forbidden to do this or that, coaxed, cajoled, threatened long before he is old enough to understand the meaning ofthe words spoken, although he knows the tone in which they are utteredand loves to produce it at will. How he enjoys it all! Watch him drawnear the fire, the one place that is forbidden him. He does not meanto do himself harm. He knows that it is hot and would hurt him, butfor the time being he is out of the picture and he is intent onproducing the expected response, the reproof tone from his motherwhich he knows so well. He approaches it warily, often anticipatinghis mother's part and vigorously scolding himself. He desires nothingmore than that his mother should repeat the reproof, forbidding him adozen times. The mind of all little children tends easily to work in agroove. It delights in repetition and it evoking not the unexpectedbut the expected. If his sport is stopped by his mother losingpatience and removing him bodily from the danger zone, his sense ofimpotence finds vent in passionate crying. But if his mother takes nonotice, the sport soon loses its savour. He is conscious that somehowor other it has fallen flat, and he flits off to other employment. 

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

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

In matters of greater moment the same impulse to oppose the will ofthose around him is seen. In considering the point of the child'ssusceptibility to suggestion, we have mentioned the refusal of sleepand the refusal of food. In both it is possible to detect theinfluence of this pronounced force of opposition. As the child liessobbing or screaming in bed, every new approach to him, every freshattempt at pacification, renews the force of his opposition in acrescendo of sound. But it is in his refusal of food that the child isapt to find his chief opportunity. Meal-times degenerate into astruggle. There at least he can show his complete mastery of thesituation. No one can swallow his food for him, and he knows it. Hecan clench his teeth and shake his head and obstinately refuse everymorsel offered. He can hold food in his mouth for half an hour at atime and remain deaf to all the appeals of his helpless nurse. If shetries force, he quells the attempt by a storm of crying. If shedeclines upon entreaty and coaxing, he will not be persuaded. It isthe little scene of the fireplace over again. The attempts at force orthe attempts at persuasion, by making much of it, have concentratedthe attention of the child upon the difficulty, and have taught himhis own power to dominate the situation. 

It is right that parents should realise that the disturbing andirritating element in the child's environment is nearly alwaysprovided by the intrusion of the adult mind and its contact with thechild's. Some supervision and some intrusion, therefore, is of courseabsolutely necessary, but the best-regulated nursery is that in whichit is least evident. Something is definitely wrong if a child of twoyears will not play for half an hour at a time happily and busily in aroom by himself. It is an even better test if the child will playamicably by himself with nurse or mother in the room, without the twoparties crossing swords on a single occasion, without reproof orrepression on the one side or undue attempts to attract attention onthe other. If the child is entirely dependent upon the participationof grown-up persons in his pursuits, then not only do those pursuitslose much of their educative force, but they become a positive sourceof danger because of the constant interplay of personality withpersonality. The child who, seated on the ground, will play with histoys by himself, rises with a brain that is stimulated but notexhausted. Only very rarely do we find that solitary play, or playbetween children, is too exciting. In older children of very quickintelligence and nervous temperament we occasionally find that thepace which they themselves set is too exciting or exhausting. I recalla little boy of seven, an only child of particularly wise andthoughtful parents, who was brought to me with the complaint that heexhausted himself utterly both in body and mind by the intense nervousenergy which he threw into his pursuits. For instance, he had beeninterested in the maps illustrating the various fronts in the EuropeanWar, with which the walls of his father's study were hung, andalthough left entirely by himself he had become intensely excited andexhausted by the eagerness with which he had spent a whole morning, with a wealth of imaginative force, in drawing a map of the garden ofhis house and converting it into the likeness of a war map, filledwith imaginary Army Corps. Such excessive expenditure of nervous forceis unusual even in older children, and as in this case is foundusually only when there is a pronounced nervous inheritance. In littlechildren in the nursery, solitary play or play between themselvesseldom produces nervous exhaustion. It is quite otherwise when thechild is dependent to a too great extent upon the participation ofadults. It is almost impossible for the mother and nurse not to takethe leading part in the exchange of ideas, and no matter what may betheir good intentions, the pace set is apt to be too great. Environment, without the intrusion of the adult mind, is best able toadjust the necessary stimulus and produce development withoutexhaustion. Play with grown-up persons, the reading aloud of storybooks, the showing of pictures, and so forth, undoubtedly have theirown importance, but they should be confined within strict limits andto a definite hour in the daily routine. There is sometimes too greata tendency for parents to make playthings of their little children. Save at stated times, they must curb their desire to join in theirgames, to gather them in their arms, to hold them on their knee, whilethey stimulate their minds by a constant succession of newimpressions. With an only child, whose existence is the singlepreoccupation of the nurse and mother, and, often enough, of thefather as well, it is difficult to avoid this fault. Yet, if wisdom isnot learnt, the damage to the child may be distressingly serious. Herapidly grows incapable of supporting life without this excessivestimulation. Without the constant society and attention of a grownperson, he feels himself lost. He cannot be left alone, and yet cannotenjoy the society he craves. He grows more and more restless, dominating the whole situation more and more, constantly plucking athis nurse's skirts, perversely refusing every new sensation that isoffered him to still his restlessness for a moment. The result of allthis stimulation is mental irritability and exhaustion, which in turnis often the direct cause of refusal of food, dyspepsia, wakefulness, and excessive crying. 

The devices by which children will attract to themselves theattention of their elders, and which, if successful, are repeated withan almost insane persistence, take on the most varied forms. Sometimesthe child persistently makes use of an expression, or asks questions, which produce a pleasant stir of shocked surprise and renewed reproofsand expostulations. One little boy shouted the word "stomachs" withunwearied persistence for many weeks together. A little girl dismayedher parents and continued in spite of all they could do to prevent herto 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 isdeprived of the sense of satisfaction which he has in the interestwhich his conduct excites. His behaviour is only of importance becauseit indicates certain faults in his environment and a certain elementof nervous unrest and overstrain. 

The young child demands from his environment that it should give himtwo things--security and liberty. He must have security from shocks tohis nervous system. It is true that from the greater shocks thechildren of the well-to-do are as a rule carefully guarded. No onethreatens or ill-uses them. They are not terrified by drunken brawlsor scenes of passion. They are not made fearful by the superstitionsof ignorant people. Nevertheless, by the summation of stimuli littleemotions constantly repeated can have effects no less grave upontheir nervous system. From this constantly acting irritation the childneeds security. In the second place, he requires liberty to develophis own initiative, which should be stimulated and sustained anddirected. Without liberty and without security conduct cannot fail tobecome abnormal. 

(_d_) THE REASONING POWER OF THE CHILD

Before we proceed to a closer examination of the various symptoms ofnervous unrest in detail, we may very briefly consider the scope andpower of the child's understanding. As a rule I am sure that it isgrossly underestimated. The mental processes of the child are farahead of his power of speech. The capacity for understanding speech iswell advanced, and an appeal to reason is often successful while thechild is still powerless to express his own thoughts in words. Becausehe cannot so express himself there is a tendency to underestimate theacuteness of his reasoning, to talk down to him, and to imagine thathe can be imposed upon by any fiction which seems likely to suit thepurpose of the moment. A child of eighteen months is not too young tobe talked to in a quiet, straightforward, sensible way. Only if he istreated as a reasonable being can we expect his reasoning faculties todevelop. Children dislike intensely the unexplained intervention offorce. If a pair of scissors, left by an oversight lying about, hasbeen grasped, the first impulse of the mother is to snatch the dangerhurriedly from the child's hands, and her action will generally befollowed by resistance and a storm of weeping. She will do better toapproach him quietly, telling him that scissors hurt babies, and showhim where to place them out of harm's way. Watch a child at play afterhis 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 thatdinner is over he is for a moment master of his time and busilyengaged in some pursuit dear to his heart. At two o'clock inexorableroutine ordains that he must again be placed in the perambulator andwheeled forth on a fresh expedition. If the nurse does not know herbusiness she will swoop down upon him, place him on her knee, andbegin to envelop his struggling little body in his outdoor clothes, scolding his naughtiness as he kicks and screams. If she has a waywith children she will open the cupboard door and call on him to helpfind his gaiters and his shoes because it is time for his walk. In amoment he will leave his toys, forgetting all about them in the joy ofthis new activity. 

If the reason for things is explained to children they grow quick tounderstand quite complicated explanations. A little girl, not yet two, was playing with her Noah's Ark on the dining-room table with itspolished surface. The mother interposed a cloth, explaining that theanimals would scratch the table if the cloth were not there. Within afew minutes the child twice lifted the cloth, peering under it andsaying, "Not scratch table. " Yet how often do we findfacetiously-minded persons confound their reasoning and confuse theirjudgment by foolish speeches and cock-and-bull tales, which, justbecause of their foolishness, seem to them well adapted to the infantintelligence. 

An attempt to deceive the child is almost always wrong, and because ofour tendency to underestimate the child's intelligence it generallyfails. If a little girl has a sore throat, and the doctor comes to seeher, she knows quite well that she is the prospective patient. It isuseless for the mother to begin proceedings by trying to convince herthat this is not so--that mother has a sore throat too. Such a planonly arouses apprehension, because the child scents danger in theartifice. 

Closely connected with the reasoning powers of the child is thedifficult question of the growth of his appreciation of right andwrong, or, to put it in another way, the growth of obedience ordisobedience. Sooner or later the child must learn to obey; on thatthere can be no two opinions. Nevertheless, I think there can be nodoubt that far more harm is done by an over-emphasis of authority thanby its neglect. If the nurse or mother is of strong character, and theauthority is exercised persistently and remorselessly, so that thewhole life of the child is dominated, much as the recruit's existencein the barrack yard is dominated by the drill sergeant, hisindependence of nature is crushed. He is certain to become acolourless and uninteresting child; he runs a grave risk of growingsly, broken-spirited, and a currier of favour. If a child isruthlessly punished for disobedience from his earliest years, thereis, it need hardly be said, a grave risk that he will learn to lie tosave his skin. I have seen a few such cases of what I may call theremorseless exercise of authority, and the result has not beenpleasing. Fortunately, perhaps, not many women have the heart to adoptthis attitude to the waywardness of little children--a waywardness towhich their whole nature compels them by their pressing need tocultivate tactile sensations, to experiment, and to explore. Therefore, much more commonly, the authority is exercisedintermittently and capriciously, with the result that the child'sjudgment is clouded and confused. Conduct which is receivedindulgently or even encouraged at one moment is sternly reprimanded atanother. Every one who has the management of little children mustabove all see to it, whatever the degree of stringency in disciplinewhich they decide to adopt, that their attitude is always consistent. The less that is forbidden the better, but when the line is drawn itmust be adhered to. If once the child learns that the force whichrestrains him can be made to yield to his own efforts, the future isblack indeed. From that day he sets himself to strike down authoritywith a success which encourages him to further efforts. I have known achild of five years terrorise his mother and get his own way by thethreat, "I will go into one of my furies. "

The difficulty of successfully enforcing authority, and of carryingoff the victory if that authority is disputed, should make motherswary of drawing too tight a rein. The conflict between parent andchild must always be distressing and must always be prejudicial to thechild, whatever its outcome, whether it brings to him victory ordefeat. He learns from it either an undue sense of power or an unduesense of helplessness, and the knowledge of neither is to his benefit. Although frequently worsted in the conflict, nurses will often returnto the attack again and again and hour after hour, restraining, reproving, forbidding, and even threatening. Nor do they see that theyare really goading the children into disobedience by their misdirectedefforts at enforcing discipline. Reproof, like punishment, loses allits effect when it is too often repeated, and the child soon takes itfor granted that all he does is wrong, and that grown-up people existonly to thwart his will, to misunderstand, to reprove, or even topunish. 

In the nursery the word "naughty" is far too frequently heard. It isnaughty to do this, it is naughty to do that. There is no gradation inthe condemnation, and the child loses all sense of the meaning of theword. He himself proclaims himself naughty almost with satisfaction:his doll is naughty, the dog is naughty, his nurse and mother arenaughty, and so forth. In reality the little child is peculiarlysensitive to blame, if he is not reproof-hardened. It is hardlynecessary to use words of blame at all. If he is asked kindly andquietly to desist, much as we would address a grown-up person, anddoes not, he can be made to feel that his conduct is unpopular bykeeping aloof from him a little, by disregarding him for the timebeing, and by indicating to him that he is a troublesome little personwith whom we cannot be bothered. 

Any one who has had much to do with children will realise that, ifwrongly handled, they are apt to take a positive delight in doing whatthey conceive to be wrong. There is clearly a delightful element ofexcitement in the process of being naughty, of daring and of bravingthe wrath to come, with which they are so familiar and for which theycare nothing at all. But the perverseness of which we are now speakinghas 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 mentaldisorders. The unhappy patient always does the opposite of what isdesired or expected of him. If he be asked to stand up he willendeavour to remain seated, or if asked to sit he will attempt to riseto his feet. Like many other symptoms of nervous disturbance which weshall study later, this negativistic spirit is often displayed toperfection by little children when the environment is at fault andwhen grown-up people have too freely exercised authority. A mother, anxious to induce her little son to come to the doctor, and knowingwell that her call to him to enter the room, as he stands hesitatingat the door, will at once determine his retreat to the nursery, hasbeen heard to say, "Run away, darling, we don't want _you_ here, " withthe expected result that the docile child immediately comes forward. To the doctor, that such a device should be practised almost as amatter of course and that its success should be so confidentlyanticipated, should give food for thought. It may shed light on muchthat is to follow later in the interview. 

The question of punishment, like that of reproof, is beset withdifficulty. There are fortunately nowadays few educated mothers whoare so foolish as to threaten punishment which they obviously do notintend to administer and which the child knows they will notadminister. It is clear that punishment must be rare or else the childwill grow habituated to it, and with little children we cannot bebrutal or push punishment to the point of extreme physical pain. It ismore difficult to say, as one is tempted to say, that all punishmentis futile and should be discarded. Probably mothers are likeschoolmasters in that no two schoolmasters and no two mothers obtaintheir effects in exactly the same way or by precisely the same means. Nor do all children accept reproof or submit to punishment in the sameway. Some make light of it and take a pleasure in defying authority. Others are unduly cast down by the slightest adverse criticism. It isgenerally true that extreme sensitiveness to reproof is a sign of acertain elevation of character. Always we must remember that for amother to inflict punishment, whether by causing physical pain ormental suffering, is to take on her shoulders a certainresponsibility. It is a serious matter if she has misapprehended thechild's act--if the sin was not really a sin, but only some pervertedaction, the intention of which was not sinful, but designed for goodin the faulty reasoning of the child. A little girl, in bed with afeverish cold, was found shivering, with her night-dress wet andmuddy. It was an understanding mother who found that her littlebrother, having heard somehow that ice was good for fevered heads, hadbrought in several handfuls of snow from the garden, not of thecleanest, and had offered them to aid his sister's recovery. It needhardly be said that punishment should always be deliberate. The hastyslap is nothing else than the motor discharge provoked by theirritability of the educator, and the child, who is a good observer onsuch points, discerns the truth and measures the frailty of his judge. 

The frequent repetition of words of reproof and acts of punishment hasa further disadvantage that the older children are quick to practiseboth upon their younger brothers and sisters. There is something wrongin the nursery where the lives of the little ones are made a burden tothem by the constant repression of the older children. But althoughset and artificial punishments are as a general rule to be used butsparingly, the mother can see to it that the child learns byexperience 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 theobvious lesson. If the baby throws his doll from the perambulator, insheer joy at the experience of imparting motion to it, she need notprevent him from learning the lesson that this involves also sometemporary separation from it. Throughout all his life he is to learnthat he cannot eat his cake and have it too. The use of rewards isalso beset with difficulties. Their coming must be unexpected andoccasional. They must never degenerate into bribes, to be bargainedfor upon condition of good behaviour. Rewards which take the form ofspecial privileges are best. 

The æsthetic sense of children develops very early. From the verybeginning of the second year they take delight in new clothes, and inpersonal adornment of all sorts. They show evident pleasure if thenursery acquires a new picture or a new wall-paper. They havepronounced favourites in colours. Even tiny children show dislike ofdirt and all unpleasant things. Personal cleanliness should be clearlydesired by all children. A sense of what is pleasant and what isunpleasant should be encouraged. Any delay in its appearance is apt toimply a backwardness in development of mind or of body. Only childrenwho are tired out by physical illness or by nervous exhaustion willlie without protest in a dirty condition. 

Affection and the attempt to express affection appear clearly markedeven in the first year. Too much kissing and too much being kissed isapt 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 complexquality as unselfishness or self-abnegation. The child's conception ofhis own self has but just emerged. It is his single impulse to develophis own experience and his own powers, and his attitude for manyyears is summed up in the phrase: "Me do it. " We must not expect himto resign his toys to the little visitor, or the little visitor tocease from his efforts to obtain them. In all our dealings withchildren we must know what we may legitimately expect from them, andjudge them by their own standards, not by those of adult life. Wecannot expect self-sacrifice in a child, and, after all, when we cometo think of it, obedience is but another name for self-sacrifice. Ifthe tiny child could possibly obey all the behests that are heapedupon him in the course of a day by many a nurse and mother, he wouldtruly be living a life of complete self-abnegation. Surely it isbecause the virtue of obedience, the virtue that is proclaimedproverbially the child's own, is so impossible of attainment that itis become the subject of so much emphasis. As Madame Montessori hasput it: "We ask for obedience and the child in turn asks for themoon. " Only when we have developed the child's reasoning powers, bytreating him as a rational being, can we expect him deliberately todefer his wishes to ours, because he has learned that our requests aregenerally reasonable. 

CHAPTER III

WANT OF APPETITE AND INDIGESTION

The mind of the child is so unstable and yet so highly developed, thatsymptoms of nervous disturbance are more frequent and of greaterintensity than in later life. Only rarely and in exceptional cases docertain symptoms, common in childhood, persist into adult life orappear there for the first time, and then usually in persons who, ifthey are not actually insane, are at least suffering from intensenervous strain. We have already mentioned the symptom of negativismand noted its occasional occurrence as an accompaniment of mentaldisorder in adult life, and its frequency among children who areirritable or irritated. Similarly, we may cite the digestive neurosesof adult life to explain the common refusal of food and the commonnervous vomiting of the second year of life. Thus, for example, thereexists in adult life a disturbance of the nervous system which iscalled "anorexia nervosa. " A boy of nineteen was brought to theOut-patient Department of Guy's Hospital suffering from thiscomplaint. He was little more than a skeleton, unable to stand, hardlyable to sit, and weighing only four and a half stones. His mother, who came with him, stated that he had always been nervous, and thatlately, after receiving a call to join the army as a recruit, hisappetite, which had for some time been capricious, had completelydisappeared. In spite of coaxing he resolutely refused all food, ortook it only in the tiniest morsels, although at the same time it wasthought that he sometimes took food "on the sly. " A carefulexamination showed absolutely no sign of bodily disease. He wasadmitted to a ward for treatment by hypnotic suggestion, but beforethis could be begun he endeavoured to commit suicide by setting fireto his bed. 

A girl of twenty-four years of age had become almost equallyemaciated. Constant vomiting had persisted for many years and haddefied many attempts at cure. It had even been proposed to perform theoperation of gastro-enterostomy in the belief that some organicdisease existed. In suitable surroundings and with the energeticsupport of a good nurse, who spent much time and care in restoring herbalance of mind, the vomiting ceased, and she gained over two stonesin weight. Work was found for her in some occupation connected withthe War, and she left the Nursing Home to undertake this, bearing withher four pounds which she had abstracted from the purse of anotherpatient. 

Those who have not opportunities of observing how all-powerful is theeffect of the mind upon the body, and especially perhaps upon theprocess of digestion, may find it hard to believe that thesedistressing symptoms and profound changes in the aspect and nutritionof the patients were due entirely to mental causes and were symptomsin accord with the attempted suicide or the theft of the money. Innervous little children we shall not often find such complex actionsas suicide or theft, although they do occur, but combined with otherevidence of nervousness we shall meet commonly enough with apersistent setting aside of appetite and refusal of food and withcontinuous and habitual vomiting, from nervous causes. 

The experiments of Pawlow and others have explained the dependence ofdigestion upon mental states. They show that even before the food istaken into the mouth, while the meal is still in prospect, there hasbeen instituted a series of changes in the wall of the stomach, whichgives rise to the so-called psychic secretion of gastric juice. Thesechanges are preceded by the sensation of appetite, which is evoked notby the presence of food in the stomach--for the food has not yet beenswallowed--but by the anticipation of it, by the sight and smell offood, 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, orexcitement--put a stop to the process or interfere with its action, sothat the sense of appetite is absent, and the taking of food is apt tobe followed by discomfort or pain or vomiting. No doubt good digestionleads to a placid mind, but it is equally true that a placid mind isnecessary for good digestion. Therefore we civilised people, livinglives of mental stress and strain, try to increase the suggestiveforce of our surroundings and to provoke appetite by all devicescalculated to stimulate the æsthetic sense. The dinner hour is fixedat a time when all work and, let us hope, all worry is at an end forthe day. The dinner-table is made as pretty as possible, with flowersand sparkling glass. We are wise to dress for dinner, that with ourworking clothes we may put off our working thoughts. 

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

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

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

In early childhood the difficulty of the refusal of food often passesor diminishes when the child learns to feed himself with precision andcertainty. To teach him to do so, it is not wise to devote all ourattention to making him adept at this particular task. The fault isthat the brain centres which control the movements of hands, mouth, and tongue have not been developed, because his activities in alldirections have not been encouraged. It is much less trouble for anurse to feed a little child than to teach him to feed himself, and ifhe is not given daily opportunities of practice he will certainly notlearn this particular action. But the fault as a rule lies deeper. Thechild who cannot feed himself cannot be taught until fingers and brainhave been developed in the thousand activities of his daily routine, by which he acquires general dexterity. A child who is still too youngto feed himself is learning the dexterity which is necessary as apreliminary in every action of the day. If he can carry the tableclothand the cups and saucers to the tea-table, imitating in everything theaction of his nurse, it will be strange if he does not also imitateher in the central scene, the actual eating of the food. If, on theother hand, he is waited upon hand and foot, if he is restrained andconfined, sitting too much passively, now in his perambulator, now inhis high chair, now on his nurse's lap, his imitative faculties andhis tactile dexterity alike remain undeveloped. The child who is slowin learning to feed himself shows his backward development in everymovement of his body. One may note especially the stiff, "expressionless" hands, indicating a general neuro-muscular defect. Ihave seen many children of eighteen months or two years of age in whomthe movements necessary for efficient mastication and swallowing hadfailed to develop satisfactorily. In some a pure sucking movementpersisted, so that when, for example, a morsel of bread or rusk wasput in the child's mouth, it would be held there for many minutes andsubmitted only to suction with cheeks and tongue. Attempts to swallowin such a case are so incoordinate that they give rise frequently toviolent fits of choking, which distress the child and produceresistance and struggling, while at the same time they alarm themother or nurse so much that further attempts to encourage the takingof solid food are hastily and for a long time abandoned. In thishelpless condition the other factors which tend to develop what wehave called negativism have full play. The want of imitation and thelack of dexterity is not the sole or perhaps the main cause of thechild's refusal of food and of the apparent want of appetite, but itis the cause of the failure to learn to feed himself, which placeshim in a condition which is peculiarly favourable to the operation ofother factors. If only we can teach the child to feed himself, thedifficulties of the situation become much less formidable. 

The first of the factors which encourage the persistent refusal offood is the extreme susceptibility of the child to suggestion. Aparticular article of diet may be refused on one occasion, perhaps inpique, because another more favoured dish was hoped for or expected, or perhaps because the taste is not yet familiar. Then if on thisoccasion a struggle for the mastery is waged, and a painful impressionis made on the child's mind connecting this particular dish withstruggling and tears, from that day forward the child may persistentlyrefuse it on every occasion it is offered. Matters are made worse ifthe nurse, anticipating refusal, attempts to overcome the resistanceby peremptory orders, or by excessive praise extolling the deliciousflavour with such fervour that the child's suspicions are at oncearoused. Previous experience has made him connect these excessivepraises with articles which have aroused his distaste. If these fadsand fancies on the part of the child are to be avoided, it isessential that we should do nothing to focus his attention on hisrefusal. It is better that his dinner should be curtailed on oneoccasion than that taste and appetite should be perverted perhaps foryears. Every nurse or mother should cultivate an off-hand, detachedmanner of feeding the child, and should patiently continue to offerthe food without uncalled-for comments or exhortations. Let her alwaysremember the force of suggestion on the child's mind, and that aconfident manner which never questions the child's acceptance willmeet with acceptance, while a hesitating address, from fear of theimpending refusal, will be apt to meet with refusal. Sometimes a stillworse fault manifests itself, when nurse and mother speak before thechild of the smallness of his appetite, and of his persistent refusalof this or that article of diet. The suggestion then acts still morepowerfully on his mind. He is aware that the whole household isdistressed by his peculiarity, and he grows to identify it with hisown individuality, and to regard himself with some satisfaction aspossessing this mark of distinction. If there is any difficulty ofthis sort it is often directly curative to reverse the suggestion andto speak before him of his improving appetite, and to say that hebegins every day to eat better and better, even if to do so we have tobreak 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 foodappear and persist, we must be content to bide our time. When thechild grows of an age to reason, we should seize every opportunity tomake him feel that his persistent refusal is a little ridiculous andchildish. Little by little the seed is sown, and will germinate tillone day we shall note with surprise that he has taken of his ownaccord that which he has neglected for so long and with suchobstinacy. 

But the force which is acting most strongly in producing this refusalof food is the force of which we have spoken in a previouschapter--the force which results in negativism, the force which is inreality the habit of opposition, the love of power, and the desire toattract attention. Here again the refusal of food, if due to thiscause, is never the sole manifestation of the fault. Just as the delayin learning to swallow and to chew properly and to feed himself ispart of a general want of dexterity and capacity manifested in all hisactions, so it will seldom happen that the child's anxiety to opposeis only seen at meal-times. Watch a nervous child in the nurserybefore 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, nodoll. " At the same moment he may catch sight of his ball, and it toois violently rejected, "No, no ball. " Everything in turn is treated inthe same way. Finally he falls upon his nurse, crying and beating herwith his hands, saying, "No, no Nurse. " If that long-suffering womanat that moment summons him to dinner, it will be strange indeed if hisattitude is not "No, no dinner, " and "No, no" to every mouthfuloffered him. How strong this love of opposition may be is illustratedby 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 hisgrandfather's to midday dinner on Sunday, when his absolute refusal offood had spoiled the day and had occupied the attention and theefforts of the whole party. Doubtless he had enjoyed himself, forthree weeks later, when he caught sight of the car which was to bringhim 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 orsound of the preparation of a meal was enough to bring on a paroxysmof opposition. Now this force of opposition, as we have seen, onlydevelops into a serious difficulty when the child's own will has beenopposed too much, when authority has been too freely exercised, andwhen the child has been urged and entreated and reproved with toogreat frequency. His opposition grows with all counter-opposition. Andhe is not really naughty, only irritable and restless from thethwarting of his natural impulses, and unable to express his thoughtsand desires. Negativism will not often confine itself to meal-times. It will show clearly in all the actions of the child, and to get himto eat well and freely we must so change our management of him thatnegativism disappears or at least diminishes. There is no other way. No entreaty, no force, no threats of force will ever succeed, but willonly make him worse, and, since negativism is due to mental unrest, the struggles and crying will only perpetuate the cause. The one wayto banish negativism and overcome the opposition is to cease tooppose, and to practise this aloofness not so much at meal-times, forsomehow by patience the child must be got to take his food, but in allour conduct to him. Repression and reproof, and thwarting of thechild's will, and coaxing and entreaty must cease. There is no fearthat we shall thereby make the child unduly disobedient. We havealready, in another chapter, decided that negativism is not strengthof will on the part of the child which must be broken, but is theresult of constant attempts to oppose his nature, and the consequentnervous unrest. If we cease to oppose, the symptoms will tend rapidlyto disappear, the child will become busy and contented and happy inhis play, and we shall hear no more of his refusal of food. Ifsometimes it recurs for a week or two, we shall know how to deal withit. 

In children, as with us, periods of nervous unrest and unhappiness areapt to recur in a sort of cycle. This cyclical character of mentaldisturbance is often a marked feature. We see it in epilepsy andin what the French have called Folie Circulaire. We see it in thedipsomaniac, in the intermittency of his craving for drink and of hisperiodical outbursts, and we see it in ourselves in those periods ofdepression which recur so often, we know not why. Little children toosometimes get out on the wrong side of their beds, and never get rightthe whole long day. Their own experience of the vagaries of mentalstates should lead mothers to be indulgent to the children in theirdays of cloud and to be particularly careful not to goad them bywell-intentioned efforts into bursts of naughtiness and passion, eachone of which tends to perpetuate the condition and increase thenervous unrest. We know how closely dependent is the sensation ofappetite upon emotional states, and we must do all in our power--andthe task is sometimes one of real difficulty--to keep the child's mindsufficiently at rest to preserve the healthy desire for foodunimpaired. If there is no sign of appetite, but every sign ofrestlessness and irritability, we must seek in the management of thechild until we find the fault. 

If food is taken mechanically and without appetite, if the preliminarychanges in the stomach wall which are necessary for adequate digestiondo not take place, but are inhibited by the mental unrest, the meal isapt to be followed by gastric pain and discomfort, or, more commonlywith children, the stomach may promptly reject its contents. At theworst, nervous vomiting of this sort may follow almost every meal, although, again, it is curious to note how little, comparativelyspeaking, the nutrition of the child suffers. The vomiting too, as inadults, comes very near being a voluntary act, and mothers and nurseswill often remark that they get the impression that it can becontrolled at will. If once the diagnosis is made that the want ofappetite or the vomiting is of nervous origin, the treatment of thecondition is clear. Sedative drugs directed towards quieting thenervous excitability may be of service, but tonics, appetisers, laxatives, and drugs with a direct action on the stomach will have butlittle effect. Nor is there as a rule anything to be gained bymodifying the diet or by excluding this or that article of food. Thefrequency of the vomiting is such that it is apt to have broughtdiscredit one after the other upon almost every article of food whichthe child can take, with the result that many useful and necessaryfoods have been abandoned for long on the ground that they are thecause of the dyspepsia. A permanent cure will only be effected whenthe faults of environment have been overcome, when the cause of thenervous unrest has been removed, and when the child's mind is atpeace. 

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

CHAPTER IV

WANT OF SLEEP

So far, almost all that has been written--and there has been a greatdeal of unavoidable repetition--has been devoted to an attempt todetermine the causes which lead the child to refuse food and themethods which we adopt to prevent or overcome the difficulty. Otherneuroses may be studied in less detail, because they depend for theirexistence upon the same causes. For example, the habit of refusingsleep, which is as common and almost as distressing as the habit ofrefusing food, depends both upon a perversion of suggestion and uponthe phenomenon that we have called negativism. 

If struggling and crying has occurred upon a series of nights, thechild comes to associate his bed not with sleep but with tears. If amother values her peace of mind, if she would spare herself thediscomfort of hearing her child sob himself nightly into uneasy sleep, she must be wary how this all-important event of going to bed isapproached. With a nervous and restless child the preliminaries ofpreparing for bed must be managed carefully and tactfully. The hourbefore bedtime is almost universally the most interesting of thewhole day for the child. Then the baby, with his best frock on, andbooks and toys, is the centre of interest in the drawing-room, tillthe clock strikes and the nurse appears at the door. Suddenly it isall over, and inexorable routine sends him off to bed. The good nursewill give the child a little time to recover from the shock of herarrival, and will not hurry him. She knows that his little mind isslow 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 hisunfinished pursuits, resistance and tears are almost sure to follow, and the difficult task of the day--the putting to bed--has made theworst possible start. When this has happened on one or two successiveevenings, 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 withchildren will arouse his interest in a new pursuit, in which he canplay 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 allottedplace in the room, at least he can show his learning by pointing outthe spot. In the waving of good-byes he is expert and takes alegitimate pride, and upstairs he has learnt that there are newdelights. He himself can turn on the taps in the bathroom, and he canset every article in the proper place ready for use. All children lovetheir 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 isnot carried off without a hitch. Afterwards, for a little, nervousbabies, 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 thenurse puts all the garments one by one to bed. Each as it goes to restwill be greeted by him with cheerful farewells; and so does the forceof suggestion act, till the central figure himself plays his part inthe scene, of which he feels himself the controller and director, andclimbs to bed. But if there has been a hitch anywhere, if the bugbearof negativism has appeared, if he has been scolded or coaxed orrepressed too much and there have been tears and struggles, then goingto bed is a poor preparation for instant and quiet sleep. 

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

If, in spite of our care to avoid unrest and irritation of the child'sbrain, sleep is refused, as may often happen, it is, as a rule, wiseto cut short the crying if we can, before a vicious circle has beenformed and the unrest has been intensified by the emotional storm. Itis useless with little children to urge them to go to sleep or tocoax. It is not usually wise to leave the child for a little and thento return. Each time the child is left, each time the mother or nursereturns, the crying bursts forth again with renewed force and vigour. It is at least one good plan with a little child to turn the lightout, and, treating the whole incident in the most matter-of-fact waypossible, lightly to stroke his head or pat his back rhythmicallywithout speaking. With older children, if the crying is morepurposeful and less emotional, the mother may busy herself for alittle with some task in the room, ostentatiously neglecting the stormand making no reference to it. If she speaks to the child at all sheshould do so in a matter-of-fact way, referring lightly to othermatters. If only she can convince him that his conduct is a matter ofindifference to her, the victory is won. It is because the child knowsso 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 andthe tyrannous cry of a wilful child who demands his own way. 

Light and broken sleep is a common accompaniment of a too excitableand overstimulated brain. The placid child, who eats well, playsquietly, and does not cry more than is usual, as a rule sleeps sosoundly that no ordinary sounds, such as conversation carried on inquiet tones in his neighbourhood, have the power to waken him. When hewakes, he does so gradually, perhaps yawning and stretching himself. The nervous child may move at the slightest sound, or with a suddenstart or cry is wide awake at once. A hard mattress should be chosenwithout a bolster, and with only a low pillow. Flannel pyjamas, whichcannot be thrown off in the restless movements of the child, should beworn. The temperature of the room should be cool, and the air from theopen window should circulate freely, while draughts may be kept fromstriking on the child by a screen. All the sensations of the nervouschild are abnormally acute. Thus, for example, an itching eruption, ortight clothing, will produce an altogether disproportionate reaction, and may result in a frenzy of opposition. Especially such a child issensitive to a stuffy atmosphere or to an excess of bedclothes. Coolrooms and warm but light and porous clothing are essential. Anelectric torch, which can be flashed on the child for an instant, willassist the mother or nurse to make sure that the child has not thrownoff all the bedclothing. 

Sometimes want of sleep is accounted for by a real want of physicalexercise. Town children especially are apt to suffer from theirlimited opportunities of running freely in the open. It is oftenconsidered enough that the child seated in his perambulator shouldtake the air for three or four hours daily, while much of his timeindoors as well is devoted to sitting. It is necessary for his properdevelopment that he should have opportunities of daily exercise in theopen. If for any reason this is not always practicable, a large room, as free as possible from furniture, should be chosen, with windowsthrown 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 casewe are now considering, to be troubled by bad dreams, nightmares, ornight-terrors. If these should occur, obstructed breathing due toadenoid vegetations is sometimes at work as a contributory cause. 

Finally, we should always remember that refusal of sleep is, for themost part, caused and kept up by harmful suggestions derived frommother and nurse, who allow the child to perceive their distress andagitation, who speak before the child of his habitual wakefulness, whounwittingly focus his attention on the difficulty. It is cured in themoment that the suggestion in the child's mind is reversed, in themoment when he comes to regard it as characteristic of himself not tomake a fuss about going to bed, but to sleep with extraordinaryreadiness and soundness. Let every one join together to produce thiseffect. Let the suggestion act strongly on his mind that all thesetroubles of sleeplessness are diminishing, that night after night seesan improvement, and soon his reputation as a good sleeper will beestablished, and, as always with children, it will be rigidly adheredto. 

In assisting to break the habit of sleeplessness, and in the processof altering the character of the suggestions which act on the child'smind, we can be of the greatest assistance to the mother byprescribing a suitable hypnotic. As to whether it is right in insomniain childhood to prescribe depressant drugs is a question on which veryvarious opinions are held. That it is wrong and probably ineffectiveto trust entirely to the drugs is certainly true, but as a temporarymeasure, to break the faulty suggestion and the bad habit, their useis both legitimate and successful. The dose required in childrenrelatively to the adult is much smaller. In grown people, somespecific distress of mind, whether real or imaginary, may suffice toresist very large doses of hypnotic. In children it is rare to findthe same resistance, and comparatively small doses have a veryconstant effect. With deeper and more refreshing sleep, the conduct ofthe child during the day almost always changes for the better. A soundsleep, for a few nights in succession, will produce apparently quite aremarkable change in the whole disposition of the child. When goodtemper and interest take the place of fretfulness and restlessness, wemay confidently expect that the symptom of sleeplessness will begin toabate. Sleeplessness by night and fretfulness by day form a viciouscircle, and attempts must be made to break it at all points. 

Chloral occupies the first place as a hypnotic for young children. Incombination with bromide its effects are wonderfully constant andcertain. Two grains of chloral hydrate and two grains of potassiumbromide 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 thedose may be twice as great, and three times at six years. It is seldomthat other means are required. Aspirin for children seems relativelywithout effect. For children who are both sleepless and feverish, agrain of Dover's powder, and a grain of antipyrin, for each year ofthe child's age up to three, is very helpful. Lastly, if chloral andbromide cannot break the insomnia, and the condition of the child isbecoming distressing, we can almost always succeed if we combine theprescription 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 frequentmanifestation of nervous unrest is provided by the group of symptomswhich we may call, with a certain latitude of expression, HabitSpasms. By a habit spasm is meant the constant repetition of an actionwhich was originally designed to produce some one definite result, butwhich has become involuntary, habitual, and separated from itsoriginal meaning. The nervous cough forms a good example of a habitspasm. A cough may lose its purpose and persist only as a bad habit, especially in moments of nervousness, as in talking to strangers, inentering 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 wholescalp may be put into movement, and blepharospasm are all commontricks 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 mildcases we may note hardly more than a restless movement of mouth orforehead, or constant plucking or writhing of the fingers whenever thechild's attention is aroused, when he is spoken to, or when he himselfspeaks. In nervous children these movements, which should properly beconfined to moments of real emotional stress, become habitual, and aredisplayed apart from the excitement of particular emotions. Whatevertheir intensity, habitual and involuntary movements of this natureshould not be overlooked, and should be regarded as evidence of mentalunrest. They do not commonly appear during the first or second yearsof the child's life. They are more frequent after the age of five, butthey may begin to be marked as early as the third year. With refusalof food and refusal of sleep they form the three common neuroses ofearly childhood. 

Two of the three qualities which we have mentioned as characteristicof the child's mind are concerned in the causation of habit spasm. Inthe early stages the movement is sometimes due to imitation, but thesusceptibility of the child to suggestion plays the chief part indetermining its persistence. It is an interesting speculation how fartricks of gesture, attitude, or gait are inherited and how far theyare acquired by imitation. A child by some characteristic gesture maystrikingly call to mind a parent who died in his infancy. A wholefamily 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 thedistinctive family gait, that when a boy his ears were once boxed byan old gentleman who chanced to observe him hurrying to overtake hisparent, and who resented what he took to be an act of impertinentcaricature. In the reproduction by the child of the habitual actionsof his parents, heredity is largely concerned, but imitation too playsits part. In habit spasm the force of imitation is clearly seen. Achild who has developed a habit spasm of one sort or another willreadily serve as a model to other children. The malady will sometimesspread through a school almost with the force of a contagiousdisorder. A child affected in this way may prove an unwelcome guest. The little visitor with a trick of contorting his mouth and grimacingis apt to leave his small host an expert in faithfully reproducing theaction. A cough that is genuine enough in one member of the family mayproduce a crop of counterfeits in brothers and sisters. 

The force of suggestion acting upon the child's mind can clearly betraced. Once his attention is focused upon the particular movement byunwise emphasis on the part of the parents, he loses the power tocontrol its occurrence. This trio of common neuroses--refusal of food, refusal of sleep, and habitual involuntary movement--grows only in anatmosphere of unrest and apprehension. Parents and nurses anxiouslywatch their development. They are distressed beyond measure to notetheir steady growth in spite of every attempt which they make tocontrol or forbid them. And of all this unrest and unhappiness thechild is acutely conscious. The whole household may become obsessedwith the misfortune which has befallen it, and the mother, losing allsense of proportion, feels that she cannot regain her peace of minduntil it has been overcome. The child is in need of mental and moralsupport from those around him, and all that he finds is an openlyexpressed apprehension and sense of impotence. Even grown-up people, when their nerves are on edge, are apt to be obsessed byuncontrollable impulses or by vague and nameless apprehensions, andsurely all have learnt the support they gain from contact andconversation with some one strong and sane, who treats their worriesin such a matter-of-fact way that immediately they lose their powerand become of no account. The child with habit spasm cannot controlthese movements. The more he is reproved or entreated, the less abledoes he find himself to hold them in check. He does not wish them tocontinue. He has lost control of what he once controlled, and therealisation of this is not pleasant, and may be alarming to him. Yetwhen unconsciously he looks to his mother for support, he finds in heropen dismay that which serves only to increase his uneasiness. Shemust subdue her own feelings and give the child strength. If shetreats the whole thing in a matter-of-fact way, as a temporarydisturbance which is of no importance in itself, and only has meaningbecause it implies that the brain has been over-stimulated, she willno longer exercise a prejudicial effect on the child. If the bad habitis taken as a matter of course, if too much is not made of it, if thechild is encouraged to think that nobody cares much about it at all, then recovery will soon take place. It goes without saying that habitspasms and tics of all sorts are made worse by excessive emotionaldisplay and by nervous fatigue. On the other hand, if the childbecomes absorbed in some interesting occupation, the movements willdisappear for the time being. 

AIR SWALLOWING, THIGH RUBBING, THUMB SUCKING

At a somewhat earlier age than that in which habit spasms becomecommon, and before bed wetting appears as a formidable difficulty, wemeet with another group of habitual actions which yet retain theirvoluntary character. Among such habitual actions are thumb sucking, thigh rubbing, and air swallowing. If the child is old enough toexpress himself on the subject, he will explain that these actions areperformed because of the satisfaction derived from them, because it is"comfy" and "nice. " Even if the child is too small to speak, theexpression is that of beatitude and content. These actions are notconfined to nervous children, and their occasional practice need notbe taken to imply that there is any strong element of nervousoverstrain. It is only when the action is repeated with greatfrequency and persistence, and when signs of irritation ensue ifgratification is not obtained, that we are justified in classing itamong the symptoms of mental unrest. 

The second of these actions, thigh rubbing, is found for the mostpart in little girls, and inasmuch as it consists of a stimulation ofthe sexual organs sometimes causes much distress to the parents. It isin reality a habit of small importance unless exercised with verygreat frequency. It is, of course, not associated in the child's mindwith any sexual ideas, and is of precisely the same significance asthe other two actions of the same class. Children who can speak willrefer to it openly without any sense of shame. As a rule the action isperformed in a half-dream state, that condition between sleeping andwaking which is found when the child is lying in the morning in hercot or in her perambulator after the midday nap. The child's attentionshould not be focused on the symptom. She should lie on a hardmattress, and when she wakes in the morning she should either leaveher cot at once or she should be roused into complete wakefulness byencouraging her to play with her toys. Little children should betaught to sleep with their hands folded and placed beside the cheek. If the movement occurs on going to sleep, it is best left alone andcompletely neglected. As a rule each child has his or her ownfavourite action of this class, and they are seldom combined in thesame child. If thigh rubbing is very constant and obstinate and doesnot yield to the measures suggested, it may even sometimes be asuccessful manoeuvre to substitute the thumb-sucking habit in theexpectation that this less distressing habit may eject the other moreobjectionable action. As a rule, however, a wise neglect and carefulwatching during the drowsy condition that follows sleep in a warm bedwill succeed in stopping the practice of thigh rubbing before the endof the second or third year. Apparatus designed to restrain movementof the child's legs or blistering the opposed surfaces of the thighsare both of no effect. They have indeed the positive disadvantage thatthey focus the child's attention on the practice. The habit ceasesonly when the child has forgotten all about it, and these devicesserve only to keep it in remembrance. The same may be said of anysystem of punishments. Further, we cannot always have the child underobservation, and at some time or other opportunity will be found forgratification. Of older children, in whom self-control and a sense ofhonour can be cultivated, I am not here speaking. 

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

PICA AND DIRT EATING

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

CONSTIPATION

As has been already mentioned, much of the common constipation of thenursery is due to neurosis. The excessive concentration of the nurse'sthoughts on this daily question communicates itself to the child. Thedifficulty is emphasised, and an attempt is made to substitute willpower for forces of suggestion which are at once inhibited byconcentration of the mind upon the process. Here also, just as in therefusal of food, a further stage of "negativism, " that is, of activeresistance with crying and struggling, is reached, so that complaintmay be made by the mother that defæcation is painful. The samenegativism may be shown in micturition, and mothers will givedistressing accounts of the suffering of the child during the passingof water. 

BREATH-HOLDING AND LARYNGISMUS STRIDULUS

In some children, in the first two years of life, we find a definiteand measurable increase in the irritability and conductivity of theperipheral nerves. The strength of current necessary to produce bydirect stimulation of the nerve a minimal twitch of the correspondingmuscle may be many times less than the normal. Of this heightenedirritability of the nervous system, to which the name "spasmophilia"has been given in America and on the Continent, the most strikingsymptom is a liability alike to tetany or carpo-pedal spasm, togeneralised convulsions, and to laryngismus stridulus. In addition, inmost cases it is generally possible to demonstrate the presence ofChvostek's sign and of Trousseau's sign. Chvostek's sign consists in avisible twitch of the facial musculature, especially of theorbicularis palpebrarum or of the orbicularis oris, in response to agentle tap administered over the facial nerve in front of the ear. Trousseau's sign is the production of tetany by applying firm andprolonged pressure to the brachial nerve in the upper arm. Theætiology of spasmophilia is still a matter for dispute, but theevidence which we possess is in favour of the view that we have hereto deal with a disturbance of calcium metabolism. The calcium contentboth of the blood and of the central nervous system has been shown tobe much lowered. It is in keeping with this that clinically we notehow frequently spasmophilia and rickets occur in the same child. Insome families the condition recurs through many generations. 

For our present purpose--the examination of some common neuroses ofnursery life--it would be out of place to enter into a detailedconsideration of this disorder of spasmophilia as a whole. The symptomof laryngismus stridulus--the so-called breath-holding--alone needconcern us, and that for a special reason. The spasm of the glottis isproduced under the influence of any strong emotion--in anger, forexample, or in fear, in excitement or in crying for any reason. Tocontrol or prevent it we must direct attention not only to thecondition of spasmophilia, but also to the management of the childrenwho are always excitable and emotional. In these children every burstof crying, however produced, whether by a fall, by a fright, by theentrance of a stranger, or by a visit to a doctor, is apt to beushered in by a long period of apnoea, due to spasm of the glottisand of the diaphragm. The first few expirations are not followed byany inspiration. For several seconds the silence may be complete, while the child steadily becomes more and more cyanosed, or the bodymay be shaken by incomplete expiratory movements and strangled crieswhich are suppressed because the chest is already in a position ofalmost complete expiration. In the worst cases, when the apnoealasts a very long time, there may be convulsive twitching of themuscles of the face, or the attack may even terminate in generalconvulsions. Very occasionally the spasm is actually fatal. In allfatal cases which have come to my notice the child at the moment ofdeath had been alone in the room. I have met with no fatal case wherethe baby could be picked up and assisted. As a rule, therefore, thecause and mode of death must be conjectural, but when an infant isfound dead in its cot unexpectedly, it would seem likely that it haswaked from sleep with a sudden start, become excited, and, about tocry, has been seized by the fatal spasm. In two instances reported tome a cat had been found in the room with the dead child, and it wassuggested that the animal had lain upon the child's face. Both thesechildren, however, were vigorous and capable of powerful movements ofresistance. I think it more likely that the cat may have awakened themin fright, and that the emotional excitement, giving rise to thespasm, was the cause of the suffocation. That the apnoea in theseextremely rare instances should end fatally produces a difficultposition for the doctor. It need hardly be said that the seizures arealarming to the parents. For the sake of great accuracy in thestatement of our prognosis are we to add a hundred times to themother's alarm by stating the possibility of death? In each case wemust use our own judgment. I believe that in a child over a year oldthe risk is almost negligible. 

Fortunately in all save the rarest possible instances the apnoeayields and a deep inspiratory movement follows. As the air rushes pastthe glottis, which is still partially closed, a sound recalling thewhoop of pertussis is heard. Often this recurs throughout all theburst of crying which follows, and each inspiration is accompanied bya shrill stridulous sound. With the re-establishment of respirationthe cyanosis rapidly fades, to be succeeded in some cases by pallorand perspiration. 

It need hardly be said that we should do all in our power to preventthese alarming and distressing attacks. Each seizure predisposes to arepetition. In some children we notice that months and even yearsafter an attack of whooping-cough, a slight bronchial catarrh may besufficient to bring back the characteristic cough. In laryngismus inthe same way we may suppose that the reflex path is made easy and theresistance lowered by constant use. Fortunately the spasms are notusually difficult to control. Calcium bromide, in doses of from two tofour grains, according to age, three times daily, is generallysuccessful with or without the addition of chloral hydrate in smalldoses. At the same time we must endeavour in every way possible tokeep 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 isnot able to achieve its effect unless we are able at the same time toguarantee a reasonable immunity from emotional upsets. It is for thisreason that I have included some description of laryngismus, althoughits origin is undoubtedly very different from that of the otherdisorders of conduct which we have examined. 

MIGRAINE AND CYCLIC VOMITING

The ætiology of cyclic or periodic vomiting in childhood is not yetcompletely understood. We do not know how far it is dependent upondisturbance of the liver, and it is still disputed whether theacidosis which accompanies it is the cause or the result of theprofuse vomiting. Into these difficult questions we need not at themoment enter. It is enough in the present connection to recognise thatthe great majority of children who suffer from cyclic vomiting aresensitive, excitable, and nervous, and that every one is agreed thatthe nervous system is intimately concerned in its causation. 

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

Cyclic vomiting seldom occurs before the fourth year. It ischaracterised by sudden profuse and persistent vomiting and by verygreat prostration. All food, it may be even water, is promptlyrejected. The vomited matter is generally stained with bile;occasionally the violence of the vomiting causes hæmatemesis. In manycases 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 lastlonger than forty-eight hours. On the other hand, attacks lasting aslong as a week are by no means unknown. Within a short time of theonset the urine may be found to contain acetone bodies, the breath maysmell distinctly of acetone, and the child may become torpid anddrowsy or agitated and restless. At times there may be exaggerated anddeepened respiratory movements--the so-called air hunger. In manycases, however, otherwise characteristic, these more severemanifestations are absent or but little apparent. Recovery is usuallyrapid and complete. The child asks for food, which is retained. Afatal ending is very rare, though not unknown. The frequency ofattacks is very various. Sometimes months or even years may elapsebetween successive seizures; in other cases a fortnightly or monthlyrhythm establishes itself. 

It is clear that both the frequency and the severity of the attacksare much influenced by the general state of the child's health. Likemigraine, cyclic vomiting appears to be a symptom of nervousexhaustion. It affects, for the most part, children who areintellectually alert, impressionable, and forward for their age, andwho, when well, throw themselves into work or play with a greatexpenditure of nervous energy. Often their physical development isunsatisfactory, and we must set ourselves to correct this as the firststep in prevention. It is highly important that children suffering inthis way should have free opportunities for exercise in the opencountry, and that all the excretory organs--the skin, kidneys, andbowels--should be acting freely and efficiently. The child should livea life of ordered routine. Sleep should be sound and sufficient inamount. The diet must not exceed the strict physiological needs. Manyof these children appear to have a lowered tolerance for fats of allsorts, and it may be necessary to limit strictly the consumption ofmilk, cream, butter, and so forth. A daily administration of a smalldose of alkali by the mouth is credited with preventing attacks. Inthe present connection, however, we shall not do wrong to emphasisethe part played by the nervous system in the production of theattacks. In all cases of cyclic vomiting it should be our endeavour torecognise and remove the elements in the daily life of the child whichare proving too exhausting. 

UNEXPLAINED PYREXIA

In nervous children we sometimes meet with inexplicable rises oftemperature. The pyrexia may have the same periodic character as thatjust 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 evenhigher, which may last for two or three days before subsiding. Inother cases the chart shows a slight persistent rise over many weeksor months. That in nervous children the temperature may be veryconsiderably elevated without our being able to detect much that isamiss does not of course make it any the less necessary to be carefulto exclude organic disease. Pyelitis, tuberculosis, and latent otitismedia occur with nervous children as with others and must not beoverlooked. If, however, organic disease can be excluded, and if thepyrexia is the only circumstance which prevents the decision that thechild is well and should be treated as well, then the thermometer maybe overruled and the pyrexia neglected. 

CHAPTER VI

ENURESIS

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

It is usually taught that a great variety of causes is concerned inproducing enuresis. It is said to be due to a partial asphyxia duringsleep from adenoid vegetation. It is said to be caused by phimosis, and to be cured by circumcision. It is said that the urine is oftentoo acid and so irritating that the bladder refuses to retain it forthe usual length of time. It is said that enuresis may be due to adeficiency of the thyroid secretion, and that it can be cured bythyroid extract. Such a number of rival causes may make us hesitate toaccept the claims of any one of them. Certainly I have not been ableto satisfy myself that any one of these conditions exercises anyinfluence at all or is commonly present in cases of enuresis. I thinkthat if we examine a large number of cases of bed wetting in childrenwe can come to no other conclusion than that the cause of the troubleis due to just such a pervasion of suggestion as we have beenconsidering above. 

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

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

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

_(c)_ In the third place, it is easy to recognise in the history ofmany of the cases, the ill-effects of circumstances which add newforce to the fear of failure or shake the confidence in the controlwhich had been regained. Thus a boy, an only child, who had sufferedfrom enuresis till his seventh year, had regained complete controltill his eleventh year, when he went to school. In his dormitory atschool was a boy who had enuresis, and who was being fined andpunished by the schoolmaster. The enuresis at once reappeared andcontinued unchecked so long as he was at school. As might be expected, school life is very inimical to cure, unless the trouble can be keptfrom the knowledge of the other boys. Anything which directlyincreases the nervousness of the child--an illness, for example, withloss of weight and failure of nutrition, or some mental stress, suchas the approach of an examination--is apt to accentuate the enuresis. 

_(d)_ In the fourth place, the incontinence sometimes spreads to thedaytime, and the child is wet both by day and night. Further, in badcases it is not uncommon to find incontinence of fæces making itsappearance also. These extensions of the fault only take place whenthe management continues to be very faulty, when the grown-up peoplearound them are more than usually distressed and pessimistic, and haveredoubled their expostulations and appeals. 

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

The forms of treatment which have been recommended from time to timeare, 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 skinin the perineal and pubic regions, with object of lowering theexcitability of the bladder by counter-irritation. (ii) Gradualdistension of the bladder by hydrostatic pressure, (iii) Tilting thefoot of the bed so as to throw the urine to the fundus of thebladder, in order to protect the sensitive trigone from irritation. 

_(c) Educative. _--(i) Curtailing the fluid drunk. (ii) Waking thechild 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 hypnoticsuggestion. 

I do not think that any single one of these various forms of treatmentoutlined under the first four heads has any effect other than to aidthe suggestion of cure which we proffer in adopting it. Removal oftonsils and adenoid vegetations might conceivably cure an enuresiswhich is nocturnal, it cannot account for an incontinence whichspreads to the day. We might believe that to distend the bladder byhydrostatic pressure was a cure for incontinence of urine, and that itacted by removing the local cause, --the smallness and contraction ofthe bladder, --were it not that the loss of control is so apt to spreadto the rectum as well. There is no evidence that the urine ispeculiarly irritating. Indeed, such evidence as we have goes to showthat, as in some other neuroses, the urine in enuresis is undulycopious, and of very low specific gravity. Incidentally, we have inthis polyuria a further argument against the view recently advancedthat a small and contracted irritable bladder is the cause ofenuresis. We do, of course, meet with cases of irritable bladder oftenenough, but the complaint is then not of incontinence, but always ofthe discomfort of having to rise so frequently for micturition. 

To deprive the child of fluid, to wake her many times at night, totilt the foot of the bed, are devices which may help in the hands ofsome one who is confident of his ability to cure the condition and cancommunicate the confidence to the child. Carried out hopelessly andpessimistically by a tired and exasperated mother, they are wellcalculated to strengthen the hold which the obsession has on thechild, so that often we meet with a mother who rightly enoughmaintains that the more she wakes the child, the oftener the bed iswet, till she wonders where it all comes from. 

The treatment of enuresis to be successful must be conducted throughand by means of the grown-up persons who have the control of thechildren. To stop the development of enuresis in early infancy we mustintervene to prevent the concentration of the child's mind on thedifficulty. During the time when control is ordinarily developed, inthe second and third year, judicious management of the child isessential. The emphasis should be laid upon successes, not uponfailures. For every child his reputation will sway in the balance fora time. He must be helped and encouraged to self-confidence, notrendered diffident or self-conscious. 

If the case is well established before it comes under our notice, themother, the nurse, the schoolmaster, or whoever is responsible for thechild's management, must understand clearly the nature of the trouble. The suggestion acting on the child's mind must be altered, andself-confidence restored. The child must learn to see that the thingis not so desperately tragic. He should be told that the troublealways gets well, and that it only goes on now because he is worriedabout it and keeps thinking of it. If the whole environment of thechild is bad, so that such a change of suggestion is not possible, andif enuresis is but one of many symptoms of mental or moralinstability, it may be necessary to remove the child and place himunder the influence of some one else. Sometimes the prescription of arubber urinal, which the child can slip on at night, is directlycurative. A public school boy, who was about to be sent away fromschool for this failing, fortified by the possession of thisapparatus, wrote six months later to say that he knew now that it mustbe all worry that caused the trouble, because with the urinal inposition 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 areobjections to its use. Often enuresis is evidence that the child'shome environment has been at fault, and that his mental and moraldevelopment has been retarded. It is the management which must bemodified or the home, if necessary, changed. Hypnotic suggestion willmake this one symptom disappear promptly enough, but it will ratherperpetuate than combat the cause--that undue susceptibility tosuggestion, which is characteristic alike of the little child and ofmany older neuropathic persons. 

CHAPTER VII

TOYS, BOOKS, AND AMUSEMENTS

Any one who has an opportunity of watching little children must haveobserved that they are happiest and most contented when playing alone. The education of the little child is carried on by means of games andtoys. Handling the various objects which we give him, impartingmovement to them, transferring them from hand to hand and from onesituation to another, he learns dexterity and precision of movement, and in the process hand and brain grow in power. When at play, hiswhole 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 thisfervour of self-education it is necessary that the child should beaccustomed 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 momentswithout breaking into tears or displaying bad temper. Engrossed in hisown tasks, he should be content to leave his nurse to move in and outof the room without protest. If this fault has appeared and the childcannot be left alone, our whole educational system is undermined, andplay will be profitless and over-exciting, because it demands theconstant participation of grown-up people. As a preliminary to allimprovement in the management of a nervous child, we must see to itthat he becomes accustomed to being alone. We must so arrange hisnursery that he can do no damage to himself. Scissors and matches mustnot be left lying about, and a fireguard must be fixed in position sothat it cannot be disturbed. Then, disregarding his protests, thenurse 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 separationdoes not mean that we have abandoned him for all time. Then the periodof absence can be gradually lengthened till all difficulty disappears. Once his attention is removed from the grown-up people who mean somuch to him, his natural impulse to explore and experiment with hisplaythings will show itself. Those toys are best which are neitherelaborate nor expensive. For a little child a small box containing amiscellaneous collection of wooden or metal objects, none of themsmall enough to be in danger of being swallowed, forms the materialfor which his soul craves. Everything else in the room may be out ofhis reach. A dozen times he will empty the box and then replace eachobject 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 willhave made more complex pursuits possible. As a rule the objects whichare most prized and which have most educative value are those whichlend themselves best to the actions with which alone the child isfamiliar. Hence the supreme importance of the doll and the doll'sperambulator. The doll will be treated exactly as the child is treatedby the nurse. It will be washed, and dressed, and weighed, and put tobed in faithful reproduction of what the child has daily experienced. Dusting, and sweeping, and laying the table will be exactly copied. Ifa child has no opportunity of being familiar with horses, if he hasnot seen them fed, and watered, and groomed, and harnessed, he may notfind any great satisfaction in a toy horse, or pay much attention toit, 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 timethe increased imaginative powers will give attraction to toy soldiersor a toy tea-service. Playing at shop, robbers, and rafts aredevelopments of still later growth. In the child's games we recognisethe instinct of imitation--playing with dolls, sweeping and dusting, playing at shop or visitors; the instinct of constructiveness--makingmud pies and sand castles, drawing or whittling a stick; and theinstinct of experiment--letting objects fall, rattling, hammering, taking to pieces. All this activity must be encouraged, never undulyrepressed or destroyed. But whatever form it takes, the bulk of theplay must be carried on without the intervention of grown-up persons, or it will lose its educative value and prove too exacting. Ifgrown-up people attempt to take part, the child will lose interest inthe play and turn his attention to them. 

Children differ very much in their attitude towards books. One childquite early in the second year will be happy poring over picturebooks, while another will seldom glance at the contents and findspleasure only in turning over the pages, opening and shutting them, and carrying them from place to place. Such differences are naturalenough and foreshadow perhaps the permanent characteristics thatdivide men and women, and produce in later life men of thought and menof action, women who are Marthas and women who are Marys. Nevertheless, we should bear in mind that there is danger in atraining that is too one sided, and that books and toys have boththeir part to play in developing the powers of the child. All theactivities 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 isanother, the hand a third. 

From pictures an imaginative child will derive very strongimpressions, and mothers should be careful in their choice. It isfoolish to confuse the growth of æsthetic perceptions by presentingchildren with books which depict children as grotesquely ugly beingswith goggle eyes and heads like rubber balls. Children love animalsand endow them with all their own reasoning attributes, and instories of the home life of rabbits, and bears, and squirrels theytake a pure delight. Books of the "Struwwelpeter" type are less to berecommended. The faults which they are intended to eradicate becomepeculiarly attractive from much familiarity. A little boy of two and ahalf who resolutely refused all food for some days was in the enddetected to be playing the part of that Augustus, once so chubby andfat, who reduced himself to a skeleton, saying, "Take the nasty soupaway; I don't want any soup to-day. " Tales of naughty children whomeet with a distressing fate may either frighten the child unduly, orelse produce in a child of inquiring mind the desire to brave his fateand put the matter to the test. Pictures should not be terrifying orhorrible. Ogres devouring children are out of place as subjects forpictures and may cause night-terrors. 

Children should be taught to be careful of books and toys. Theindestructible book, generally falsely so called, is often responsiblefor the immediate dissolution of all others less protected which cometo hand. The sympathy which little children have with the sufferingsof all inanimate objects and their habit of endowing them with theirown sensations may be made of use in teaching them care andgentleness. They are naturally prone to sympathise with the doll thathas been crushed or the book that has been torn. They will learn veryeasily to be kind to a pet animal and to be solicitous for itsfeelings, and the lesson so learnt will be applied to inanimateobjects as well. 

There is, however, another side to the question. It is true that ifthe child is not to be over-stimulated upon the psychical side, wemust see to it that his play, for the most part, is not dependent uponthe participation of grown-up persons. In practice this excessivestimulation is the common fault with which we meet. There are fewchildren in well-to-do homes, with loving mothers and devoted nurses, who suffer from too little mothering and nursing. Too many show signsof too much. To observe the opposite fault we must seek the infantsand children who for a long time are inmates of institutions, orphanages, infirmaries, hospitals, and so forth. In such surroundingsthe mental life of the child may languish. His physical wants arecared for, but there the matter ends. In a rigid routine he is washedand fed, but he may not be talked to or played with or stimulated inany way. His day is spent passively lying in his cot, unnoticed andunnoticing. I have seen a poor child of three years just released fromsuch a life, and after eighteen months returned to his mother, unableto talk and almost unable to walk, crying pitifully at the novelty andstrangeness of the noisy life to which he had returned, worried bycontact with the other children, and without any desire or power tooccupy himself in the home. For an hour in the day mothers may devotethemselves wholeheartedly to the children, and if they set themromping till they are tired out, so much the better. In the garden orin an airy room with the windows open, a game with a ball or a toyballoon, or a game of hide-and-seek, will be all to the good, and thechildren may climb and be rolled over and swung about to their heart'scontent. With an only child, especially with a child whose home is intown, and whose outings are limited to a sedate airing in the park, such free play is especially necessary. It may help more than anythingelse to quiet restless minds and tempers that are on edge all day longfrom excessive repression. 

On the other hand, those forms of entertainment which are known as"children's parties" are generally fruitful of ill results, at anyrate with nervous and highly-strung children. Sometimes they entail apostponement of the usual bedtime, and nearly always they involveover-heated and crowded rooms. Perverse custom has decreed that thesegatherings shall take place most commonly in the winter, when dark andcold add nothing to the pleasure and a great deal to the risk ofinfection which must always attend the crowding of susceptiblechildren together in a confined space with faulty ventilation. Thereis clearly on the score of health much less objection to summer gardenparties for children, but these for some reason are less the vogue. Asa rule parties are not enjoyed by nervous children. There is intenseexcitement in anticipation, and when at length the moment arrives, there is apt to be disillusion. Either the excitement of the child maypass all bounds and end in tears and so-called naughtiness, or theunfamiliar surroundings may leave him distrait with a strange sense ofunreality and unhappiness. It is not always fair to blame the want ofwisdom in his hostess's choice of eatables, if the excited andoverstimulated child fails in the work of digestion and returns to thenursery to suffer the reaction, with pains and much sickness. 

The same arguments may be urged against taking little children to thetheatre. The nerve strain is apt to be out of proportion to theenjoyment gained. If children must go to theatres and parties, thetreat should be kept secret from them until the moment of itsrealisation, in order that the period of mental excitement should becontracted as much as possible, and grown-up people should be advisedto treat the whole expedition in a matter-of-fact sort of way thatdoes nothing to add to the excitement or increase the risk ofsubsequent disillusion. 

CHAPTER VIII

NERVOUSNESS IN EARLY INFANCY

We may now pass back to consider the nervous system of the child ininfancy. There, too, from the moment of birth there are clearly-markeddifferences between individuals. The newborn baby has a personality ofhis own, and mothers will note with astonishment and delight howstrongly marked variations in conduct and behaviour may be from thefirst. One baby is pleased and contented, another is fidgety, restless, and enterprising. At birth the baby wakes from his longsleep to find his environment completely changed. Within the uterus helies in unconsciousness because no ordinary stimulus from the outerworld can reach him to exert its effect. He lies immersed in fluid, which, obeying the laws of physics, exercises a pressure which isuniformly distributed over all points of his body. No sound reacheshim, and no light. After birth all this is suddenly changed. The senseof new points of pressure breaks in upon his consciousness. Cold airstrikes upon his skin. Loud sounds and bright lights evoke acharacteristic response. A placid child who inherits a relativelyobtuse nervous organisation will be but little upset by this suddenand radical change in the nature of his environment. His brain isreadily but healthily tired by the new sensations which stream in fromall sides, and he falls straight away into a sleep from which herouses himself at intervals only under the impulse of the newsensation of hunger. 

Babies of nervous inheritance, on the other hand, will show clearly bythe violence of the response provoked that their nervous system iseasily stimulated and exhausted. They will wriggle and squirm forhours together, emitting the same constant reflex cry. The whole bodywill start convulsively at a sudden touch or a loud sound which wouldevoke no response from a more stolid infant. The sleeplessness andcrying exhaust the baby, rendering the nervous system more and moreirritable, while the sensation of hunger which is delayed in otherchildren by twelve hours or more of deep sleep appears early and is ofextreme intensity. We must see to it that sense stimuli are reduced tothe lowest possible level. True, we cannot again restore the child toa bath of warm fluid, of the same temperature as his body, where hecan be free from irksome pressure and from all sensations of sound andlight, but we can so arrange matters that he is not disturbed by loudsounds and bright lights, and that he is not moved more than isnecessary. Sudden unexpected movements are especially harmful. Jogginghim up and down, patting him on the back, expostulation, andentreaties are all out of place and do all the harm in the world. Thefirst bath should be as expeditious as possible, and above all thebaby must not be chilled by tedious exposure. Cold irritates hisnervous system more than anything else, unless it be excessive warmth. In preserving the proper temperature so that we do not render thechild restless by excess of heat or by excess of cold, wetoo-civilised people have made our own difficulties. We haveexaggerated the completeness of the sudden separation of mother andchild which nature decrees. It is the function of all mother animalsto approximate the unstable temperature of the newly born to their ownby the close contact of their bodies, which provide just the properheat. Labour is nowadays so complicated and exhausting a process formothers that, all things considered, we are wise in completing theseparation of mother and child and in removing the baby to his owncot. But the difficulty remains, and we must arrange that anyartificial heating needed is constant and of proper degree. 

If the baby is very restless and irritable, too wide awake and tooconscious of his surroundings, the all-important task of getting himto the breast and getting him to draw the milk into the breast is aptto 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 movementwithout the child's consciousness being aroused. The placid childwhose mind is at rest will suck well and strongly. If, on the otherhand, the brain is too much stimulated and the child is restless andirritable, the reflex act of suction is inhibited, and it is adifficult matter to get the child to the breast. He is too eager, mouthing, and gulping, and spluttering. Or sometimes his mentalsufferings seem too much for his appetite, and though wide awake andcrying loudly, he refuses to grasp the nipple, turning his head awayand wriggling blindly hither and thither. This effect of mental unreston the newborn infant is often disastrous, because it is one of thecommon causes of the failure of women to nurse their children. This isnot the place to sketch in detail a scheme for the proper technique ofbreast nursing, a matter which is much misunderstood at the presentday. It will be enough shortly to say that an efficient supply of milkdepends upon the complete and regular emptying of the breast. Thebreasts of all mothers will secrete milk if strong and vigoroussuction is applied to the nipple by the child. If anything interfereswith suction, the milk does not appear or, if it has appeared, itrapidly declines in amount. The mother's part is to a great extent apassive one, provided that she can supply one essential--a nipple thatis large enough for the child to grasp properly. Within wide limitswhat the mother eats or drinks, whether she be robust or whether shehas always been something of an invalid, matters not at all. A frailwoman may naturally not be able to stand the strain of nursing formany months, but that is not here the point in question. We aredealing only with the establishment of lactation and with the milksupply of the early days and weeks which is of such vital importancefor the child. If the mother is ill, if, for example, she hasconsumption, we may separate her from the child in the interests ofboth; but if this is not done, she will continue to secrete milk for atime as readily as if she were in perfect health, and the breasts ofmany a dying woman are to be seen full of milk. Mothers are too apt toattribute the disappointment of a complete failure to nurse to someweakness or want of robustness in their own health. This is never thereason of the failure, and the fault, if the mother has a well-formednipple, is generally to be found in some disturbance in the child. Prematurity, with extreme somnolence, breathlessness from respiratorydisease, nasal catarrh, which hinders breathing through the nose, infections of all sorts, are common causes of this failure to suckeffectively. But perhaps the most common cause of all is theinhibition from nervous unrest of that reflex act of sucking whichworks so well in the placid and quiet child. It is a point to whichtoo little attention is paid, and mothers and the books which mothersread commonly neglect the nervous system of the child and devotethemselves to such considerations as the relative merits of two-hourlyand four-hourly feedings--important points in their way, but lessimportant than this. 

The matter is complicated in two other ways. In the first place, thenervous 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 hesuffers, and like them is unduly acute. It is difficult not to giveway and to provide artificial food from the bottle. Yet if we do so wemust face the fact that these restless little mortals are quicker toform habits than most, and once they have tasted a bottle that flowseasily without hard suction, they will often obstinately refuse theungrateful task of sucking at a breast which has not yet begun tosecrete readily. The suction that is devoted to the bottle is removedfrom the breast, and the natural delay in the coming in of the milk isincreased indefinitely. At the worst, the supply of milk fails almostat its first appearance. We must devote our attention to quieting thenervous unrest by removing all unnecessary sensory stimulation fromthe 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 aminimum. Sometimes sound sleep will come for the first time if he isplaced gently in his mother's bed, close to her warm body. If he isapt to bungle at the breast from eagerness and restlessness, it is notwise always to choose the moment when he has roused himself into apassion of crying to attempt the difficult task. So far as is possiblehe should be carried to the breast when he is drowsy and sleepy, notwhen he is crying furiously, and then the reflex sucking act mayproceed undisturbed. 

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

It is not, of course, suggested that these drugs should be givenfreely or as a routine to every hungry baby wailing for the breast, orthat we can hope to combat or ward off an inherited neuropathy by afew doses of a sedative. There are, however, not a few babies in whomthere develops soon after birth a sort of vicious circle. They cansuck 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. Theonly effective treatment is to secure sleep and to carry a slumberingor drowsy infant to the breast. Then the sucking reflex comes to itsown again, the breast is drained steadily and well, and digestionproceeds thereafter without disturbance and during a further spell ofsleep. Two or three times in the day we may be forced, as meal-timeapproaches, to cut short the restlessness of the child by giving ateaspoonful 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 quarterof an hour until soundly asleep. Then very gently he can be carried tohis mother and the nipple inserted. If in this way a few days of soundsleep and less disturbed digestion can be secured, the difficulty willin most cases permanently be overcome. The steadier suction and moreefficient emptying of the breast will promote a freer flow of milk, and the deeper and more prolonged sleep will lower greatly the needsof the child for food. Most of the babies who show this fault arethin, meagre, and fidgety, and with some increase of muscular tone. The head is held up well, the limbs are stiff, the hands clenched, theabdomen retracted, with the outline of the recti muscles unusuallyprominent. If we can relax this exaggerated state of nervous tension, if we can help them to become fatter and to put on weight, thedyspepsia will disappear with the other symptoms. 

It is a question still to be answered whether the rare conditions ofpyloric spasm and pyloric hypertrophic stenosis are not furtherdevelopments of the same disturbance. Certainly these gravecomplications appear most commonly in infants with a pronouncednervous inheritance, and, as might be expected, they are more commonlyfound in private practice than among the hospital classes. 

In passing, we may note that there are babies who exhibit the oppositefault, and in whom the contrary regimen must be instituted. Prematurechildren, children born in a very poor state of nutrition, andchildren born with great difficulty, so that they are exhausted by theviolence of their passage into the world, are apt to show the oppositefault of extreme somnolence. They are so little stimulated by theirsurroundings, and they sleep so profoundly, that the sucking reflex isnot aroused. Put to the breast they continue to slumber, or after afew half-hearted sucking movements relapse into sleep. We must rousesuch children by moving them about and stirring them to wakefulnessbefore we put them to the breast. 

Once the child has been got to the breast, once the milk has becomefirmly established, we have overcome the first great difficulty whichbesets us in the management of nervous little babies, but it is by nomeans the last. Restlessness and continual crying must be combated ordigestion suffers, and may show itself in a peculiar form of explosivevomiting, which betokens the reflex excitability and unrest of thestomach. 

The sense of taste is as acute as all other sensations. If the childis bottle-fed, the slightest change in diet is resented because of theunfamiliar taste, and the whole may promptly be rejected. The tendencyto dyspeptic symptoms is apt to lead to much unwise changing of thediet, and everything tried falls in turn into disrepute, until perhapsall rational diets are abandoned, and some mixture of very faultyconstruction, because of its temporary or accidental success, becomespermanently adopted--a mixture perhaps so deficient in some necessaryconstituent that, if it is persisted with, permanent damage to thegrowth of the child results. We must pay less attention to changes ofdiet and explore our management of the child to try and find how wecan make his environment more restful. 

It is wise to accustom a nervous child from a very early age to take alittle water or fruit juice from a spoon every day. Otherwise whenbreast-feeding or bottle-feeding is abandoned one may meet with themost formidable resistance. Infants of a few months can be easilytaught; the resistance of a child of nine months or a year may bedifficult to overcome. The difficulty of weaning from the breastrecurs with great constancy in nervous children. By this time theinfluence of environment has become clearly apparent. The child isoften enough already master of the situation, and is conscious of hispower. Such children will sometimes prefer to starve for daystogether, obstinately opposing all attempts to get them to drink froma spoon, a cup, or even a bottle. When this happens, sometimes theonly effective way is to change the environment and to send the babyto a grandmother or an aunt, where in new surroundings and with newattendants the resistance which was so strong at home may completelydisappear. When weaning is resented, and difficulties of this sortarise, it is clear that the mother, whose breast is close at hand, isat a great disadvantage in combating the child's opposition. 

For nervous infants, alas! broken sleep is the rule. What, then, is tobe done? It is astonishing to me that any one who has studied thebehaviour of only a few of these nervous and restless infants shoulduphold the teaching that the crying of the young infant is a badhabit, and that the mother who is truly wise must neglect the cry andleave him to learn the uselessness of his appeals. It is true that theyoungest child readily contracts habits good or bad. Either he willlearn the habit of sleep or the habit of crying. Mercifully theinclination of the majority is towards sleep. But to encourage habitsof restlessness and crying there is no surer way than to follow thisbad advice and to permit the child to cry till he is utterly exhaustedin body and in mind. It is unwise _always_ to rock a baby to sleep; itis also unwise to allow him to scream himself into a state ofhysteria. A quiet, darkened room, the steady pressure of the mother'shand in some rhythmical movement, will often quiet an incipientstorm. The longer he cries, the more trouble it is to soothe him. Sleep provokes sleep, so that often we find restlessness and soundsleep alternating in a sort of cycle, a good week perhaps following abad one. The nurse who is quick to cut short a storm of crying and tosoothe the child again to sleep is helping him to form habits ofsleep. The nurse who leaves him to cry, believing that in time he willof his own accord recognise the futility of his behaviour, is makinghim 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 mustbe educated to sleep, not taught to cry. A baby has but little powerof altering his position when it becomes strained or uncomfortable. Hecannot turn over and nestle down into a new posture. If we watch himwake, the first stirring may be very gradual, and in a moment he mayfall 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 thirdwaking, by a summation of stimuli, that he is finally roused andbreaks into loud crying. The nurse who is on the watch, who, sleepingbeside him, wakes at the slightest sound and is quick to turn him overand settle him into a new position of rest, will probably report inthe morning that the baby has had a good night. The nurse who lets thechild grow wide awake and start crying loudly, will spend perhaps manyhours before quiet is again restored. Of the voluntary, purposivecrying of infants a little older I am not here speaking. Infants inthe second six months are quite capable of establishing a "Tyranny ofTears" and feeling their power. Fortunately it requires no greatexperience to distinguish one from the other, and to adopt for eachthe appropriate treatment. 

Again, in elementary teaching upon the management of infants stress islaid, rightly enough, upon the importance of regularity in the timesof feeding, and on the observance in this respect also of a verystrict routine. But in the case of the very nervous infant a certainlatitude should be allowed to an experienced nurse or mother. We maywreck everything by a blind adhesion to a too rigid scheme, which maydemand 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 hoursof wakefulness, we should proceed to wake him. 

Symptoms of dyspepsia which are due to continued nervous excitementdemand treatment which is very different from that which would beappropriate to dyspepsia which is due to other causes, such asoverfeeding or unsuitable feeding. The temporary restriction of food, which is commonly ordered in dyspepsia from these causes, is verybadly supported by the nervous infant. Hunger invariably increases theunrest, and the unrest increases the dyspepsia. 

The difficulties of managing a nervous infant are very real, and callfor the most exemplary patience on the part of the mother and theclearest 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 themost part, follow passively the traction exercised by nurses andmothers, sometimes consciously, but more often unconsciously. We havenow to consider a period when the child becomes possessed of a drivingforce of his own, and moves in this direction or that of his ownvolition. In this new intellectual movement through life he will notavoid tumbles. He will feel the restraints of his environment pressingupon him on all sides, and he will often come violently in contactwith rigid rules and conventions to which he must learn to yield. Fromtime to time we read in the papers of some terrible accident in apicture-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 arelost from the crowding and crushing. Yet all the time the doors havestood wide open, and through them an orderly exit might have beenconducted had reason not given place to unreason. It is the task ofthose responsible for the children's education to guide them withoutwild struggling along the paths of well-regulated conduct towards thedesired goal, influenced not by the emotions of the moment, but onlyby reason and a sense of right; not ignorant of the difficulties to bemet, 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 theindividual is a task, the immeasurable difficulty of which we are onlybeginning to appreciate with the failure of thirty years of compulsoryeducation before us. A recent writer[2] gives it as his opinion thatthe aim of education is to equip a child with ideals, and that thistask should not be difficult, because the lower savages successfullysubject all the members of their tribe to the most ruthlessdiscipline. Their lives, he says, "are lived in fear, in restraint, insubmission, in suffering, subject to galling, unreasoning, unnecessary, arbitrary prohibitions and taboos, and to customaryduties equally galling, unreasoning, unnecessary, and arbitrary. Theyendure painful mutilations, they submit to painful sacrifices. . . . Howare these wild, unstable, wayward, impulsive, passionate naturesbrought to submit to such a rigorous and cruel discipline? Byeducation; by the inculcation from infancy of these ideals. In theseideals they have been brought up, and to them they cling with theutmost tenacity. " One might as well contend that it was easy to teachall men to live the self-denying life of earnest Christians becausesome savage tribe was successful in maintaining among its members auniversal and orthodox worship of idols. The ideals set before thechild are too high and too complex to be inculcated by physical force, or even by force of public opinion. A rigid discipline, with manystripes and with terrible threats of a still worse punishment in theworld to come, was the almost invariable lot of children until thelast century was well advanced. Yet has this drastic treatment ofyoung children fulfilled its purpose? Were the men of fifty years agobetter conducted and more controlled than the men of to-day? In anyone family did a greater proportion turn out well? Is it not true thatat least among the educated classes the relaxation of nursery andschoolroom discipline which the last fifty years has seen has beenjustified by its results? Is it not true that the childhood of ourgrandmothers was often lived "in fear, in restraint, in submission, insuffering subject to galling, unreasoning, unnecessary, arbitraryprohibitions and taboos, and to customary duties equally galling, unreasoning, unnecessary, and arbitrary. " And though perhaps thegrandmothers of most of us may not have been much the worse for allthis discipline, is it not true that of the little brothers who sharedthe nursery with them a surprising number broke straightway intodissipation when the parental restraints were removed? If we are toteach a child to be gentle to the weak it is not wise to beat him. Thequalities which we wish him to possess are not more subtle than themeans 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 earliertimes physical strength and the power to fight well, alone were prizedand were the chief objects to be gained in the education of youth. Later, under the stress of intellectual competition for success inlife, mental acquirements have come to occupy the first place. We areonly now learning to lay emphasis upon the supreme need for moraltraining. Not that it is possible to separate the sum of educationinto its constituent parts, and to regard each as distinct from theothers. That many men of great intellectual activity, and many menpre-eminent for their moral qualities have harboured a great brain ora noble character in a weakly or deformed body, forms no argument todisprove the general rule that a healthy, vigorous physique is theonly sure foundation upon which to build a highly developed intellectand a stable temperament. In childhood the intimate connection betweenvigour of mind and vigour of body is almost always clearly shown. Achild with rickets, unable to exercise his body in free play, as arule shows a flabbiness of mind in keeping with his useless musclesand yielding bones. Such children talk late, are infantile in theirhabits and ways of thought, and are more emotional and unstable thanhealthy children of the same age. The connection between bodilyailments and instability of nervous control is even more clearly seenin the frequent combination of rheumatism and chorea. A very highproportion of older children suffering from the graver neuroses, suchas chorea, syncopal attacks, phobias, tics, and so forth, showdefective physical development. Scoliosis, lordosis, knock-knee, flatfoot, pigeon chest, albuminuria, cold and cyanosed extremities, arethe rule rather than the exception. If the body of the child isdeveloped to the greatest perfection of which it is capable we shallnot often find a too sensitive nervous system. The boy of finephysique may have many faults. He may be bad-tempered or untruthful orselfish, but such faults as he has are as a rule more primitive intype, more readily traced to their causes, and more easy to eradicatethan the faults which spring from that timidity, instability, andmoral flabbiness which has so often developed in the lax delicatechild reared softly in mind and body. 

PHYSICAL TRAINING

Children thrive best in the healthy open-air life of the country, andif there is any tendency to nervous disturbances the need for thisbecomes insistent. Physical training, further, includes the manualeducation of the child. The system of child-training advocated by Dr. Montessori is based upon the cultivation of tactile sensations and thedevelopment of manual dexterity. Exercises such as she has devisedhave an immediate effect in calming the nervous system and in changingthe restless or irritable child into a self-restrained and eagerworker. Lord Macaulay, whose phenomenal memory as a child has becomeproverbial, was so extraordinarily unhandy that throughout life he hadconsiderable difficulty in putting on his gloves, while he had suchtrouble with shaving that on his return from India there were found inhis luggage some fifty razors, none of which retained any edge, andnearly as many strops which had been cut to pieces in his irritatedand ineffectual efforts. If we teach a child manual dexterity it is anadvantage to him, because manual dexterity is seldom associated withrestlessness and irritability of mind. To excel in some handicraft notonly bespeaks the possession of self-control, it helps directly tocultivate it. The teaching of Froebel and Montessori holds good afternursery days are over. 

MENTAL TRAINING

Mental training enables the child to retain facts in his memory, toobtain information from as many sources as possible, to understand andpiece them together, and finally to reach fresh conclusions frompreviously acquired data. So far as is possible the teacher mustsatisfy the natural desire to know the reason of things. It must behis endeavour to prevent the child from accepting any argument whichhe has not fully understood, and which, as a result, he is able not toreconstruct but only to repeat. Mental work which is slovenly andperfunctory is as harmful to the child's education as mechanical workwhich is bungled and ineffective. Taking advantage of his naturalaptitudes, his interest should be developed and extended in every waypossible. Tasks which are accomplished without enthusiasm are labourexpended in vain, because the knowledge so acquired is notassimilated and adds nothing to the child's mental growth. Thereshould be no sharp differentiation between work and play. 

MORAL TRAINING

Moral training depends upon the force of example rather than ofprecept. Parents must be scrupulously just and truthful to the child, for his quick perception will detect the slightest deceit, and theevil impression made on his mind may be lasting. They must confidentlyexpect conduct from him of a high moral standard, and be careful atthis 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 upto his reputation. He comes in time to regard this failing of his aspart of himself just as much as is the colour of his hair or thelength of his legs. It may be said of a schoolboy that he shows noaptitude for his work. Term by term the same report is brought homefrom school, and each serves only to confirm the boy in his beliefthat this failing is part of his nature, and that no effort of his owncan correct it. If one subject only has escaped the condemnation ofhis master, then it may be to that study alone that he returns withzest and enjoyment. Spendthrift sons are manufactured by those fatherswho many times a day proclaim that the boy has no notion of the valueof money. 

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

In efforts at moral training there is often too great an emphasis laidupon negative virtues. It is wrong to do this: to do that isforbidden. Children cannot progress by merely avoiding faults any morethan a man may claim to be an agreeable companion at table because hedoes not eat peas with a knife or drink with his mouth full. Theremust be a constant effort to achieve some positive good, to acquireknowledge, to do service, to take thought for others, to disciplineself, and the parent will get the best result who is comparativelyblind to failure but quick to encourage effort and to appreciatesuccess. When the child knows well that he is doing wrong, exhortationand 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 bein helping some overwrought and nervously exhausted man or woman toregain peace of mind and self-control. After an intimate conversationwith a medical man who knows how to draw from the patient a freeexpression of the doubts, anxieties, and fears which are obsessinghim, many a patient feels as though he had awakened in that instantfrom a nightmare, and passes from the consulting-room to find histroubles become of little account. Not a few patients return to bereassured once more, and derive new strength on each occasion. Yetvisits such as these must be infrequent or they will lose their power. Now, just as the physician is well aware that his intervention if toofrequently repeated will lose its effect, so the parent must be charyof too frequent an appeal to the moral sense of the child. At longintervals opportunity may be taken with all seriousness to set beforethe child ideals of conduct, to-speak to him of the meaning ofcharacter and of self-discipline, and of the standards by which wejudge a man or woman to be weak and despicable, or strong and to beadmired. The effect of such an intimate conversation, never repeated, may persist throughout life. Constantly reiterated appeals, on theother 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 indicateto the child that he is for the moment unpopular, but which at thesame time denies to the small sinner the interest of attempting hisown defence. On the other hand, should the child be reasonably indoubt as to the nature of his offence we must spare no trouble inexplaining it to him. Punishment will be most effective when the childis convinced that he is rightly convicted. If it is to act as a realdeterrent, he must agree to be punished--a frame of mind which, if itcan be produced, may be welcomed as a sure sign that training isproceeding along the right lines. 

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

It must be granted that there are some unfortunate children in whomthe moral sense remains absent and cannot be developed--children whosteal and lie, who seem destitute of natural affection, or who appearto delight in acts of cruelty. These moral degenerates need not beconsidered here. Serious errors of conduct, however, in children whoare not degenerate or imbecile, frequently arise directly from faultsof management and can be controlled by correcting these faults. Suppose, for example, that a child is found to have taken money nothis own. The action of the parents faced with this difficulty anddisappointment will determine to a great extent whether the incidentis productive of permanent damage to the child's character. Thepeculiar circumstances of each case must be considered. For example, the parent must bear in mind the relation in which children stand toall property. The child possesses nothing of his own; everythingbelongs in reality to his father and mother, but of all thingsnecessary for him he has the free and unquestioned use. Unless hisattention has been specially directed to the conception of ownershipand the nature of theft, he may not have reasoned very closely on thematter at all. Very probably he knows that it is wrong to take what isnot given him, but he does not regard helping himself to some daintyfrom a cupboard as more than an act of disobedience to authority. Hemay have imbibed no ideas which place the abstraction of money from apurse belonging to his parents on a different plane, and which havetaught him to regard such an action as especially dishonourable andcriminal. Finally, a child who, undetected, has more than once takenmoney belonging to his father and mother, may pass without muchthought to steal from a visitor or a servant. To deal with such a caseeffectively, to ensure that it shall never happen again, requires muchinsight. If the father, shocked beyond measure to find his son anincipient criminal, differing in his guilt in no way from boys who aresent to reformatories as bad characters, convinces the child thatalthough he did not realise it, he has shown himself unworthy of anyfurther trust, untold harm will be done. Almost certainly the childwill act in the future according to the suggestions which are thusimplanted in his mind. If the household eyes him askance as a thief, if confidence is withdrawn from him, he sees himself as others see himand will react to the suggestions by repeating the offence. Theseriousness of what he has done should be explained to him, and afterdue punishment he must be restored completely and ostentatiously toabsolute trust. Only by showing confidence in him can we hope to doaway with the dangers of the whole incident. To inculcate good habitsand encourage good behaviour we must let the child build up his ownreputation for these virtues. It need not make him priggish orself-satisfied if parents let him understand that they take pride inseeing him practise and develop the virtue they aim at. For example, it is desired above all that he should always speak the truth. Thenthey must ostentatiously attach to him the reputation of truthfulnessand show their pride in his possessing it. If he falls from grace theymust remember that he is still a child, and that if that reputation islightly taken from him and he is accused of a permanent tendencytowards untruthfulness, he is left hopeless and resigned to evil. Letany mother make the experiment of presenting to her child in this waya reputation for some particular virtue. For example, if an olderchild shows too great a tendency to tease and interfere with theyounger children, let the mother seize the first opportunity whichpresents itself to applaud some action in which he has shownconsideration for the others. Let her comment more than once in thenext few days on how careful and gentle the older child is becoming inhis behaviour to the little ones, and in a little the suggestion willbegin to act until the transformation is complete. If, on the otherhand, the mother adopts the opposite course and rebukes the child forhabitual unkindness, she will be apt to find unkindness persisted in. The criminal records of the nation show too often the truth of thesaying that "Once a thief always a thief. " Deprived of his goodrepute, man loses his chief protection against evil and his incentiveto good. 

The inability of a child--and especially of a nervous and sensitivechild--to form conceptions of his own individuality except from ideasderived from the suggestions of others, gives us the key to ourmanagement of him and to our control of his conduct. He has, as arule, a marvellously quick perception of our own estimate of him, andunconsciously is influenced by it in his conception of his ownpersonality, and in all his actions. Parents must believe in hisinherent virtue in spite of all lapses. If they despair it cannot behid from the child. He knows it intuitively and despairs also. It isthen that they call him incorrigible. If it happens that one parentbecomes estranged from the child, despairs of all improvement, andsees in all his conduct the natural result of an inborn disposition toevil, while the other parent holds to the opinion that the child'snature is good, and to the belief that all will come right, then oftenenough the child's conduct shows the effect of these oppositeinfluences. In contact with the first he steadily deteriorates, affording proof after proof that judgment against him has been rightlypronounced. In contact with the other, though his character andconduct are bound to suffer from such an unhappy experience, he yetshows the best side of his nature and keeps alive the conviction thathe is not all bad. 

The force of suggestion is still powerful to control conduct anddetermine character in later childhood. The impetus given by theparents in this way is only gradually replaced by the driving power ofhis own self-respect--a self-respect based upon self-analysis in thelight 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 itssurroundings, is sensitive, mobile, and inconstant. With every yearthat passes, the normal child loses something of this impressionableand fluid quality. With increasing experience and with a growing powerto argue from ascertained facts, character becomes formed, and iftempered by discipline will come to present a more and more unyieldingsurface to environment, until finally it becomes set into thestability of adult age. 

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

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

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

More commonly, perhaps, neuropathy exhibits itself in an unduetendency to show signs of fatigue upon exertion of any sort, mental orphysical. Sustained interest in any pursuit or task becomesimpossible. Nameless fears and unaccountable sensations of dreadestablish themselves suddenly and without warning, and may beaccompanied on the physical side by palpitation, flushing, headache, or acute digestive disturbances. 

All these manifestations are best controlled by selecting a suitableenvironment, and as a rule the character of the environment isdetermined by the temperament and disposition of those who live inclose contact with the patient. Like the tiny children with whom wehave dealt so far, the behaviour of neuropathic persons is subjectwholly to the direction of stronger and more dominant natures. Withfaulty management at the hands of those around them, no matter howloving and patient these may be, the conduct of the neurotic tends tobecome abnormal. 

In children beyond earliest infancy we recognise a gradual approach tothe conditions of adult life. Fractiousness and naughtiness, ungovernable fits of temper, inconsolable weeping and inexplicablefears should disappear with early childhood even if management has notbeen perfect. If they persist to older childhood we shall find in anincreasing percentage of cases evidence of definite neuropathictendencies which urgently call for investigation and for a preciseappreciation of the nature of the abnormality. It may be that the onlyeffective treatment is that which we recognise as essential in thegrosser mental disturbances--removal from the surroundings in whichthe abnormal conduct has had free play, and separation from therelatives whose anxiety and alarm cannot be hidden. 

In young nervous children fear is the most prominent psychicalsymptom. The children are afraid of everything strange with which theycome in contact. They are afraid of animals, of a strange face, or anunfamiliar room. Older children usually manage to control themselves, suppress their tears, and prevent themselves from crying out, but itis 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, --usuallysoon after he has gone to sleep, --sits up in bed and shows signs ofextreme terror, gazing at some object of his dreams with wide-openstartled 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 isturned up and the child has been comforted, the terror continues, andhalf an hour may elapse before he becomes quiet and can be persuadedto go back to bed. In the morning as a rule he remembers nothing atall. 

Phobias of all sorts are common in nervous children, and result from amorbid exaggeration of the instinct for self-preservation. Some cannotbear to look from a height, others grow confused and frightened in acrowd; dread of travelling, of being in an enclosed space such as achurch or a schoolroom, or of handling sharp objects may develop intoa constant obsession. I have known a little girl who was seized withviolent 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 lestsome harm should have befallen them. As if with some strange notion ofpropitiating the powers of darkness these children will oftenconstantly perform some action and will refuse to be happy until theyhave done so. The same little girl who suffered such torments ofanxiety in her parents' absence would always refuse to go to bedunless she had stood in turn on all the doormats on the staircase ofher home. Other children feel themselves forced to utter certain wordsor to go through certain rhythmical movements. They fully understandthat the fear in their mind is irrational and devoid of foundation, but they are unable to expel it. Often it is hugged as a jealoussecret, so that the childish suffering is only revealed to othersyears afterwards, when adult age has brought freedom from it. We willdo well to try by skilful questioning to gain an insight into themental processes of a child when we find him showing an uncontrollabledesire to touch lamp-posts or to stand in certain positions; or whenhe develops an excessive fear of getting dirty, or is constantlywashing his hands to purify them from some fancied contamination. 

The treatment of all these symptoms calls for much insight. Thechild's confidence must be completely secured, and he must beencouraged to tell of all his sensations and of the reasons whichprompt his actions. The nervous child has a horror of appearing unlikeother children, and will suffer in silence. If his troubles arebrought into the light of day with kindness and sympathy they willmelt before his eyes. Even night-terrors are, as a rule, determined bythe suppressed fears of his waking hours. If they are provoked by hisexperiences at school, by the fear of punishment or by dismay at atask that has proved beyond his powers, he should be taken away fromschool for the time being. Night-terrors are said to be aggravated bynasal obstruction due to adenoid vegetations. Clothing at night shouldbe light and porous, and particular attention should be paid to theneed for free ventilation. 

We have spoken in an earlier chapter of the trouble sometimesexperienced in inducing a nervous child to go to sleep. In olderchildren insomnia is common enough. Even when sleep comes it may belight and broken, as though the child slept just below the surface ofconsciousness and did not descend into the depths of sound andtranquil slumber. We have often noticed how different is the estimateof the patient from that of the nurse as to the number of hours ofsleep during the night. The sick man maintains that he has hardlyslept at all, whilst the nurse, drawing us aside, whispers in our earthat he has slept most of the night. In estimating sleep we have toconsider not only its duration, but also its depth, and the patientwho denies that he has slept at all has lain perhaps half the nightwith an active restless brain betwixt sleep and wakefulness. Oftenenough when he comes to consider in the morning the problems thatvexed 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-consciousnessof his surroundings and a sense of despair at the continued absence ofa sounder sleep. 

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

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

Day-dreams also may become abnormal, and tell of an unduly nervoustemperament. Any one who watches a little child at play will realisethe strength of his power of imagination. The story of Red Riding Hoodtold by the nursery fire excites in the mind of the child anunquestioning belief which is never granted in later life to the mostelaborate efforts of the theatre. All this imaginative force isnatural for the child. It becomes abnormal only when things seen andacts performed in imagination are so vivid as to produce theimpression of actual occurrences, and when the child is so under thesway of his day-dreams that he fails to realise the difference betweenpretence and reality. Imagination which keeps in touch with reality bymeans of books and dolls and toys is natural enough. Not soimagination which leads to communion with unseen familiars or to actsof violence due to the organisation of "conspiracies" or "robberbands" amongst schoolboys. 

If evidence of abnormal imagination appears, the child must be kept inclose touch with reality. We must give him interesting and rationaloccupation, such as drawing, painting, the making of collections ofall sorts, gardening, manual work, and so forth. In older children wemust especially supervise the reading. 

In many nervous children we find a faulty contact with environment, sothat instead of becoming interested in the thousand-and-one happeningsof everyday life and experiences, they become introspective andself-conscious. As a result, sensations of all sorts, which arecommonly insufficient to arouse the conscious mind, attract attentionand, rising into consciousness, occupy the interest to the exclusionof everything else. The conscious mind is not capable of beingoccupied by more than one thing at a time. If attention isconcentrated upon external matters, bodily sensations, even extremepain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tellsus, hardly feels the scalping-knife as he shouts his death song. Thesoldier in the excitement of battle is often bereft of all sense ofpain. On the other hand, the patient who is morbidly self-consciousbecomes oblivious of his surroundings while he suffers intensely fromsensations which are usually not appreciated at all. Self-consciouschildren will complain much of breathlessness and a sense ofsuffocation, of headache, of palpitation, of intolerable itching, ofthe pressure of clothing, or of flushing and a sense of heat. Excessive introspection influences their conduct in many ways. Atchildren's parties, for example, they will be found wandering aboutunhappy, dazed and unable to feel the reality of the surroundingswhich afford such joy to the others; or they may be anxious to join inplay, but finding themselves called upon to take their turn are apt tostand helplessly inactive, or to burst into tears. At school, thoughthey may be really quick to learn, they will often be found obliviousof all that has gone on around them, not from stupidity, but frominability to dissociate their thoughts from themselves and toconcentrate attention upon the matter in hand. In such a case we mustaim at developing the child's interest to the exclusion of this morbidintrospection. Taking advantage of his individual aptitude, we muststrengthen his hold upon externals in every way possible, and we mustexplain to him the nature of his failing and teach him that hissalvation lies in cultivating his capacity for paying attention tothings around him and developing an interest in suitable occupations. 

Fainting fits are not uncommon amongst nervous children from aboutthe sixth year onwards, and are apt to give rise to an unwarrantedsuspicion of epilepsy. In other cases fears have been aroused that theheart may be diseased. In children who faint habitually the nervouscontrol of the circulation is deficient. We notice that when they aretired by play, or when they are suffering from the reaction thatfollows excitement of any sort, the face is apt to become pale, anddark lines may appear under the eyes. Yet there may be no true anæmiapresent: it is only that the skin is poorly supplied with blood forthe moment. After a little rest in bed, or under the influence of anew excitement, the colour returns, and the tired look vanishes. Ifchildren of this type are made to stand motionless for any length oftime, and if at the same time there is nothing to attract theirinterest or attention--a combination of circumstances which unhappilyis sometimes to be found during early morning prayers at school--thewant of tone in the blood vessels may leave the brain so anaemic thatfainting follows. The first fainting attack is a considerablemisfortune, because the fear of a recurrence is a potent cause of arepetition. Standing upright with the body at rest and the mindvacant, the circulation stagnates, the boy's mind is attracted by thesuggestion, he fears that he will faint as he has done before, and hefaints. Schoolmasters are well aware that if one or two boys faint inchapel and are carried out, the trouble may grow to the proportion ofa veritable epidemic. It is important that this habit of faintingshould be combated not only by general means to improve the tone ofthe body and circulation, but also by taking care that the childunderstands the nature of the fainting fit, and the part whichassociation of ideas plays in producing it. Disease of the heartseldom gives rise to fainting. 

The same vasomotor instability which shows itself in the tendency tosyncopal attacks is apparent in many other ways. Sudden sensations ofheat and of flushing, equally sudden attacks of pallor, coldness ofthe extremities, abundant perspiration, --raising in the mind of theanxious mother the fear of consumption, --and excessive diuresis arecommon accompaniments. A further group of symptoms is provided by theextreme sensibility of the digestive apparatus. Dyspepsia, hyperaesthesia of the intestinal tract, viscero-motor atonies andspasms, and anomalies of the secretions, whether specific like that ofthe gastric juice or indifferent like that of the nasal, pharyngeal, gastric, and intestinal mucus, are all of common occurrence. Wheneverthe nervous child is subjected to any exhausting experience, anyexcitement, pleasurable or the reverse, or any undue exertion, whethermental or physical, one may note the subsequent gastro-intestinalderangement, including even a coating of the tongue. The slightestdeviation from the usual diet, the most trivial fatigue, a chill ofthe body, even a change in the temperature of the food may set loosethe most extreme reactions in the gastro-intestinal tract--motor, sensory, or secretory. It is not an accident that so often the mucousdiarrhoea, which may have afflicted an excitable child in London formany months, and which a visit to the seaside, with all its healthyactivities, may seem to have completely cured, relapses within a dayor two of the return to the restricted environment and uninterestingroutine of life in London. The child who was happy and busy and atpeace with himself, at play in the open air, resents the suddencessation of all this, and the nervous unrest returns. To attempttreatment by dietetic restrictions alone is to deal only with asymptom. The gastro-intestinal reactions are so violent that theparents are generally voluble on the subject of the many foods whichcannot be taken and the few which are not suspect. To prescribe rigidtables of diet is to add to the alarm of the mother, and to sustainher in the belief that the child is in daily danger of being poisonedby a variety of common articles of diet. Only by lowering theexcitability of the nervous system, by occupying the mind and givingstrength to the child's powers of control can we effectively combatthe hyperaesthesia. If necessary the personnel of the management ofthe child will have to be altered. There may be no other way toachieve certain and rapid improvement in a condition which is causinggrave danger to the child and very genuine distress and suffering tothe parents. A violent reaction to intoxications of all sorts is afurther stigma of nervous instability. Sudden and even inexplicablerises of temperature are frequent complaints, and the constitutionaleffects of even trivial local infections are apt to bedisproportionately great. 

Fatigue is easily induced and is exhibited in all varieties ofactivity--mental, physical, or visceral. Mental work may producefatigue with extreme readiness even although the quality of the workmay remain of a high standard. To Darwin and to Zola work for morethan three hours daily was an impossibility, and yet their work doneunder these restrictions excites all men's admiration. The palpitationand breathlessness which follows upon trivial exertion, such asclimbing a flight of stairs, is a good example of visceral fatigue. 

Among adult neuropaths we recognise the harm which may be done byunwise speeches on the part of relatives, or still more on the part ofdoctors. A chance word from a doctor or nurse off their guard for themoment will implant in the minds of many such a person the unyieldingconviction 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 thispathological doubt which was implanted so easily and so carelessly. The medical student is notoriously prone to recognise in himself thesymptoms of ailments which he hears discussed. Little children, too, are apt to suffer in the same way. How much illness could be avoidedif mothers would cease to erect some single manifestation ofinsufficient nervous control into a local disorder which becomes anobject of anxiety to the child and to the whole household. 

Undue liability to fatigue, irritability, instability, lack ofcontrol over the emotions, extreme suggestibility, prompt andexaggerated reactions to toxins of all sorts, excessive vasomotorreactions and anomalies of secretion, weakness of thegastro-intestinal apparatus--these, and many other symptoms, are ofeveryday occurrence in the nervous child. To discuss them more fullywould be to pass too far from our nursery studies into a considerationof psychological medicine. 

CHAPTER XI

NERVOUSNESS AND PHYSIQUE

It has already been said that symptoms of nervousness are oftenaccompanied by faults in the physical development of the child. Thedefects may assume so many forms as to make any attempt at descriptionvery difficult. Nevertheless, certain types of physical defect presentthemselves with sufficient frequency, in combination with neurosis, tomerit a detailed description. For example, we recognise a type ofnervous child which is marked by a persistence into later childhood ofcertain infantile characteristics of the build and shape of body. Further, we meet with a group characterised by a special want of tonein the skeletal muscles, by lordosis, by postural albuminuria, and byabdominal and intestinal disturbances of various sorts. We recognisealso the rheumatic type of child with a tendency to chorea, and incontrast to this a type with listlessness, immobility, and katatonia. Lastly, in a few children, in boys as well as in girls, we may meetwith cases of hysteria. [3]

[Footnote 3: If we accept as hysterical all symptoms which areproduced by suggestion and which can be removed by suggestion, we maycorrectly speak of a physiological hysteria of childhood, whichincludes a very large number of the symptoms discussed. The term isused 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 roundedinfantile shape of body persists. The limbs are short and thick, thecheeks full and rounded, the thorax and pelvis are small, the abdomenrelatively large and full. The great adipose deposit in thesubcutaneous tissue serves as a depôt in which water is stored inlarge amounts. In the healthy child of normal development by the endof the second year a great change has taken place. The shape of thebody has become more like that of an adult in miniature. The limbshave grown longer and slimmer. The thorax and pelvis have developed soas to produce relatively a diminution in the size of the abdomen. Thebody fat is still considerable, but no longer completely obliteratesthe bony prominences of the skeleton. Delay in this change, in thisputting aside of the infantile habit of body, is commonly associatedwith a corresponding backwardness in the mental development. Suchchildren walk late, talk late, learn late to feed themselves, to bite, and to chew effectively. Watery and fat, they carry with them intolater childhood the infantile susceptibility to catarrhal infectionsof the lung, bowel, skin, etc. , and they are apt to suffer, inconsequence, from a succession of pyrexial attacks. Nasal catarrh, bronchitis, otitis media, enteritis, eczema, urticaria papulata, areapt to follow each other in turn, giving rise in many cases to apersistent enlargement of the corresponding lymphatic glands. Theeffect upon the different tissues of the body of these repeatedinfections is very various. We are probably not wrong in attributingthe failure to develop and the persistently infantile appearance to aprejudicial effect upon the various ductless glands in the body. Thecondition is associated with an excessive retention of fluid in thebody, secondary in all probability to alterations in the concentrationand distribution of the saline constituents of the body. A rapidexcretion of salts may be followed by a correspondingly speedydehydration of the body, a retention of salts by a sudden increase ofweight. The parathyroid glands are probably closely concerned inregulating the retention and excretion of salts, and especially ofcalcium, a circumstance which becomes of significance when we rememberhow frequently rickety changes, tetany, and other convulsive seizuresform part of the clinical picture which we are now considering. Whileit is difficult to determine the effect of repeated infections uponthe functions of the endocrine glands, we have clear evidence of thedeleterious influence upon almost all the tissues of the body, thefunctioning of which it is more easy to estimate. For example, thecells of the skin and of the mucous membranes which happen to bevisible to the eye show clear evidence of diminished vitality andincreased vulnerability. Physiological stimuli, incapable of producingany visible reaction in healthy children, habitually determine widelyspread and persistent inflammatory reactions. For example, thelicking movements of the tongue at the corners of the mouth producethe little unhealthy fissures which the French call _perlèche_. Thephysiological stimulus of the erupting tooth is capable of causing apainful irritation of the gum, so that the child is said to sufferfrom teething, accompanied, it may be, and the association issignificant, by "teething convulsions. " The irritation of the urineproduces rawness and excoriation of the skin of the prepuce, contactwith intestinal contents not in themselves very abnormal, anintractable dermatitis of the buttocks or a persistent diarrhoea andenteral catarrh. Improvement in the general health, the result of thecessation for the time being of the recurrent infections, perhapsconsequent upon improved hygienic conditions, always determines therapid disappearance of all these accompaniments of the generaldiminution of tissue vitality. 

The muscular system and the bones are commonly also involved, so thatrickety changes are often found in these infantile and waterychildren. In early childhood the processes of calcification anddecalcification proceed side by side and with great rapidity, and inhealth there is always a balance on the side of the constructiveprocess. In the children whom we are now considering, saturated asthey are, from time to time, with the toxins resulting from repeatedinfection, ossification may be so interfered with as to causesoftening and bending, with the evolution of a state of rickets. Between bone and muscle, too, we find a close relationship. We do notfind powerful muscles with softened bone, nor flabby muscle withrigid 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 thenervous system, on the other hand, the individual cells are longlived. Their life-history may even be coterminous with that of theindividual, and if destroyed they are not replaced. Nevertheless, theydo not escape undamaged in the general disturbance. In a deprivationof calcium we have, in all probability, the explanation of theincreased irritability of peripheral nerves and of the tendency toconvulsive seizures of all sorts which is a common accompaniment ofthe condition. Convulsions, laryngismus stridulus, tetany, orcarpopedal spasm are all frequently met with. In crying, the childrenhold their breath to the point of producing extreme cyanosis, ending, as the spasm relaxes, with a crowing inspiration, which resembles andyet differs in tone from both the whoop of whooping-cough and thecrowing inspiration of croup. 

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

The clinical picture so depicted is encountered with extreme frequencyamong the children of the poor in our large cities. To find a name forthe condition is no easy matter. To call it "rickets" is to place anundue emphasis upon the bony changes which, though common, are by nomeans invariable. Elsewhere I have suggested the name statuscatarrhalis, on an analogy with the name status lymphaticus, which inthe post-mortem room is used to describe the secondary overgrowth oflymphatic tissue which is found in these catarrhal children. In thepresent connection it is of interest to us to note how commonly thenervous system is involved in the general picture and the frequencyboth of convulsive disorders and of neuropathy. 

The nervous symptoms of both sorts are to be allayed only by improvingthe general hygiene of the child and raising its resistance againstinfection. A sufficiency of fresh air and of sunlight, and amanagement which encourages independence of action in the child, areboth necessary. The diet is of the first importance. It should besufficient, and no more than sufficient, to cover the physiologicalneeds of the child for food. The majority of these children haveenormous appetites, and excess of food, and especially of carbohydratefood, plays some part in the production of the disturbance. We mustguard 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 secondtype of physical defect associated with pronounced nervous disturbancepresents itself with some frequency. The body is thin and badlynourished, and the muscular system especially poorly developed andvery lax in tone. The most striking feature is the extreme lordosis, accompanied usually by a secondary and compensatory curve in thecervico-dorsal region, so that the shoulders are rounded, with thehead poked forward. Viewed from in front the abdomen is seen to beprominent, overhanging the symphysis pubis, while the shoulders havereceded far backwards. The scapulæ have been dragged apart, as thoughby the weight of the dependent arms, with eversion of their vertebralborders and lowering of the points of the shoulders. The positionwhich they adopt is that into which the body falls when it ceases tobe braced by strong muscular support. The muscular system is here soweakly developed and so toneless that the posture is determined by thebony structure and its ligamentous attachments. 

The lordosis resembles the similar deformity which develops in casesof primary myopathy, when the spinal muscles have undergone completeatrophy. As in myopathy the movements are very uncertain. Thechildren are apt to fall heavily when the centre of gravity issuddenly displaced, because their upright posture is maintained bybalancing the trunk upon the support of the pelvis. The frequency andseverity of the falls which these children suffer is a commoncomplaint of the mother. The faulty posture is often associated withslight albuminuria. Its appearance is very capricious, but it isdependent to a great extent upon the assumption of the erect posture. There has been much discussion as to its explanation. It has beenargued that the lordosis itself produces the albuminuria by mechanicalcompression of the renal vein, and it is said that albuminuria can beproduced, even in the prone position, by placing the child in aplaster jacket applied so as to maintain the position of lordosis. Other observers, however, have not obtained this result. It seems mostlikely that the albuminuria is due to defective tone in the vasomotormusculature, comparable in every way to the defective tone in themuscles of the skeleton. We have often further evidence of vasomotorweakness. Fainting attacks are so common as to be the rule rather thanthe exception. Again, mothers are likely to complain of the child'spallor and of dark lines under the eyes, especially after exertion orin the reaction which follows excitement of any sort. As a rule ablood count will not show any very striking evidence of true anæmia. The pallor is of vasomotor origin, determined by faults in thedistribution of the blood from vasomotor weakness and not by deficientblood formation. Circulatory and vasomotor disturbance probably alsoaccounts for the dyspeptic pains and vomiting which commonly accompanyany emotional excitement, or follow any unusual exertion or fatiguingexperience. Constipation is a common, and mucous diarrhoea anoccasional, symptom. The abdomen is often pigmented. The hands andfeet are usually cold and cyanosed. 

The extreme nervousness of the children is the point upon which moststress may be laid in the present connection. The association ofalbuminuria with neurosis in childhood has been noticed by manyobservers. The gastric and intestinal symptoms are especiallycharacteristic. If the condition of the children is not materiallyimproved, and if the symptoms, both of the physical defect and of thenervous disturbance, are not cut short, we may predict that in adultage their lives will be made miserable by a variety of abdominalsymptoms dependent both on the vasomotor disturbance and upon theaccompanying neurosis. Now that surgery forms so large a part of ourtherapeutic proceedings, they may not reach middle life without beingsubmitted to one or more surgical operations. With good managementboth on the physical side and on the moral or psychological side theycan 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 isoften to be found in the condition of the tonsils. Enucleation maythen be indicated as the first step in treatment. 

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

_(c)_ The stimulating effect of cold douches is often very evident inimproving the vasomotor tone. These children, however, will not standwell the abstraction of heat from their thin and chilly little bodies, so that it is a good plan before the colder douche to immerse thechild in a hot bath and to return again to the bath momentarilyafterwards. With these precautions children will often enjoy a coldspray, the temperature of which may be constantly lowered as theybecome used to it. Prolonged hot bathing has a correspondinglyprejudicial effect. 

_(d)_ We must be on the watch to prevent the development of furtherpostural deformities, such as scoliosis. If a child of strong musculartone and good physique habitually adopts some posture, curled up, itmay be, in some favourite easy-chair, there is little likelihood thatits constant assumption will produce deformity. When the muscularsystem is lax and weak, on the other hand, deformity such as scoliosisis very readily caused. It is important, for example, to see that thechild does not habitually incline to one side in reading or writing. When there is little energy for free and energetic play the childrenare apt to become great bookworms. If there is shortsightedness, thedangers are correspondingly increased. A special chair may be madewith a well-fitting back and the seat a little tilted upwards so as tothrow 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 theproper position. The child, sitting straight and square, with theweight supported by the foot-rest and back as well as by the seat ofthe chair, should be taught to write with an upright hand, avoidingthe slope which leads to sitting sideways with the left shoulderlowered. 

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

(3) RHEUMATISM AND CHOREA

It is certain that there is a close association between rheumatism inchildhood and the common nervous affection known as chorea. We arestill ignorant of the precise nature of the infection which we know asrheumatism. There is much to suggest that in rheumatism we have todeal only with a further stage in those catarrhal infections to whichso much infantile ill-health is to be attributed, and thatendocarditis and arthritis, when they arise, signalise the entry ofthese catarrhal, non-pyogenic organisms into the blood stream, overcoming at last the barrier of lymphoid tissue which hashypertrophied to oppose their passage. Certainly the connection ofrheumatism with catarrhal infections of the mucous membranes andadenoid enlargements of all sorts is a close one. Whatever itsnature, the rheumatic infection in childhood is more lasting andchronic than in adult life. Rheumatism in childhood is not manifestedby acute and short-lived attacks of great severity so much as by along-continued succession of symptoms of a subacute nature, atransient arthritis, perhaps, succeeding an attack of sore throat withtorticollis, to be followed by carditis, to be followed again byanother attack of tonsillitis. And so the cycle of symptoms revolves. In most cases the child grows thin and weak; in most cases he becomesrestless, irritable, and unhappy; often there is definite chorea. Ofthis cerebral irritability chorea is the expression. In adults, choreais perhaps more obviously associated with mental stress of all sortsand with states of excitement and agitation. In the case of littlechildren it is often only the mother who really appreciates howradical an alteration the child's whole nature has undergone, and howgreat the element of nervous overstrain has been before the chorea hasappeared. 

Of the treatment of chorea there is no need to speak. It is purelysymptomatic. Isolation, best perhaps away from home, as might beexpected, gives the best results. If there are pronounced rheumaticsymptoms, the salicylates will be needed; if there is anæmia, arsenicand iron; if there is sleeplessness and great restlessness, bromidesor chloral. Hypnotism is often almost instantly successful, but, apartfrom hypnosis, curative suggestions proceeding from the attendantsform 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 asevidence of cerebral exhaustion a group of symptoms which in a senseare the reverse of those which characterise cerebral irritation andchorea. The healthy child is a creature of free movement. The childrenwe are now considering will sit for a long time motionless. Theexpression of their faces is fixed, immobile, and melancholy. If thearm or leg is raised it will be held thus outstretched without anyattempt to restore it to a more natural position of rest for minutesat a time. The posture and expression remind us at once of thekatatonia which is symptomatic of dementia præcox and other stuporoseand melancholiac conditions in adult life. Symptoms of this sort areespecially common in children with intestinal and alimentarydisturbances of great chronicity. 

The symptom is so frequently met with that it is strange that itshould have attracted so little attention as compared with thecontrasting condition of chorea. And yet it is of more serioussignificance, more difficult to overcome, and with a greater dangerthat permanent symptoms of neurasthenia will result. In earlychildhood a careful dietetic régime, suitable hygienic surroundings, and a stimulating psychical atmosphere will often effect greatimprovement. As in chorea, however, relapses are frequent, and thereare cases which for some unexplained reason are peculiarly resistantto all remedial influences. 

(5) HYSTERIA

In hysteria, in contrast to the types previously described, theinfective element may be completely absent. Except in some specialfeatures of minor importance the symptoms of hysteria do not differfrom those of adults, and, as in adult age, the condition of hysteriamay be present although the physical development may be perfect. Wecannot here speak of any physical characteristics which are associatedwith the nervous symptoms. 

The third or fourth year represents the age limit, below whichhysterical symptoms do not appear. Thereafter they may be occasionallymet with, with increasing frequency. At first, in the earlier years ofchildhood, there is no preponderance in the female sex. As pubertyapproaches, girls suffer more than boys. 

It may be said to be characteristic of hysteria in childhood that itssymptoms are less complex and varied than in adult life. The naiveimagination of the child is content with some single symptom, and isless apt to meet the physician half-way when he looks for theso-called stigmata. Similarly mono-symptomatic hysteria ischaracteristic 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 inchildhood. 

CHAPTER XII

THE NERVOUS CHILD IN SICKNESS

In time of sickness the management of the nervous child becomes verydifficult. Restlessness and opposition may reach such a pitch that itmay be almost impossible to confine the patient to bed or to carry outthe simplest treatment. Sometimes days may elapse before thesick-nurse who is installed to take the place of the child's usualattendant is able to approach the cot or do any service to the childwithout provoking a paroxysm of screaming. In such a case anysystematic examination is often out of the question, with the resultthat the diagnosis may be delayed or rendered impossible. There isonly one reassuring feature of a situation, which arises only innurseries in which the management of the children is at fault; thedoctor has learned from experience that this pronounced opposition ofthe child to himself, to the nurse, and even to the mother, is ofitself a reassuring sign, indicating, as a rule, that the condition isnot one of grave danger or extreme severity. When the child is moreseriously ill, opposition almost always disappears, and the child liesbefore us limp and passive. Only with approaching recovery orconvalescence does his spirit return and renewed opposition showitself. 

Extreme nervousness in childhood carries with it a certain liabilitytowards what is known as "delicacy of constitution. " The sensitivenessof the children is so great that they react with striking symptoms todisturbances so trivial that they would hardly incommode the child ofmore stable nervous constitution. For example, a simple cold in thehead, or a sore throat, may cause a convulsion or a condition ofnervous irritability which may even arouse the suspicion thatmeningitis is present. Or, again, a little pharyngeal irritation whichwould ordinarily be incapable of disturbing sleep may be sufficient tokeep the child wide awake all night with persistent and violentcoughing. The little irritating papules of nettlerash from which manychildren suffer are commonly disregarded by busy, happy childrenduring the day, and even at night hardly suffice to cause disturbance. The nervous child, on the other hand, will scratch them again andagain till they bleed, tearing at them with his nails, and making deepand painful sores. 

The temperature is commonly unstable and readily elevated. Moreover, feverishness from whatever cause is often accompanied by an activedelirium, which is apt to occasion unnecessary alarm. This symptom ofdelirium is always a manifestation of an excitable temperament. Iremember being called to see a young woman who was thought to besuffering from acute mania. Examination showed that she was sufferingfrom pneumonia in the early stages. It was only later that wediscovered that she had always been of an unstable nervoustemperament, and had been in an asylum some years before. Those of uswho are fortunate in possessing a placid temperament and havedeveloped a high degree of self-control are not likely to showdelirium as a prominent symptom should we fall ill with fever; just aswe 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 thistendency is peculiarly marked in those who are unduly nervous. 

As a consequence of this extreme sensitiveness, the nervous child islikely to suffer more than others from a succession of comparativelytrifling ailments and disturbances. The delicacy of the child has, inthis sense, a real existence, and is not confined to the imaginationof over-anxious and apprehensive parents. No doubt the nervous motherof an only child does worry unnecessarily, and is far too prone tofeed her fears by the daily use of the thermometer or theweighing-machine; but her friends who are happy in the possession ofnumerous and placid children are not justified in laying the wholeblame upon her too great solicitude. Children who are members of largefamilies, whose nervous systems have been strengthened by contact withtheir brothers and sisters, are not habitually upset by trifles, andsuffer even serious illnesses with symptoms of less severity. Nervouschildren, and only children, on the other hand, show the oppositeextreme. Nevertheless, the mother of a nervous and delicate child--achild, that is to say, who, even if he is not permanently an invalid, nevertheless never seems quite well and lacks the robustness of otherchildren--should realise clearly how much of this sensitiveness is dueto the atmosphere of unrest and too great solicitude which surroundshim. It is a matter of universal experience that excess of care foronly children has a depressing influence which affects theircharacter, their physical constitution, and their entire vitality. Atall costs we must hide our own anxieties from the child, and we musttreat his illnesses in as matter-of-fact a way as possible. 

When illness comes, his daily routine should be interrupted as littleas possible. In dealing with nervous children, it is often better tolay aside treatment altogether rather than to carry out a variety oftherapeutic procedures which have the effect of concentrating thechild's mind upon his symptoms. When we grown-up people are sick, weoften find a great deal of comfort in submitting ourselves to someform of treatment. We have great faith, we say, in this remedy or inthat. It is _our_ remedy, a _nostrum_. The physician knows well thatthe opportunities which are presented to him of interveningeffectually to cut short the processes of disease by the use ofspecific cures are not very numerous, and that often enough thejustification for his prescription is the soothing effect which itmay exercise upon the mind of the patient, who, believing either inthe physician or in his remedy, finds confidence and patience tillrecovery ensues. As a rule this form of consolation is denied tolittle children. They have no belief in the efficacy of the remedieswhich are applied with such vigour and persistence. Indeed, it is notthe child, but his anxious mother, who finds comfort in the thoughtthat everything possible has been done. Therefore, a prescription mustbe written and changed almost daily, the child's chest must beanointed with oil, and the air of the sick-room made heavy with somearomatic substance for inhalation, and all this when the disturbanceis of itself unimportant, and owes its severity only to the unduesensitiveness 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 ofhis symptoms, and we can keep the most scrupulous watch over hishealth without allowing him to perceive at all that our eye is on him. With older children the evil results of suggestions, unconsciouslyconveyed to them by the apprehension of their parents, become veryobvious. The visit of the doctor, to whom in the child's hearing allthe symptoms are related, is often followed by an aggravation which isapt to be attributed to his well-meant prescription. The harm done byexaminations, which are specially calculated to appeal to the child'simagination, as, for instance, an X-ray examination, is often clearlyapparent. I remember a schoolboy of thirteen who was sent to mebecause he had constantly complained of severe abdominal pain. He wasa nervous child with a habit spasm, the son of a highly neuroticfather and an overanxious mother. An X-ray examination was made, butshowed nothing amiss. The child's interest and preoccupation in theexamination was painfully obvious. That night his restraint broke downaltogether, and he screamed with pain, declaring that it had becomeinsupportable. Younger children, less imaginative but equallyperverse, noticing how anxiously their mothers view their symptoms, will often make complaint merely to attract attention and to exciteexpressions of pity or condolence. Sometimes they will enforce theirwill by an appeal to their symptoms. I have had a little patient of nomore than thirteen months of age who suffered severely and for a longtime from eczema, and who in this way used his affliction to ensurethat he got his own way. If he was not given what he wantedimmediately he would fall to scratching, with an expression upon hisface which could not be mistaken. To him, poor child, the grown-uppeople around seemed possessed of but one desire--to stop hisscratching; and he had learnt that if he showed himself determined toscratch they would give way on every other point. 

The ill-effects of departing too readily from ordinary nursery routineon account of a little illness, and of adopting straightway a varietyof measures of treatment, is well shown in cases of asthma inchildren. The asthmatic child is almost always of a highly nervoustemperament, and often passionate and ungovernable. Often the mosteffective treatment of an attack, which usually comes on some hoursafter going to bed, is to make little of it, to talk naturally andcalmly to the child, to turn on the light, and to allow him, if hewill, to busy himself with toys or books. To be seized with panic, tosend post-haste for the doctor, to carry the patient to the openwindow, to burn strong-smelling vapours, and so forth, not only is aptto prolong the nervous spasm on this occasion, but makes it likelythat a strong impression will be left in his mind which byauto-suggestion will provoke another attack shortly. With nervouschildren a seeming neglect is the best treatment of all trivialdisorders. Meanwhile we can redouble our efforts to remedy defects inmanagement, and to obtain an environment which will gradually lowerthe heightened nervous irritability. 

When the illness is of a more serious nature, as has been said, therestlessness as a rule promptly disappears. In each case it must bedecided whether it is best for the child to be nursed by his motherand his own nurse, or by a sick-nurse. In the latter event theordinary nurse and the mother should absent themselves from thesick-room as much as possible. Often the firm routine of the hospitalnurse is all that is wanted to obtain rest. Less often, the child willbe quiet with his own nurse, and quite unmanageable with a stranger. 

There is, however, another side to the question. The relation ofneurosis in childhood to infection of the body is complex. I have saidthat with the nervous child a trivial infection may produce symptomsdisproportionately severe. Persistent and serious infection, however, is capable of producing nervous symptoms even in children who were notbefore nervous, and we must recognise that prolonged infection makes afavourable soil for neuroses of all sorts. The frequency with whichSt. Vitus's dance accompanies rheumatism in childhood forms a goodexample of this tendency. The child who, from time to time, complainsof the transient joint pains which are called "growing pains, " and whois found by the doctor to be suffering from subacute rheumatism, iscommonly restless, fretful, and nervous. Appetite, memory, and thepower of sustained attention become impaired. Often there is excessiveemotional display, with, perhaps, unexplained bursts of weeping. Thechild is readily frightened, and when sooner or later the restless, jerky movements of St. Vitus's dance appear, the usual explanation isthat some shock has been experienced, that the child has seen a streetaccident, has been alarmed by a big dog jumping on her, or by a manwho followed her--shocks which would have been incapable of causingdisturbance, and which would have passed almost unappreciated had notthe soil been prepared by the persistent rheumatic infection. 

The management of the nervous child whose physical health remainscomparatively good is difficult enough, but these difficulties areincreased many times when the physical health seriously fails. Tosteer a steady course which shall avoid neglecting what is dangerousif neglected, and overemphasising what is dangerous ifover-emphasised, calls for a great deal of wisdom on the part both ofthe mother and her doctor. 

CHAPTER XIII

NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS

In this chapter I approach with diffidence a subject which is rightlyenough occupying a great deal of attention at the present time: theinstruction of our children in the nature, meaning, and purpose ofsexual processes. It is a subject filled with difficulties. Everyparent would wish to avoid offending the sense of modesty which is thepossession of every well-trained child, and finds it difficult toescape the feeling that discussion on such matters may do more harmthan good. There is certainly some risk at the present time that, putting reticence on one side, we may be carried too far in theopposite direction. The evils which result from keeping children inignorance are well appreciated. We have yet to determine the effectupon them of the very frank and free exposure of the subject which isrecommended by many modern writers. Nevertheless, it must be grantedthat it is not right to allow the boy or girl to approach adolescencewithout some knowledge of sex and the processes of reproduction. Ifnothing is said on such subjects, which in the nature of things arebound to excite a lively interest and curiosity in the minds of olderchildren, evil results are apt to follow. Because parents have nevermentioned these subjects to their child, they must not conclude thathe is ignorant of all knowledge concerning them. It is not unlikelythat the question has often occupied his thoughts, and that hisspeculations 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 matterswhich they feel instinctively are taboo, have pieced together, fromtheir reading and observation, a faulty theory of sexual life. Thepursuit of such knowledge, in secret, is not a healthy occupation forthe child. His parents' silence has given him the feeling that theunexplored land is forbidden ground. In satisfying his curiosity he ismost certainly fulfilling an uncontrollable impulse, but he has beenforced to be secretive, and to look upon the information he hasacquired as a guilty secret. So far even the best of children will goupon, the dangerous path. If training has been good, and if the childhas responded well to it, he will go no further. Though he can hardlybe expected to refrain from constructing theories and from testingthem in the light of any chance information which may come his way, hewill instinctively feel that the subject is one best left alone. Hewill not talk of it with other boys--not even with those who are olderthan himself and whose superior knowledge in all other matters he isaccustomed to respect. We need not be surprised, however, that themajority of children do not attain to this high standard of conduct, and that the interest and excitement of exploring the unknown and theforbidden proves too great. Children will consult with each otherabout such matters, and knowledge of evil may spread rapidly from theolder to the younger. In some schools, as is well known, there maygrow up with deplorable facility an unhealthy interest in sexualmatters. On the surface of school life all may seem fair enough, butbeneath, hidden from all recognised authority, lies much that isunspeakable. If the boy has not been taught to have clean thoughtsupon matters which are essentially clean, if he has not learned toknow evil that he may avoid it, he may not escape great harm. Thefault in us which kept him in ignorance will recoil upon our ownheads. He will maintain the barrier which was erected in the firstplace by our own unhappy reticence, and we may find it a hard task topenetrate behind it and prevent his constant return to secret thoughtsand imaginings or secret habits and practices. Certain physiologicalprocesses come to have for him an unclean flavour which is yetperniciously attractive. He knows little of the real meaning of sexualprocesses or of the great purpose for which they are designed. It isonly that an unhealthy interest becomes attached to all subjects whichare scrupulously avoided in general conversation. In secret hedevelops a wrong attitude to all these matters. 

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

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

 * * * * *

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

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

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

 * * * * *

Now in the minds of many boys and some girls certain words and ideasconnected with certain physiological processes become polarised. It isthe parents' duty to depolarise them. It is a task which cannot wellbe deputed to others; nor can much help be derived from books, thoughmany have been written with the object of initiating children into themysteries of sex. No one but a parent is likely to be on sufficientlyintimate terms with the child to enable the subject to be approachedwithout restraint or awkwardness, and no book can adapt itself to thevarying needs of individual children. An exposition in cold print, ora single formal lecture on the subject, is apt to do more harm thangood. I have seen instructions to parents to deliver themselves of setspeeches, examples of which are given, which seem to me wellcalculated to repel and frighten the nervous child. Still moredangerous is the advice to make sexual hygiene a subject for classstudy. The task requires that parents should be upon very intimateterms with their children, and on suitable occasions, when thisfeeling of intimacy is strong, children should be encouraged to speakfreely and to ask for explanations. By a judicious use of suchopportunities piece by piece the whole may be unfolded. In order thatthe child may approach the subject in the proper spirit we maystimulate interest by a few lessons in Natural History. A child ofeight or ten years of age is not too young to learn a little of theoutlines of anatomy and physiology. If he is told a few bald factsabout the skeleton, about the circulation and the processes ofdigestion such as any parent can teach at the cost of a few hours'study of a handbook, this will lead naturally enough, in laterlessons, to a similar talk upon the excretory organs, reproduction, and the anatomy and processes of sex, suitable to the individual. Toachieve "depolarisation, " there is nothing more efficacious than thefrankness and explicitness of scientific statement, howeverelementary. Later a little knowledge of Botany and Zoology will enablea parent to sketch briefly the outlines of fertilisation andreproduction. The child may grasp the conception that the life of allindividual plants and animals is directed towards the single aim ofcontinuing the species. He can be told how the bee carries the malepollen to the female flower, how all living things habituallyconjugate, the lowest in the scale of development as well as thehighest, and how the fertilised egg becomes the embryo which ishatched by the mother or born of her. As the child grows older andunderstands more and more of these natural processes an opportunitycan be used to make the presentation of the subject more personal. Hecan be told that during childhood his own sexual processes have beenundeveloped, but that as he grows older they will awake. That withtheir awakening in adolescence new temptations to self-indulgence inthought or action may assail him, but that these temptations aredelayed by the wisdom of Nature until his understanding has grown andhis man's strength of character has developed. A high ideal of purityshould be set before boy and girl alike, and the conception of sexfrom the beginning should be associated in their minds with the highpurpose to which some day it may be put. Before the boy goes to aboarding-school he should have imbibed from his father the desire formoral cleanliness, the knowledge of good and of evil, and a cordialdislike 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 nowand then during later childhood and in adolescence. To attempt toimpart all this interesting information in a single constrained andawkward interview is to court failure, or at least to run the riskthat the explanation is not fully understood, so that the child ismystified, 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 achild of nervous inheritance, or with a child in whom symptoms ofneurosis have developed in a faulty home environment. Misconduct insexual matters is a sign of deficient nervous and moral control, andwhen the conduct in other respects is ill-regulated, the developmentof sexual processes must be watched with some anxiety. There are thosewho see a still more intimate relationship between errors of conductor symptoms of neurosis in childhood and the sexual instincts. 

It is perhaps necessary here briefly to refer to the teaching ofSigmund Freud of Vienna, because his views have attracted a great dealof attention in this country and have become familiar to a great partof the reading public. Freud believes that the origin of many abnormalmental states and of the disturbances of conduct which are dependentupon them is to be traced back to forgotten experiences, therecollection of which has faded from the conscious mind, but which arestill capable of exerting an indirect influence. He regards theprocess of forgetting, not as merely a passive fading of mentalimpressions, but as an active process of repression, by which theexperience, and especially the unpleasant experience, is thrust andkept out of consciousness. There thus arises a mental conflict betweenthe forces of repression and the forces which tend to obtrude therecollection into consciousness, and at times the energy engendered inthis conflict escapes from the censorship of the repressing forces andfinds vent in the production of abnormal mental states or disorders ofconduct. Thus to take a simple example, a business man who has had atrying day at the office, on returning home in the evening may succeedin thrusting out of his consciousness the thought of hisdisappointments and worries, yet the disturbance in his mind may showitself in quarrels with his wife or complaints of the quality of thecooking at dinner. 

Freud has called attention to the part which the suppressed andlong-forgotten experiences of early childhood play in the productionof neuroses of all sorts at a later date, and he has laid especialemphasis on sexual experiences as peculiarly fruitful causes of suchdisturbances. Those who have embraced Freud's teaching have gone evenfarther than he in this direction, and by psycho-analysis--that is tosay, by attempting in intimate conversation to arouse the dormantmemory and lay bare the buried complex, the suppression of which hasproduced the conflict in the mind of the sufferer--will seldom fail todiscover the influence of sexual forces and sexual attractions which, while capable of causing disorders of mind and of conduct, showthemselves only obscurely and indirectly, as, for example, in dreamsor in symbolic form. 

So far as the nervous disorders of children are concerned, much thatis written to-day upon the influence of repressed sexual experiencesmay be dismissed as grotesque and untrue. The conclusions to which thepsycho-analyst is habitually led, and which he puts forward with suchconfidence, can be convincing only to those who have replaced thestudy of childhood by the study of the writings of Freud and hisschool. Thus it is common enough to find a mother complaining that herchild of two or three years of age is bitterly jealous of the new babywho has come to share with him his mother's love and attention. According to the views of Freud, we are to recognise in this jealousyan exhibition of the sexual instincts of the older child, who scents apossible rival for the affections of his mother. Even if we give tothe term sexual the widest possible meaning, it is difficult for aclose observer of children to detect any truth in this conclusion. Thebehaviour of the older child to the newly born will be determinedmainly by the attitude adopted by the grown-up persons around him andby the unconscious suggestions which his impressionable mind receivesfrom them. If the mother is fearful of what may happen, and refuses toleave the children alone, she will find it hard to hide from the olderchild her conviction that danger is to be apprehended from him. Ifthis suggestion acts upon his mind, and if the reputation that he isjealous of the new baby becomes attached to him, he will assuredly notfail to act up to it, and her daily conduct will appear to prove thejustness of his mother's apprehension. Fortunately, mothers arecommonly able to divest themselves of such fears as these. The olderchild is brought freely to the baby to admire him, to bestow caresseson him, and to speak to him in the very tones of his elders. In a fewdays his reputation is established, that he is "so fond of the baby, "and to this reputation too he faithfully conforms. We have seen in anearlier chapter that constantly and ostentatiously to oppose a child'swill is to produce a counter-opposition which because of itspersistence and vigour appears to have behind it the strongestpossible concentration of mind and power of will. Yet if we cease tooppose, the counter-opposition which appeared so formidable at oncedissolves, and the difficulty is at an end. We took as an example thechild's apparent determination to approach as near as possible to thefire, the one place in the room which our fear of accident forbidshim. The difficulty with the new baby is but another example of thesame tendency. If he does not know that the ground is forbidden, if wedo not concentrate his attention on the prohibition, he will show noparticular desire to approach it. His apparent jealousy of his littlebrother is the result not of the rivalry of sex, but of badmanagement. 

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

Although the nervous troubles of infancy are not commonly due, asFreud and his numerous followers would have us believe, to suppressedsexual desires or experiences, it is clear that in the sensitive mindof the child the reception of a severe shock may have effects longafter the memory of it has disappeared from consciousness. In amedical journal there was recently recounted the case of an officer ofthe R. A. M. C. Who all his life had suffered from claustrophobia--thefear of being shut up in a closed space. By skilful questioning, theremembrance of a terrifying incident in his childhood was regained. Asa child of five he had been shut in a passage in a strange house bythe accidental banging to of a door, unable to escape from theattentions of a growling dog. A complete cure was said to follow uponthe discovery that in this incident lay the origin of the phobia. Nevertheless, observation would lead me to lay the greater stress notupon any one particular shocking or terrifying experience, but uponthe attitude of parents and nurses in focusing the child's attentionupon the danger, and in sapping his confidence by showing their ownapprehensions and communicating them to him. 

As a method of treatment for neuroses of childhood, psycho-analysis isnot only unsuccessful, it has dangers and produces ill effects whichfar outweigh any advantage which may be gained from it. 

There can be no doubt that Freud has exaggerated the part which sexualimpulses play in causing neurosis. It will be sufficient for us torecognise that for the nervous child the sexual life has especialdangers, and we should redouble our efforts to prevent his ideas onthe subject becoming "polarised. " For the child whose environment hasbeen 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 ofadolescence begins. Into these further stages of development it is notproposed to enter, but it may be well to consider a question which isapt to present itself for answer at this period: "Should the boy, orgirl, of nervous temperament, or whose development up to this pointhas been accompanied by symptoms of nervous disorder, be sent to aboarding-school?" So long as the child remains at home the homeenvironment is the force which alone is concerned in moulding hischaracter. We have seen how plastic the young child is, how imitative, how suggestible, how prone to form habits good or bad. The diversityof type shown by the homes is reflected in the diversity of characterand conduct exhibited by the children. The home is the culture medium, and in no two homes is its composition the same. For each child homeinfluence remains to a great extent unchanged, and in great partunchangeable. Its action upon the child is constant and longsustained. Hence, it is not surprising that the growth of hischaracter and powers is commonly unequal. At one point we may find agood crop of virtues, at another a barren tract; and the homeinfluences which have ripened the one and blighted the other arecalculated by the lapse of time to increase the contrast rather thanto diminish it. 

I suppose it is for this reason that the custom of sending children toboarding-schools has so firm a hold among us. The boarding-schoolforms an environment selected to correct the inequalities which resultfrom the special action upon the child of individual homes. The lifeof a boy in one of our large public schools is well calculated to actas a corrective in this way not only by reason of its ordered routineand discipline, but still more because it is affected, perhaps for thefirst time, by the strong force of public opinion. It is the strengthof this public opinion which gives to our public schools theirpeculiar character and produces their peculiar effects. That which theschoolboy most despises is what he calls "Bad Form, " and he bows downand worships an idol he himself has set up, the name of which is "GoodForm. " Public opinion forms the code of morals observed in the school. The standard set is commonly not so high as to be very difficult ofattainment. It demands many good qualities. To lie, to sneak, to telltales, to bully, to "put on side, " are bad form. In some respects thedefinition of what is virtuous may be a little hazy. Thus it may bewrong to cheat to gain a prize, but to copy from one's neighbour onlyso much as will enable one to pass muster and escape condemnation isno great sin. In short, good form demands that a boy should have allthe social virtues: that he should be a good fellow, easy to livewith, and possessed of a high sense of public spirit--good qualitiescertainly, though perhaps not those which help to make the reformersor martyrs of this world. 

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

Now what is true of public-school life is of course also true of thelarger life after schooldays are over for which all education is apreparation. These qualities of sociability and good sportsmanshipwill stand a man in good stead throughout life. Even the most ardentand active spirit will benefit by being subjected for some years tothis steady pressure of public opinion. The most part will learn fromit good sense, consideration for others, and self-control. As theypass from the lower forms to the higher in the school they will learntoo to support authority without doing injustice, and to bring theweight of public opinion to bear upon others. And to all thistraining many a man owes his happiness in after life--a happinesswhich he could not have secured if his character had been moulded onlyby the environment of his home, or by the home in combination with theless-powerful corrective of a day school. For the nervous child thepassage from home to school life may involve considerable mentalstrain. He may be morbidly self-conscious and timid, or, unknown tohimself--because he has as yet no power of self-analysis and has noopportunities of comparing himself with others--he may have developedcertain eccentricities. In most cases the plunge into school life willbe taken well enough; in a few the little vessel will not rightitself, and proves permanently unseaworthy. No doubt as a rule aprivate school will have preceded the public school, and thisgradation should make the entrance to the public school a lesserordeal. But it often happens that it is just in the case of thenervous child that this intermediate stage has been omitted, and thathis thirteenth birthday finds him still in the home circle. 

If the boy's father has first-hand knowledge of life in the lowerforms of public schools, his experience may enable him to form someestimate of the effect of school life upon the nervous system of hisson. It is when parents or guardians have no such experience of theirown to guide them that mistakes are most liable to be made. I canmyself remember the unhappy state of some solitary and eccentricschoolfellows of mine who aroused the resentment of "the Herd" bytheir behaviour or opinions. If it is clear that the boy has apeculiar temperament and is likely to suffer in this way, some _viamedia_ must be found. The home has failed so that he must leave homeand come under the influence of some one who understands the nature ofthe difficulty and can adapt the boy to school life. A change ofenvironment of this sort as a preliminary to the public school isoften all that is needed. If his age permits, every effort should bemade in this way to obtain for the nervous child who has developedpeculiarities or faults the benefits of a public-school education. 

Some types of nervous children will show immediate improvement whenthey go to school. The boy who is passionate and disobedient, andwhose parents cannot control him, is best at school. Boys who, frombeing much with grown-up people, have become too precocious and haveacquired the habits and tastes of their elders, will dislike school atfirst, but it will do them good. Their fault shows that they are quickto learn and sensitive to the influences of others, and they will soonadapt themselves to their new surroundings. Boys who are dreamy andimaginative, who early adopt a "specialist" attitude towards life, who, however ignorant they may be of everything else, cultivate areputation for omniscience in some particular subject, such asEgyptology, astronomy, or the construction of battleships, are usuallynervous boys whose symptoms will disappear at school. Where unduetimidity, phobia, or habit spasm is present, the question is moredifficult to decide. Every individual case must be studied as a whole, and our object should be not unnecessarily to deprive the boy of thewholesome training of public-school life. 

There are parents who from sheer ignorance add to the difficultieswhich the boy encounters in going to school. Failure to appreciatevery small points may cause unnecessary suffering. To be the only boyin the school to wear combinations is not a distinction that any newboy craves, however strong his nerves may be. A friend of mine stillrelates with feeling how, twenty years ago, he arrived at school withshirts which _buttoned_ at the neck! At night when every one else inthe dormitory was asleep he sat for hours on his bed, miserable beyondwords, removing the buttons and doing his best in the dark to borebuttonholes which would admit what every other boy in the schoolhad--a collar stud. 

With girls perhaps this question of fitness for school life does notarise in so urgent a way. Girls are usually older when they go toschool, and girls' schools are perhaps less terrifying and more likehome. There is, however, one important point which should be borne inmind. The date of the onset of puberty varies much in both sexes. Ifthe boy grows to a great hulking fellow at fourteen, and even displaysa desire secretly to borrow his father's razor, he is at no particulardisadvantage as compared with his fellows. He is so much bigger andstronger than the others that he may thereby early enjoy thedistinction of playing at "big side, " or of getting a place in theschool Eleven. He is probably much envied by those of the same agewho, with the aid of their youthful aspect, can still occasionallyextract compensation by inducing the railway company to let themtravel to school at half fare. But with girls it is different. Many atfourteen or fifteen are children still; some are grown up, with thetastes, feelings, and attraction of maturity. Those who have developedfastest are often, for that very reason, kept backward in schoollearning. Often they are nervously the least stable. Now that largeschools for girls on the model of our public schools are become thefashion, such precociously developed and nervously unstable girls areapt to find themselves in the very uncongenial society of little girlsof twelve or thirteen. The elder girls commonly hold aloof, whilemistresses are apt to view this precocious development withdisapproval, and to attempt to retard what cannot be retarded byinsisting that the young woman has remained a child. I remember beingcalled in consultation by a surgeon who had been asked to operate forappendicitis upon a girl of fourteen. I found a tall, well-grown girl, with an appearance and manner that made her look four years older. Icould find no signs of appendicitis, but I learned from her that shehad been for three months at a large girls' school, and that in a fewdays' time her second term was due to begin. As we became friends, sheagreed that her appendicitis and her resolve not to return to school, where she was unhappy, were but different ways of saying the samething. She was an only child who had travelled a great deal with herparents, had found her interests in their pursuits, and had grownbackward in school work. The little girls with whom she was expectedto associate seemed to her mere children. The elder girls did not wanther friendship, and snubbed her. I prescribed a change to a smallboarding-school with only a few girls, where age differences would notmatter so much, and where she could make friends with girls older thanherself, though not more mature. 

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

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

The nervous infant, restless, wriggling, and constantly crying! Thenervous child, unstable, suggestible, passionate, and full of namelessfears! The nervous schoolboy or schoolgirl prone to self-analysis, subject-conscious, and easily exhausted! And how many and how variousare the manifestations of this temperament! Refusal of food, refusalof 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 goodmanagement and a clear understanding of their nature. 

The hygiene of the child's mind is as important as the hygiene of hisbody, and both are studies proper for the doctor. Neuropathy and anunsound, nervous organisation are often enough legacies from thenervous 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'.